Monday, 30 September 2013

'Evidence of Racial Bias in MRCGP CSA exam claims author of independent GMC review'

Subjective Bias Due to Racial Discrimination

'Conclusion: Subjective bias due to racial discrimination in the clinical skills assessment may be a cause of failure for UK trained candidates and international medical graduates.’ Prof Aneez Esmail, BMJ online, 26 Sept 2013.

According to the RCGP Impact Report 2013, 'Since October 2012, the College has received a number of legal challenges to the Clinical Skills Examination (several Employment Tribunals and a Judicial Review). The GMC is also subject to similar legal proceedings'.
World-renowned racism expert Manchester University Professor Aneez Esmail was commissioned by the General Medical Council to conduct an independent review of the Membership of the Royal College of GPs Clinical Skills Assessment (CSA) GP licensing exam.
On September 26, 2013, the release of Prof Esmail's GMC report (restricted by its narrow terms of reference) coincided with both the release of his academic paper on CSA (no restrictions) in the British Medical Journal 'Academic performance of ethnic minority candidates and discrimination in the MRCGP examinations between 2010 and 2012: analysis of data' and the British Medical Journal Careers investigative report 'white doctors are three times more likely to land hospital jobs than ethnic minority doctors.'

Update October 13, 2013:

'Britain's leading medical journal was threatened with legal action by the family doctors' professional body (RCGP) over a report that considered whether there was racial bias in the way that trainee GPs are examined.'


What is subconscious bias and how may it affect GP licensing exams and future patient safety if the licensing exam is not adequately controlled for bias?
Here is a classic example of the dangers of positive subconscious bias in action. Have a look at this photo of a kind caring face with spectacles and showing silver streaked hair and beard.
Why did elderly vulnerable women trust Killer GP Dr Shipman?

Because he triggered positive subconscious bias of trustworthy and endearing Father Christmas. They could not help themselves but to trust a man who reminded them of paternal Father Christmas.
I present an argument that the extraordinarily high CSA pass rate of 96% for white UK GP trainees in the actor CSA exam  may be influenced by positive subconscious bias as most of the actors and examiners are also white British and in one on one 10 minute stranger encounters between a white GP trainee and one white examiner and one white actor behind closed doors, hidden biases may not be adequately controlled.


Why is the ethnic minority pass rate for CSA so low? The Irish GP trainee pass rate much lower than for Welsh, Scottish and English GP trainees? I suggest this may be due to accent bias as well as negative subconscious bias.
On September 25, 2013 ITV broke the news that 28% of Britons felt discriminated against based on accents. A poll showed that a received pronunciation (Queen's English) was perceived as the highest for intelligence and a Liverpool accent (the lowest for intelligence, most untrustworthy and most unfriendly).
As a GP educator, I have found GP trainees come to me as resits who speak fluent English but with an Indian accent, a Caribbean accent, a Chinese accent, an Irish accent (white Brit males), a Birmingham/Manchester/Liverpool/Cockney/South London accent (asian Brits) and by asking them to change their accents to received pronunciation or posh, their scores have dramatically increased and they went on to pass CSA.
I strongly urge the RCGP to improve controls for bias by adopting the old MRCGP viva exam method of having 2 examiners per station to reduce bias and allow candidates to sit the exam, either in Edinburgh or in London to reduce regional accent bias.
Having sat the FRCS viva exam myself numerous times unsuccessfully in London, a white female consultant surgeon advised I sit the FRCS exam in Ireland or Edinburgh. I questioned why? I passed the written paper in the FRCS exam in London with a perfect 9+ score but kept failing the viva in London, even though at one time I wrote down all the questions and my answers to prove to myself after the exam that I had answered all the questions correctly yet still received a clear fail?! So I took her advice and flew to Scotland and sat in Edinburgh. The Scottish male consultant surgeons (a mix of white Scottish and Indian) awarded me a merit pass for answering all my viva questions correctly instead of a clear fail which had been the case in London with all white English male consultant surgeons. The only difference was location of exam and the nationality of the examiners, as I was the same individual, an ethnic minority female doctor.

What is negative subconscious hidden bias?

When you see an Indian in a turban with a long beard, who does your subconscious mind see?

How can Sikh GP trainees sit the CSA exam if subjective bias in not adequately controlled, if the white examiners and white actors are not tested for susceptibility to subconscious bias with the Harvard Implicit Association Test?
A 31 year old Sikh Columbia University Professor is attacked and name-called Osama.

Miss America Indian Nina faces abuse and is accused of being Al-Quaeda and a terrorist on public twitter.

I leave you with this youtube video of a social experiment of the white girl, white boy and black boy, all posing as bicycle thieves. A white male stranger even helps the white blonde girl steal the bicycle even though she makes it clear it does not belong to her. The RCGP CSA exam pass rate for white UK females is an incredulous 98%. Why does the RCGP refuse to release videos of the CSA stations for appeals? Are some white actors and white examiners prompting white female candidates?
Please watch the social bicycle theft experiment.

A heartfelt plea from an ethnic minority Asian GP trainee:

'The College is never going to acknowledge hidden bias .The only way of eliminating this is by use of video recording, 2 examiners and increasing diversity of actors and examiners.

This exam does not reflect true UK general practice as it claims. I have very often done sessions where 100% of my patients were ethnic minorities or east europeans as they felt more comfortable talking to an Asian doc.

Are the failure rates the same for MRCGP taken internationally. Those countries would probably scrap these exams if the failure rates were the same. But perhaps the failure rates are low because they are designed to see actors or even real patients which reflect the diversity of their patients. What would the failure rate be if these UK CSA was applied overseas......the results are predictable. Doesn't mean they are bad doctors!!!

Hidden bias is natural but as practising doctors we never let this affect our consultations. I respect all my patients and try to understand them no matter what the age, colour, sex or ethnicity. I enjoy my everyday consultations even though I have failed my CSA because I value every human being.......I have tears in my eyes when writing this....have to stop.'

A heartfelt plea from a white UK GP trainee:

'Just want to say how very sorry I am and how much I think of all of you who have failed the CSA. I will never forget the IMG trainee in my practice who broke down, distraught at her 3rd 'failure'. What kind of system - what kind of country - allows doctors to get this far only to dump them?

The public might think that there is a generic 'doctor' but the reality for a failed GP trainee is dire. Who can count the hours of work, study and financial cost? Who can imagine what it feels like that an exam score - remember it is only about one third of the entire MRCGP assessment - decides a person's fate and livelihood? There is no easy future.

I'm a white UK GP trainee and I am ashamed at how you are treated. I know that a London medical school was shown to use racially biased selection:

Even now international students suffer the cost of re-sits at medical schools too. The medical schools don't do much with the extra cash whereas they perhaps should be fined for not delivering the teaching these students have paid for - or the exam system that fails them too.

This is something we must all fight against and it is not enough for the RCGP to say the CSA is not biased: it must be shown - without doubt - to be unbiased. I urge Clare Gerada to back down: please face the reality, apologise and move forward for the sake of the desolate plight of our colleagues.'

A NHS consultant psychiatrist makes October 1, 2013 a day to remember

'You have seen the recent message from BAPIO's President Dr Mehta (NHS Consultant Paediatrician) about donating one day of your salary towards the CSA campaign. I hope this gesture inspires all of you to do the same. It has inspired me for sure and I have donated one day of my salary. Not just any day but I have donated my salary for a specific day - 1 October 2013. It is the start of a new month, so I thought it would be great to start a new month with a gesture of this nature.
How often are we part of something this important? (Hope you have all read the recent BMJ report by Aneez Esmail). So as I drive to work on Tuesday, 1 October, I will experience a deep sense of satisfaction because I have been able to make use of this opportunity to contribute towards an issue that is very important in nature. And I will feel connected to everyone who strives for equality and fairness.
As I get through work, see my patients, attend meetings, etc on 1 October, I will feel part of something special because whatever I earn on that day will go towards a worthy cause. And as I leave work at the end of the day, I am sure to feel a sense of accomplishment.
I am a Consultant Psychiatrist, so the CSA issue does not affect me at all - or does it? Actually I think it does because it is not just about passing an exam - it is about the principle of fairness and equality and I believe in it. Not special treatment but fair treatment. I eagerly look forward to 1 October. I hope you will make it your special day as well by donating one day of your salary.
If there ever was a time to stand up and be counted, it is now. If there ever was a time to get involved, it is now. The time for massive action has arrived. Let us make the most of this opportunity.

Best wishes'