Friday, 29 March 2013

BAPIO and BPDF leaders say NO to the effects of 'Unconscious Bias' in the actor RCGP CSA exam!

The British Association of Physicians of Indian Origin and the British Pakistani Doctors Association say NO to 'unconscious bias' in the RCGP actor CSA exam that has decimated the lives and careers of over 300 Asian, black and chinese male GP trainees.


Dammu (2012)

I have spent years teaching ethnic and black GP trainees how to negate the effects of  'unconscious bias' towards black, chinese and asian GP trainees (UK and IMG graduates) and Caucasian UK graduates with 'working class accents' in the CSA exam. I had written to the RCGP CSA chief examiner to ask that all the CSA examiners and actors be tested for unconscious bias using the renowned Harvard Implicit Association Test. We are now seeing 'extreme hawk examiners' awarding anywhere from 0 to 3 out of 9 marks to an ethnic or black GP trainee. I had asked that each CSA room be video-monitored for appeals to challenge bias. Unconscious bias can be positive or negative. Since the CSA exam was toughened from 2010, there has been an increase in Caucasian UK pass rates and a sharp decline in ethnic and black pass rates. To do the right thing, is for IMGs (international medical graduates) and ethnic, black and chinese UK graduate GP trainees to:

  • say NO to the actor CSA (clinical skills assessment) exam with no shadow examiners, no controls for extreme hawk examiners, no testing for 'unconscious bias', no video monitoring for appeals, no video module alternative to the CSA;
A clip of 'unconscious bias' in action against a Sikh doctor at airport security and this is why BAPIO (British Association of Physicians of Indian Origin), BPDF (British Pakistani Doctors Association), BIDA (British International Doctors Association) and BMA (British Medical Association) organisations have all raised concerns. The actor CSA exam may have unconscious bias against 'foreign-looking' or 'foreign or working-class sounding' doctors. The acting GP licensing exam is failing some of our good male doctors, doctors who want to continue to be the workforce for our struggling NHS and for real patients, doctors who were former medical registrars, surgeons, A&E registrars who flew out on helicopter emergency medical rescue missions, hospital staff grades, and as GP trainees treated 2,000 NHS patients each. When the government says they want to deliver secondary care into the community, it is these doctors with the medical acumen and experience to deliver and alleviate the load. An exam with positive unconscious bias may 'help' a local Caucasian graduate  and with negative unconscious bias may influence the actor and/or examiner subconsciously to 'hinder' an Asian doctor from passing. The only way to control human bias is to acknowledge its existence, to test with i.e. the Harvard Implicit Association Test for unconscious bias and to control with a shadow observer examiner in each CSA room and video-recording of each CSA room to monitor for bias, with tape evidence that asian, chinese and black male doctors may have access to for appeals.
  • say NO to borrowing £1525 to cover the actor CSA exam fee x 4-5 times from your elderly parents or maxing out your credit cards;
  • say NO to SSRI antidepressants and marital breakups;
  • say NO to beta blockers and sedatives;
  • say NO to despair;
  • say NO to praying and weeping as you and your wife await your CSA results;
  • say NO to depriving your family of Christmas presents to cover exam fees yet again;
  • say NO to spending only 5 minutes with your wife each day as you are consumed with depression and stress over the CSA exam as an Asian male doctor;
  • say NO to passing and then being failed on WPBA (work-placed based assessment eportfolio);
  • say NO to passing and then being refused CCST as you passed a few days or weeks outside of your GP training extension;
  • say NO to failing a 5th CSA by 1 mark;
  • say NO to GMC referrals for multiple fails of an actor CSA exam;
  • say NO to only receiving 82 marks out of 117 yet passing all 13 CSA stations with no crosses for improvement;
  • say NO to watching all the IMGs or ethnic/black GP trainees in your GP VTS (vocational training scheme) fail the CSA exam, thus creating an unintentional apartheid among GP trainees who once nearly all passed the Deanery summative assessment (video and MCQ modules) prior to October 2007;
  • say NO to 612 ethnic (UK and IMG) GP trainees failing the actor CSA exam first-time between 2011 and 2012;

  • In 2007, Harvard psychologists Banaji and Greenwald educated the world about a new phenomenon called 'unconscious bias' and how to test for this.

  • say NO to an exam using healthy actors who allegedly help or hinder GP trainees, with no clinical exam findings as they are faking illnesses;
  • say NO to an exam module in which an examiner fans herself with an examination card to prompt a female GP trainee and when confronted says it is due to the heat in 4 degree weather;
  • say NO to CSA in which ethnic GP trainees report the examiner and actors allegedly smile at each other when an IMG mispronounces a word or makes a mistake and laugh as they exit;
  • say NO to CSA in which ethnic GP trainees report the actors allegedly forget their lines, over-act or are overly aggressive to ethnic and black GP trainees and the RCGP refuses to videomonitor this behaviour for appeals;
  • say NO to an exam in which ethnic GP trainees report the actor sits in silence, avoids eye contact with an ethnic or black GP trainee and refuses to answer his questions until the last minute of the exam or hides his or her underlying concern from an IMG but readily shares with a UK graduate, who has a 98% CSA pass rate, if also female;
  • say NO to an exam in which GP trainees report the examiner prompts UK graduates with 'you will be assessed on your prescription,' 'is there anything else you would like to examine?' and readily gives out exam findings yet the ethnic GP trainee has to ask for the blood pressure reading twice from the examiner and is not interrupted by the examiner when performing a full examination on a healthy actor, awaiting an announcement of the exam findings;
  • say NO to an exam in which GP trainees report and lodge complaints that the actors are yawning and tired and are not sure if they are acting hypothyroid?
  • say NO to an exam that asked a male Asian GP trainee to sit CSA without a clock to keep to time so he was unable to time-manage, and when he asked for one after a couple of exam stations without a clock, was provided a small clock while others had access to a standard CSA room desk clock. He was then failed in CSA.
  • say NO to an exam in which a male Asian GP trainee alerted the marshall on the day that the actor was biased and gave reasons why and asked that a video of this actor be kept for appeals, only to be told it would not affect his results; he got the maximum number of crosses for this station and failed the exam with no access to a video for evidence.
  • say NO to an exam which was conducted while construction was going on in the building causing noise disruption.
  • say NO to an exam which was conducted in cold CSA rooms in winter. Candidates complained and were provided with noisy fan heaters which made listening to the actors difficult and necessitated asking the actor or examiner to repeat himself. Some then reported being failed on 'listening skills.'
  • say NO to an exam which has a 66% pass rate for Irish GP trainees and a 91% pass rate for UK GP trainees.
It is time to donate to BAPIO's CSA judicial review to be filed shortly after the final response from the RCGP on the 5th of April and to make a stand for honour, dignity and a fair GP licensing exam. Stand up for your rights! Stand up for your soul! Stand up for knowing the difference between right and wrong and saying NO to evil and sorrow!
It is time for this country to do the right thing! It is time for the Equality and Human Rights Commission to respond to the numerous letters of complaints from ethnic and black minority GP trainees and a formal complaint from BAPIO's President Dr Ramesh Mehta (NHS consultant paediatrician) over the CSA exam, as they responded many years ago when a local London medical school was found guilty of computer selection bias against ethnic applicants. It is time for the EHRC to commission an independent review of the CSA exam and not the GMC who subcontracted the RCGP and gave retrospective approval to the CSA exam. It is time to speak up for the 300 expelled ethnic and black GP trainees (UK and IMGs), many who suffered being summoned to a GMC Fitness to Practice Trial over multiple CSA actor exam fails. It is time for the RCGP to listen to the concerns raised by a RCGP Council Motion submitted by Dr Saqib Anwar (RCGP Chair of the Associates in Training Committee) and seconded by Christian RCGP CSA GP examiner Dr Rhona Knight, who questioned the CSA exam on Council February 2011 with its wide disparity in pass rates for UK whites vs UK ethnics;  to admit the CSA exam is flawed and inherently biased and to go back to the old video module of real patient consultations as is used by the US family physician board licensing exam. It is time for justice not to come with a £100k legal price tag for GP trainees or NHS whistleblowers. It is TIME for truth to prevail.

Let their voices be heard this Good Friday...some of the 100s of emails BAPIO, BPDF and I have received from CSA victims...the lambs will not be silenced.

'I discovered yesterday evening that I failed the CSA for the 4th time, by 4marks. 69/117 with the pass mark set at 73. In all my previous attempts it has always been by 4-5 marks.
To say I'm devastated is an understatement, as I left a pharmacy career to pursue medicine with the ultimate aim of becoming a GP.
My origins are Nigerian, but I was born in Hackney, East London, my hopes was to go & work in the inner city where I feel most at home.
I am well & truly lost & would very much value any advice you could offer. Can I sit the exam again?
I have read your comments on the subjective bias of the exam & I'm in total agreement, speaking from personal experience. Unnecessarily aggressive actors etc etc.
Please, if there is any advice you can offer, I would be extremely grateful.
Kind regards.'

'I failed again and this was my last attempt.
3 other candidates failed in their 4th attempt in the same deanery (West of Scotland) whom I know. Several others failed in their 3rd attempt as well.
I just thought to keep you informed about the CSA failures.
Thanking you.'

'I am one of the IMGs who have been traumatised with repeated CSA failure often by 1 mark and then "released" from training...I failed this one by 1 mark, again.
As you can see, the marking is wild - some very good (Clear Pass) marks and some straight Fs... for similar domains - same candidate, same day, same exam.
Given the same candidate, this great variation of marks over the same domains speaks of an immense variation in judgement ... ( - for example, how comes I can communicate very well to get a clear pass in one scenario and suddenly for another scenario, I am a clear fail also in communication? either I can communicate well or I cannot).
I have taken and passed many exams in my time and never experienced such an unjust system I wish you all the best in your fight for equality and justice
Best Regards
A kind London CSA examiner/invigilator arranged for him to practice 'acting' with CSA actors in her surgery to no avail. The CSA examiners are 86% white British and the actor mix is predominantly white British.

'I'm an Indian-origin GP trainee in South Wales. I got the result of CSA today (first attempt). I'm utterly disappointed that I scored 72 & pass score was 75.

I'm writing to ask some advice please as I want to challenge this. What are my options?

Can I ask college for a case-by-case feedback (in each domain)? Also would I be able to ask the video of my CSA exam?

It's frustrating that I failed, whereas all my six colleagues who are White British passed. Although we all had CSA on different days, I know of some serious mistakes made by a couple of them (giving COC pill to women who had migraine with aura & almost prescribing Sildenafil to someone on nitrates), they still passed!!

I'm aware that I can't complain about someone else's performance. I feel frustrated and thinking to give up GP altogether. I don't want to get humiliated like this again. It feels like a long tunnel with no light at the end.

My trainer who's white British doesn't think there is any problem in my consultations. I've had good feedback from patients.

Your valuable advice is much appreciated. Thanking you in anticipation.'

Kind regards,'

'I am in a position now (a/w CSA result from 4th attempt, out of training, hugely in debt)..Unbelievable..failed CSA shortfall of 1 number 73/74. It was my last attempt. What shall I do? Shall I appeal? Please suggest.'
'I attended ARCP panel today along with other trainees in similar situation. Failed my 3rd CSA attempt in November '12 (by 3 marks). I was told today, my training will stop on 31/1/12 but will be able to appear for my last attempt on 1st February (got the date today).
I was told I can appeal against this decision but they recommend not to do so because there is no chance to win!
Current plan -
1) to appear for CSA for the last time
2) If I pass, move to Australia
3) If don't pass - move to Australia as Non VR GP
Please advise me.'

'appeared for CSA this February 2013 for the first time and I failed. Everyone in my surgery and my trainer were shocked. I have passed three royal college exams in England. I have been told I have good communication skills and clinical skills.

In my Wessex deanery all the whites who ever appeared passed! Surprise! Surprise! How can that be possible? Not even one of them failed?!

One of them didn't even clear the first part of the exam (AKT) - which gives you essential knowledge to pass!'

'In one of the East of England VTS schemes, 14 trainees appeared for CSA, only two trainees passed, one local white doctor - the only local doctor in the scheme and one IMG in her first attempt while the rest of the 12 failed. They were all IMGs.'

'North Lincolnshire area news (I think Sheffield deanery) 15 took the exam, 5 passed. One local white of the 15 passed. One first time pass for IMG female (4 crosses 84/117).'

'Yorkshire Deanery North Lincs VTS had 11 IMG GP trainees out of 12. CSA failed 8 IMGs.'

'Dewsbury/Wakefield/Pontefract GP VTS scheme Yorkshire + Humber Deanery has 3 fails, all 3 IMGs! Highest score of 105 goes to white male!'

'NW Deanery (confirmed)
2011. 29 total given outcome 4 released from GP training (20 due to CSA failure).
2012. 43 total given outcome 4 released from GP training (30 due to CSA). 25 have been referred to the GMC.'

'Northern Deanery Cumbria VTS 7 sat CSA.
One local first attempt. Pass/Male
One IMG second attempt. Pass/Female
one IMG first attempt Pass/Female
One IMG third attempt Fail/Male
One IMG second attempt Fail/ Male
Two IMGs first attempt. Fail/one male and one female'
BAPIO CSA survey free text responses from ethnic UK and IMG GP trainees:

‘Very tense and anxious about csa exam as it is quite unpredictable for IMGs.’

‘Once the station timings were wrong - rang the bell earlier so college provided a few of them in that batch a extra free attempt (only for candidates who were closer to the pass mark).’

 ‘Although the examiners are not in your line of vision, they are within one's visual field. Examiner keeps moving his head in no fashion. Examiner stands up to leave before the 10 min bell goes off. Examiner looks directly at you head to toe before leaving the room.’


‘Not freely giving examination findings. Talking softly when giving findings and scoring negative for "Listening Skills"

‘when i had a consultation with a teenager, the examiner actually dragged her chair close to my face and just next to the patient to look at my facial expressions. It was very intimidating and i could not perform naturally.’

‘ i could see the examiner in my peripheral vision and every move he made distracted me as if he is marking me down. At 2 different occasions when i had consultation with teenagers, the examiner actually dragged her chair close to my face and just next to the patient to look at my facial expressions. It was very intimidating and i could not perform naturally.’

‘It’s an exam which is unpredictable depends purely on the cohort taking with you.’

‘Stress and nerves paid a big role in poor performance particularly after a difficult station in the CSA exam. This got worse after each exam re-take as the anxiety increased with bigger stakes each subsequent time (expensive, fear of losing training, family responsibilities). I went into debts of about 10,000 pounds for the exam fee - 4x1500, courses, books, accommodation & travel expenses in London.’

‘I doubt, whether there exists a word, to explain the emotions that you and your family go through when you are put through the CSA mill. I suppose, anxiety, fear, stress, panic could be used, if you are putting it mildly.’

‘I felt the result was predetermined and the exam was a charade irrespective of performance.’

‘I have done CSA practice case scenarios with local graduates and felt that I performed on par with them. However when it came to the real CSA exam they invariably pass the exam unlike the high IMG failure rate.’

‘i was one of the favourite candidates in my ST group who was clear pass in CSA during our preparations and according to my records. Some of the local graduates had not enough knowledge to deal with patients independently but they passed CSA. And on the day of CSA i was competing with most of the local graduates that definitely made a huge difference of impression on examiners who of course are prejudiced about the accent and the way you talk, which will be different for IMGs.’

‘I would praise my Educational supervisor for his help but would like to comment on my GP trainers (Programme directors - PDs). Our PDs are responsible for arranging training for half day release. Our training was absolutely rubbish. There was NO focused CSA training, NO help from PDs (as they don’t know anything about CSA anyway). We were NOT given any opportunities to practice properly for CSA in 3 years. I will give only one example; we had total 3 - 4 Half Days of Mock CSA practice in 3 years. What do you expect from the candidates then.’

‘Our trainer never went through this exam. None of them understood what this exam expected out of a candidate. Our support was mainly shooting in the dark. Feedback from CSA exam would not help as it did not relate to your performance in a particular station.’

‘I think GPs should be tested in the environment where they are practicing daily.’

‘In one station the actress started dozing but the examiner either didn’t notice this or chose to ignore it.’

‘They say IMG communication skills are not at par with graduates trained here especially the caucasian candidates, that’s fine, then why has this never been pointed out in our Mini cex, cbd, CSR 360 degress feedback and PSQ which for most overseas candidates are very good to excellent, but when it comes to the csa you fail saying that your communication skills were not good, how bizarre!!!!!!!!!!!!!!’

‘Although I passed on first attempt, my score was just above passing marks. If I was of a particular race, I would have passed it with flying colours. I know one of the trainees, who has great knowledge but failed CSA on 4-5 occasions just by 1-2 marks every time. I don’t think I am a better or worse doctor than her just because I scored a few more points and just crossed the passing marks limit. I think CSA examiners should not take into account the language skills as this is NOT "language testing skills exam". This is medical exam and that should be the focus.’

‘Got 8/9 in one station and 3/9 in another, same sitting!’

‘felt that local candidates with lesser clinical knowledge (evident during preparations with them), scored significantly better for some reason.’

‘It is difficult to say but I did find some examiners unhelpful and uncooperative.’

‘One examiner gave me the findings after my examination was completed and I was about to explain management to the patient. So based on the examination findings given to me, I had to change my management.’

‘some of their expressions were not helpful especially to a stressed candidate!’

‘Actors are not patients. RCGP prefers to call them role players don’t know why. They are very misleading and never give information freely.’

‘some actors like mum keeps interrupting you whenever you pronounce the son’s name. It happened to my colleague 6-7 times.’

‘Sometimes they appear flustered and unreceptive although they're apparently standardised.’

‘actors were quite rude and refused to give information when asked a question a second time- eg 'I've already told you, didn't you listen?'

‘many actors are aggressive when they see a brown doctor and too patronising.’

‘They sometimes smile at you when you do a mistake. This is quite disturbing for the candidate.’

‘some of the actors are definitely biased.’

‘Some of the actors were overacting.’

‘Most of the actors are from the London area and if you have come from North of England, then they will mock your pronounciation - asking again and again as if they don't understand the dialect. Some of the actors are rude (not because of their role requirement) but their overall demeanour with some candidates (esp IMGs) is very biased.’

‘This is the main factor for failure of IMGs. Did the actors have any culture and diversity training? Is it not fair to ask whether actors who decide my CSA and career have had any training in culture and diversity? It would be interesting to find out if the actors divulge crucial information easily and early to some candidates and at the death hour to an IMG.’


‘The actors opening up to give you info is their prerogative, and if they do not like you, then you are stuffed. Because the same actor does the same station again and again; they become judgemental about what a passing candidate is like. Things like not very good opening sentence, hand shake or no hand shake, your look on the day could be causing them to be judgemental (and there are numerous more reasons like these). These are non measurable parameters but we all know this plays a very important part in our day to day human life. It certainly does in the exam.’

‘Many actors are quite hostile towards IMGs and do not really open up. This is seen in examination courses as well.’

‘yes as you know we usually discuss cases in general, mentioning that such and such patient gave me a hard time but it is a very different reply from the English graduates.’

‘One teenage girl stayed mute till almost 7.5 minutes! I obviously failed that station.’

‘i found most to be delaying in giving information unless asked very directly - an experience at odds with my other local white candidates who felt the patient (actors) were very forthcoming and giving up answers at the first hint/cue.’

‘Same case scenario on same day of examination done on two floors. As an IMG I felt the answers from the actress was not forthcoming compared to the local British Graduate who found the answers were volunteered.’

‘.they seem to release the important information at the very end. If you ask the ICE questions early, it is not released because no rapport is built. Many stations they release the vital cue a bit late. I passed the last attempt with excellent marks but I have to admit that I have been put through hell !!’

‘Recording of the performance would definitely help to cancel out the bias. We could appeal against the result and there will be proof of performance rather than what the examiners marking and feedback.’

‘I felt that they are not testing your clinical skills rather your acting skills.’

‘There is a definite bias towards local trainees and this is shown in the scores received by local trainees as compared to IMGs. Especially since IMGs do practice with local graduates and know where they stand in comparison (not much difference).’

‘no transparency ie no way of challenging the results as only one examiner and no recording of the exam. The feedback is not corroborative i.e. general feedback but not specific as to why candidate failed the scenario.’

‘there is unconscious bias, the trick is to "white up" as one of my colleagues put it, sounds funny but it was a mentally tiring change.’

‘It's no way like "Real life Surgery" as RCGP claims to be. When do Pts in real life walk out after 10minutes!!’

 ‘Nature of being a GP provides an option of increasing consultation time for a diff situation or case a situation unaffordable in case esp in metal health issue cases.’

‘no cameras you can't question anything.’

‘Should have recordings for every candidate giving the exam because most candidates do not know why they failed the exam and how to improve. Also felt that the stations that went well were scored lower which again was very confusing.’

‘Is CSA a language test? Is it a linguistic test or test for accent? No such teaching is done in the 3 year VTS but this plays a very important in passing CSA.’

‘i have studied throughout in an English missionary school in India, BHU as medical studies and then English with IELTS of 8.’

‘We feel that "Language" is The Only thing tested in CSA..this is a big problem for everyone with English not being the first language.’

‘the way we deliver, accent,...Real patients and staff never made me realise but I have lost my confidence since csa.’

‘i am a british graduate with good english command but i feel there is bias because of my culture and possibly race.’


‘Actors are equally as biased as the examiners. Actors are misleading. Why not keep the older system of Video assessment?’

‘Should be a clinical test, not communication test, patients come to the doctor for a diagnosis and treatment, not just for communication.’

‘Video record exam and detailed feedback including reasons for scoring low in a station.’

‘- Each room should have a video camera to record performance of candidate and made readily available to candidate (free of cost) - To provide exact feedback to all candidates. Should have scanned copies of feedback/ comments made by examiners/ their marking (in the examiner's own handwriting) so that candidates know exactly what the examiner felt. -To do away with the present feedback provided on eportfolio as it doesn't make sense and has never been a true representation of a trainee's performance in a case. - Do away with racism. -Exam should be cheaper. It also seems to be a money making scheme by the college. - Multiple centers. - If college feels that IMGs lack communication skills, they should provide communication training during the GPStR years and also make the selection procedure to get into GP training more selective. - Having a mix of candidates when sitting the exam- the day I took it there were only 3 IMGs with 36 British graduates. - Always have an option for submitting videos instead of sitting the CSA if a trainee feels unable to take the exam for final ARCP.’

‘1. Two examiners to minimise the observer bias (examiners are humans, like me and you. We all have some degree of unconscious bias) 2. Video in every room and that evidence MUST be able to use in the "appeal process"!!! In my opinion, it is illegal to take away our right to have evidence while there is an appeal process merely based on the candidates word against examiners word!!!!!! 3. Make sure the trainers are trained up to the job (majority of the trainers have no clue about CSA).’

‘If the RCGP starts respecting diversity as different Doctors have different approaches to same problem and it does not make them a good or bad from one another.’

‘This is the only exam that I am aware of where there is no evidence or proof to settle any possible dispute. Examiner can be tired or biased..where is the means of contesting or disputing, no where!!!’

‘Cameras in all room.’

‘2 examiners/ only video recording of performance without examiner, panel marking the result.’

‘Videos submitted by candidates and assessed externally.’

‘Work based assessment and video assessments of consultations from real patient would make a fair deal. An assessment with simulated patients, who will hide their agenda is very unfair. 'One need to be a good actor than a good doctor to pass this current CSA exam.’

‘Appears like csa is a test of communication skills and language test than a medical degree assessment. i have come across candidates with poor knowledge but good English who have been passing with flying colours and candidates with good knowledge who are failing. It is a biased examination and does not actually test who is a good doctor but tests who speaks good English. Certainly unfair to IMGs. Restructure whereby capabilities of the candidates is tested as a good GP. Rather than just having role plays include various stations covering other domains which can test doctors other skills than just communication skills.’

‘Video every single candidate so you have a leg to stand for appeal, also maybe having two examiners like MRCP PACES exam.’

‘use the same style as FRACGP where can do exam while seeing real patient.’

‘every station should have a video recording and videos randomly marked by independent members to make sure the markings are fair.’

‘Fair treatment for all and no bias. Rcgp needs to work on this.’

‘Lower the exam fee...Two examiners marking the candidate. Video recording of the consultation and right to challenge the marking. Exam centres at regional levels. Break examiners monopoly. Some CSA examiners said to British graduates that they didn't need to practice as they are guaranteed to pass, in front of all the IMGs.’

‘made me aware of the discriminatory nature of medicine.’

‘My confidence is shaken. I went into deep stress as I worked hard for this exam as any other exam of my life but losing it by a few marks totally shocked me. My patients, my trainer and my fellow Senior GP Partners colleagues were really worried when they saw my result as they could never think of me Failing this exam !!'

‘I had to training number taken off. I am the only bread winner in my family of four members. I can't wait for justice and fairness without a job. Royal college knows it very well. I have been forced to accept unfairness for practical reasons.’

‘I cannot imagine myself as not being GP as i have worked as GDMO for 14 years in the past and i thoroughly enjoy my role as a GP. I loved the time i spent during my training with my colleagues and patients. I am still looking forward to get well and go back on the track. I am not sure what options are available but surely there should be some, i trust my God.’

‘Some of them most certainly are not fit to be examiners. You can see bias even during this RCGP course towards particular group of candidates and this was very evident.’

‘Even in VTS teaching we are constantly being told if you are male asian and IMG , pass rate is 30%.’

‘heard from friends who attended the course that some examiners indeed made them feel very inferior and that they wouldn't be successful.’

‘I went bankrupt. I am still struggling to pay back the loan I took to sit the ridiculously expensive exam. I was depressed, and very anxious during the 18 months of my GP registrar. I broke down once in front of my supervisor. Home and family turned to hill because of my temper and depression. What can I say more. It turned my life in to hill, it was the most annoying and painful experience in my life. I found after all it’s not worth it, all this for MRCGP.....!

‘I think this exam is a sham (to be blunt it’s a racist exam) and is designed to get rid of as many IMGs as possible. This whole experience has been like a torture for me and my family and it has taken me 8-9 months to get over the depression I went into.’

‘you're treated well until you fail the exams after that you're on your own. You are dissected in observed surgeries by people who have not taken the exam and who don’t know the method of assessment - their criticisms are of no use in passing the exam I sought external help to pass the exam - no one in my programme knew anything about the exam / how to prepare me for it.’

‘My experiences are the same as other IMG candidates who failed the CSA. I feel that there is an obvious, unfair agenda in the RCGP approach to overseas doctors in this exam.’

‘No exam focus at all. VTS schemes need to take the CSA exam very serious and a part of their job. Unlike other hospital specialities general practice is a dead end for significant number of IMGs. It ruins doctors lives. I sincerely mean it!!!’

‘Extremely stressful filling in the e-portfolio, preparing for the CSA with prior knowledge that IMG candidates do poorly and also trainers in the VTS scheme constantly reinforcing the fact that it is extremely difficult for IMG candidates to pass the CSA. The CSA seems to prefer GPs who may not have that good of a knowledge base with good communication skills to a doctor who is extremely good clinically who may have minor deficiencies with regards to communication skills. I have taken and passed the MRCPCH exams previously, never felt this bias so strong.’

‘I have passed several exams before including MRCP and USMLE CS exam. I feel that this is the only exam which is very unfair and biased for IMGs to fail rather than pass. Trainers don’t know about the marking system or have much deeper insight to CSA exam. They are still doing the old style COT traning which won’t prepare you exactly for CSA.’

‘My trainer signed me off for work placed based assessment. One PD said I had no problem with my clinical skills. I have been told my knowledge was very good. I am seeing up to 40 patients a day, sometimes more than the salaried GPs in my practice. I am asked to do a lot of paperwork that a partner does normally since a few partners left. I feel like I am being exploited by the partners and I could be kicked out of the programme if I failed again. I am forced to work like a partner without supervision but not good enough to pass CSA. I worked as a medical registrar before I joined GP scheme and hold MRCP (UK) and other higher qualifications.’

‘5x exams 1500 + courses + time and effort going to evening practice and weekend practice =nearly 9-10k spent in 1 year.’

‘I have spent 12,000 pounds for the exam and incurred debts and loans due to this exam. I had to do locum work as my pay was reduced by half and struggled all the way through till I passed. Now I'm the flavour of the month and everyone pretends this horrible journey of mine was an aberration and I should just forget about it all and move on which for the most part I have, but there have been many humiliations along the way to say the least.’

‘I spent nearly £4000 to take the exam twice (including courses/travel etc) not to mention the effect on my mental health!’

‘Ridiculously expensive exam, already spent more than £5000 in exam fees this yr to the college alone, not counting the expense of travelling to London from Glasgow, food, accommodation, etc.’

‘I am still in debt to the tune of about £10,000. I've been unable to pass the examination. I was born in the UK, trained in an English-speaking country. The exam is all a bad joke.’

‘Around 45,600 pounds has been spent by a cohort/batch, that joined in the same year, just for the exam fees. It would be more, if you include the different courses, travel, accommodation charges. It should have been around 14,000 pounds, if all had cleared in their first attempt.’

‘By the time I finished all the examination attempts and paid for different courses, books etc, I could not keep paying for my mortgage for the house as at the end I did not have a job and have to leave the training programme. I really hope somebody should look at this.’


‘I spent total about £15000 and possibly more if the agonising time and ordeal I went through is taken into the account.’

‘I have not gained nMRCGP after investing 42 months of my life. It’s indirect expense/cost - my friends who didn't go for GP training made easily £160,000 and more per year (without any stress or psychological trauma. We can multiply this with 3.5 years and find the loss !!!’


On April 26, 2013, BAPIO filed for stage 1 (permission) for Judicial Review by a High Court Judge of the CSA actor exam. The RCGP continues to affirm the exam is fair and denies the existence of unconscious bias. Sadly the CSA exam has failed both the British Medical Association GP Trainee Subcommittee Chair and the British Association of Physicians of Indian Origin GP trainee representative in the recent January-March 2013 CSA exam diet. Both are male Asian GP trainees. All the IMG GP trainee regional representatives on the BMA GP Trainee Subcommittee have also failed the CSA exam.