Wednesday, 13 February 2013

BAPIO serves the RCGP and GMC with a 'letter before action' of Judicial Review over the CSA GP exam

Two weeks notice served of Judicial Review, an application to the High Court challenging the RCGP CSA exam and the GMC, who subcontracted the RCGP to deliver the CSA.


The British Association of Physicians of Indian Origin, a charitable organisation who also include physicians of all ethnicities, has now served the Royal College of GPs and General Medical Council with a 'letter before action' of Judicial Review of the CSA (Clinical Skills Assessment) GP licensing exam, a tool which employs 13 actors and 13 examiners to role play 13 different artificial cases for each GP trainee. They have enlisted the legal services of barrister Karon Monaghan QC of Matrix Chambers. She has agreed to represent for the concomittant Employment Tribunal legal action on behalf of a class action of released GP trainees who failed to clear the human-marked subjective CSA actor exam which came into existence in October 2007.

Of note, is the fact that over 40,000 of the 60,000 working NHS GPs have never sat this CSA exam tool and are working satisfactorily. 30,000 NHS GPs do not have MRCGP, as they have either never sat the College exam or may never have passed the exam. Many GP trainees would like their 3.5 years' experiences of seeing over 2,000 real patients taken into account to remain as practicing GPs, as this was the rule prior to October 2007, when the MRCGP was not obligatory to work as a NHS GP.

Many GP trainees ask to submit videos of real consultations with real patients as an alternative and authentic tool and have consideration placed on passing all their regular checks and video submissions for their workplace-based assessments, rather than have 100% weight on a 3-hour expensive £1,525 exam sat under artificial conditions with a perception of reliance on 'acting', failure of which has been the chief reason for expulsion from GP training.

Surprisingly, the RCGP refuse to record the CSA licensing exam for GP trainees to rely on as evidence of possible discrimination at an exam appeal. The College reason is that 'video is not necessarily a good record of the consultation in CSA.' Yet video recording of patient consultations was accepted to award the old MRCGP exam to 10,000s of established and training GPs prior to 2007. Random video recording for independent assessment is used by the Irish College of General Practitioners for their MICGP licensing exam and video monitoring and recording is used by the US medical licensing exam boards.

Black and minority ethnic GP trainees ask 'what do I have to do to get 9/9 marks at a CSA station?', as an Asian international medical graduate receives 6/9 marks based on this CSA examiner marking sheet in which he has passed all 3 domains (data gathering and assessment skills, clinical management skills, and interpersonal skills to receive a global mark of Pass) yet only receives 6/9 marks towards his total marks from 13 CSA stations. Of note, he receives no 'x's in 16 performance criteria indicating he has nothing to improve. He faces his 4th and final CSA as one of the 13 CSA examiners on this day gave him a mark of 1/9 which tipped the balance to overall fail. IMG trainees ask how to protect themselves against an extreme hawk examiner who by giving 0-3/9 in 1 of the 13 stations can offset total marks to result in an overall fail.

Institutional Racism rife in the NHS

BAPIO has invited affected GP trainees to contact them with points to raise and discuss at the crucial February 21 meeting with the RCGP. The controversy over this exam, has led to a speight of articles around the bigger problem of institutional racism in UK medicine. Dr Kailash Chand OBE, deputy Chair of the British Medical Association, penned a recent article in the Guardian, 'Why is racism rife in the NHS', Doc2doc conducted a survey on racism in the NHS and of 259 voters, the vast majority, 75.7% or 196 doctors voted 'yes, still shocking.' May I remind the public this is the year 2013!

BAPIO continues to fund-raise for the imminent Judicial Review of the RCGP CSA exam and of GP training, while more GP trainees are prescribed anti-depressants and anti-anxiety medication to face the CSA actor exam.

More and more GP trainees are coming forward sharing how they have been prescribed SSRI antidepressants by their respective GPs, as they have become depressed, suicidal and chronically anxious over having to re-sit the costly subjective CSA actor exam multiple times, with inadequate feedback as to why they had failed. The presence of extreme hawk examiners giving only 0-3/9 in one of the 13 stations has led to some GP trainees failing overall even when they score 8/9 in another station by another CSA examiner as the average is below 6 (the pass mark for each station) and the total mark of 74 ( 11 stations x 6 pass + 1 station x 8/9 merit pass + 1 station x 0/9 = 74) is then deemed an overall fail if the overall pass mark for that day is set at 75. Pulse magazine featured a GP trainee who was released after scoring 74 (his scores ranged from 1/9 to 8/9). Many are resitting the exam, outside of GP training, as their 6-month extension has expired and they have been 'released' from their Deanery GP specialty training with a Deanery Panel decision of an outcome 4. Many are leaving the exam feeling they had done well, and yet the fail results have shocked both them and their UK GP trainers and are at wit's end trying to figure out what else they can improve. Many are resorting to a drug combination of beta-blockers and SSRI antidepressants to combat extreme psychological anxiety when facing this career-ending exam yet again.

One male GP trainee says when he looks at his young children, he realises he must not commit suicide. To say they can then go back to their own country is like saying, 'you are a failure as a doctor despite your top marks in the AKT written exam, despite your MRCP or MRCS degrees, as you simply cannot 'act', therefore you must return with shame and dishonour back to your country, as we do not count the 2,000 GP consultations you have conducted well with real NHS patients or the approval of your UK GP trainer who has known you for over a year, much longer than the 10 minutes each of the CSA examiners know you while you are 'acting' like a GP to solve a pre-written artificial CSA actor case,' but what if that home country is Great Britain?! Some released ethnic and black GP trainees are in fact born British! Local ethnic and black UK graduates (34%) are also failing the actor CSA exam with its exceedingly high 96% pass rate for white UK graduates which then suggests an element of positive bias towards local white graduates alongside negative bias towards ethnic GPs. The RCGP reports that 86% of their CSA examiners are white British.

One British Asian writes, 'I am a devout Muslim and have had a beard since my life transforming pilgrimage to Mecca 10 years ago. For 10 years I had a neatly kept beard that in my opinion was an important part of my faith. It was suggested to me that I shave it off as that it could be working against me, especially with biased examiners. At first I couldn't believe what I was hearing but after 2 CSA fails I felt I had to as there really wasn't anything else I could change. I reluctantly shaved off my beard for the first time in 10 years and passed the CSA with an excellent mark on the 3rd attempt. I can honestly say, hand on heart that I don't think I did anything differently in the 3rd exam than in the 1st or 2nd.

I am absolutely certain that being clean shaven helped me to pass on my 3rd attempt. I feel very angry and embarrassed that I had to do what I did in order to pass an exam. What hurts the most is that my own integrity has been brought into question by friends, family and other mosque-goers. I think they feel that if I could compromise my faith for the sake of an exam then that calls into question my integrity as well. I also feel a personal moral dilemma, as a religious person I feel one day I will have to answer to my creator for compromising my faith.'

A female GP trainee has written to Pulse GP magazine that she has now resigned membership of the RCGP. CSA stance has left me disillusioned.

Bapio are now accepting Paypal contributions to the Judicial Review. Donations have started to pick up since the call for Judicial Review emerged.

A Welsh newly-qualified female GP has donated to the BAPIO legal challenge. She says that she has asked all her GP friends in Cardiff to also donate and has herself sadly been victim to and witnessed bullying of GP trainees in hospital training settings.

A hospital specialty trainee has recently donated to the BAPIO legal challenge. He is not affected but feels for the plight of his fellow male GP trainees.

Sadly the MRCGP CSA statistics for 2011/12 continue to show a great disparity  between UK graduates (based on ethnicity) and between UK and IMG graduates.

News of the GP CSA exam reaches national UK media.

Update March 20, 2013

GMC announces a review into MRCGP exam is to be led by racism expert.
Bapio's President NHS Consultant Paediatrician Dr Ramesh Mehta, 'The RCGP has requested 2 more weeks to consider all possible options. Our QC has suggested giving them until 28th March. In addition the GMC has now commissioned an independent review of the CSA. However we are determined to go ahead with JR and continue out fight until this flawed assessment is amended and those affected are taken care of. Meanwhile we are preparing for the second lot of action in Employment Tribunal for those affected by this examination. If you wish to join, then please contact'

A male asian IMG GP trainee writes yesterday that he has been awarded 82/117 yet has received NO CROSSES in all 16 performance criteria for all 13 CSA stations. This begs the question, what more did he have to do to achieve a perfect 117/117 or is this the highest marks awarded a male international medical graduate GP trainee of Asian ethnicity?

A female Nigerian UK graduate has just failed her 4th CSA. She has no sociolinguistic problems as she was born British, ie Hackney, East London. She is more than desperate after failing her final attempt, 'To say I'm devastated is an understatement....I have read your comments on subjective bias of the exam, and I am in total agreement, speaking from personal experience. Unnecessarily aggressive actors, etc.' If you are of Nigerian ethnicity, please contact, the Medical Association for Nigerian Doctors in the UK for advocacy.
If you are an ethnic or black minority GP trainee who has failed CSA, you may write to to make a Data Subject Access request of the 13 examiner marking sheets.
As a Council Rep I had asked the RCGP CSA chief examiner to test all the actors and examiners for 'unconscious bias' with the Harvard Implicit Association Test. Bias can be positive and negative. The RCGP declined to apply this test.

Update April 2013

Bapio's President Bedford NHS Consultant Dr Ramesh Mehta confirms that BAPIO are now filing for 'permission' for a Judicial Review of the CSA exam and will run BAPIO charity CSA courses to raise funds, with all proceeds going towards the BAPIO CSA Judicial Review.