Thursday, 17 January 2013

18 UK GP trainers express concerns over the RCGP CSA exit exam for GP trainees

On January 11, 2013, Pulse GP online magazine printed a letter addressed to the Royal College of General Practitioners written by 18 UK GP trainers expressing their concerns over the CSA exit exam for GP trainees It read:

'A letter from 18 GP trainers to the RCGP expressing concern at the high failure rate of international medical graduates taking the CSA exam.

We note with optimism that the issue of discrepancy in failure rates between overseas graduates and local graduates in the nMRCGP examination has been published in ‘Pulse’. It seems evident that many GP trainees are unable to surpass the examination hurdle, or in the case of some, are at risk of succumbing to the CSA/AKT at their fourth and final attempt. It is of concern that the significant difference in the success rates of this examination appears to be based on ethnicity, and it has to be acknowledged that this puts pressure not just on the candidates but also on their families.

The fact that General Practice is the only speciality where failing the exit examination means the trainees have no choice but to quit General Practice sets the RCGP apart from other Medical Colleges and Faculties. It should be noted that International Medical Graduates (IMG’s) have historically always formed a significant proportion of the GP workforce in the UK. A disparity in pass rate of this magnitude neither existed in old MRCGP nor is it heard of in any other comparable examination internationally. There has been anecdotal evidence that trainees deemed competent by their trainers, considered to be the best predictors of trainees least likely to struggle, are ending up failing the examinations multiple times.

This is a disservice not only to the trainees and their families but also to our patients, the general public and the taxpayer at large. We must not discount the adverse impact of GP workforce shortage on patient care in many parts of the country which have recruitment and retention problems, often filled by IMGs.

It is disappointing that the widely respected RCGP chair Dr Clare Gerada has termed the controversy as noise, we are extremely hopeful that she will not hesitate to do the needful. Though RCGP deserves credit for being transparent in publishing examination data based on ethnicity and country of graduation and has published a list of frequently asked questions to allay some of the concerns, however, this does not go far enough to identify the flaws in the process or to take appropriate corrective steps. It is time for all of us to recognise this as a real problem, even a crisis. All the stakeholders need to sit down to do a root cause analysis, debate the reasons and the potential solutions- whether this involves revamping the examinations, regionalising them, changing the way feedback is given to the candidates, video recording the examination, alternative route to qualification, extra trainee/ trainer support, additional training (and attempts) for candidates likely to fail or reviewing the GP training selection process.

Some have argued that there is a disparity in the AKT pass rates too which is a ‘computer-based test’. The AKT questions are long and unless English is your first language, this can be a disadvantage and it appears that often IMGs find it hard to ‘effectively’ finish this examination on time.

If it is the case that IMG’s perform poorly and that the examinations are accurate and unbiased, it raises the question as to why RCGP and Deaneries are allowing patients to be exposed to practising doctors who they statistically expect to fail these exit examinations. The selection and recruitment process into GP training, therefore, must be reviewed, as it is this very system that deems them competent to be trained and then during the course of their latter years of training concludes that they are unfit to be a GP. We hope that the Deaneries will work with the college to revisit this, looking beyond the short term aim of filling the training posts. Good career advice at the beginning of their careers would weed out those who are not suitable to GP training, or at least reduce the chances of such abject failures.

It was reported in the media after a meeting of (British Association of Physicians of Indian Origin) BAPIO with RCGP that number of attempts for AKT and CSA may be increased to six Though this will help to reduce the pressure on candidates, it is patently obvious that long term solutions are required as the RCGP’s own statistics show that increasing the number of attempts does not result in significant improvement in pass rates. The impact of cost of such examinations (CSA costs more than £1500 per attempt) can not be understated at that stage of a trainee’s career.

RCGP, as a body that conducts the examination and has a monopoly position on this has a moral obligation to acknowledge and address any concerns raised irrespective of the source and reasons. It must respond to the concerns raised by the trainees, organisations such as BAPIO, trainers, GPs, doctors or the taxpayer. Otherwise, it risks alienating itself from the profession.

We take this opportunity to kindly request the college to review the nMRCGP examinations i.e. AKT and CSA with urgency.

Signed by

Dr. Aninda Banerjea

Dr. Keith Birrell

Dr. Anne Blandford

Dr. Neil Brownlee

Dr. Richard Croft

Dr. Raj Dussad

Dr. Eamonn Kennan

Dr. Nageswarao Kolla

Dr .Nasir Nabi

Dr. Uma Narayanan

Dr. Vidya Parajulie

Dr. Geoffrey Potter

Dr. Selvarajan Rajarajan

Dr. Anand Rischie

Dr. Nitish Sahoo

Dr. Sangeeta Shah

Dr. Kamal Sidhu

Dr. Manjit Suchdev

All signatories are GP trainers except Dr Potter who is a former trainer.'
I fully concur. It echoes my concerns I first raised as RCGP Council Rep with the Chief Examiner Sue Rendel and the RCGP Chair Clare Gerada dated 30 January 2011:
'Dear Chief Examiner Sue and Chair Clare,

Thank you for answering my exam questions on behalf of trainees.

A new question has come up from trainers. First selection trainees end up in London and KSS deaneries so places like Eastern get mostly IMGs. In November one Eastern Programme Director had 50% of his trainees fail. This is to be expected as the November 1st time IMG pass rate was 42% vs 96% UK grad and alas Eastern and other deaneries may have mostly IMGs. Re-sit pass rates for CSA are even worse and go down to 28%. My concern and that of trainers and PDs is that we may be going on to fail a large % of the workforce in these less popular regions of the UK on the basis of 1 of the 3 assessments and one trainer in rural Scotland relays:

'The thing I don't like is that it's make or break.You can have a registrar who is well thought of, patients love them, practice staff think they're the bees knees, trainer thinks is flying and they fail the CSA because of a bad day. To go to Croydon from here it's a marathon journey too, either by plane, or boat and plane and road. 700 miles..Unfortunately though there has to be a something that encapsulates it all. I don't think the CSA is it, and its up to us as trainers to feed back that it isn't it.'

From my own experience of teaching IMGs and UK grads, I can see the anxiety and stress levels affecting performance in IMGs who know UK grads pass between 93 and 96% but 50% of IMGs will fail. And so I see the stress and panic attacks, ie the inability to relax facial muscles, inability to smile, clenching fists, inability to speak coherently in role play and yet during the breaks, male Asian and Nigerian IMGs speak fluently with facial animation, smiling and friendly. Is this a case of stage fright turning Asian IMGs into incoherent, serious doctors in CSA under enormous pressure to perform in front of an examiner as this is a career breaker, which may be completely different from the way they are in real-life?

The old exam offered Simulated Surgery as an option for those who could not videotape. Could the exams dept consider reinstating the video module for those who suffer extreme performance anxiety over CSA?

Should panel reviews be given flexibility to consider passing a ST3 who has outstanding patient satisfaction surveys, outstanding trainer's reports, outstanding AKT results, outstanding multi-source feedback from practice staff and yet for whatever reason is unable to show his true abilities on the CSA day?

I appreciate how much hard work and analysis has gone into CSA. This new marking has had no change for UK graduates - pass rate is still 96% when compared to the annual MRCGP report 2009 but seems to adversely affect IMGs, pass rate has dropped from 59% 2009 for CSA to 42% recent November diet. If over 1/2 UK GPSTs are IMGs, then are we not affecting the future workforce to deprived areas, if they can pass AKT, trainer's reports, pt surveys, MSF from practice staff and yet so much weight is placed on CSA, just 1 of the 3 assessments?

Anything the exams dept can consider would be much appreciated. CSA is a good exam and discriminator for UK graduates but I wonder if IMGs are unduly stressed (financially, socially, personally, family, culturally, etc) by this one assessment and are psychological disadvantaged entering Croydon, knowing 1/2 IMGs will fail.

best wishes,

Despite concerns raised informally January 2011, then formally on the RCGP Council on February 2011, the CSA remains unchanged in format, and now, in January 2013, sadly, GP trainees still voice their concerns through their GP trainers and organisations like the BMA GP Trainee Subcommittee, BAPIO, BIDA, and BPDF and now media...

A GP trainee was interviewed about the CSA exam on BBC Asian Network Lunchtime radio news (02.08 to 05.49) transmitted on January 22, 2013.