Monday, 21 October 2013

How black and ethnic minority GPs can and have controlled unconscious bias to pass the Royal College CSA GP exam.

One human race; one humanity; one global conscience;

one caring medical profession who swore an oath:

'I will keep them from harm and injustice.'

After reading a heartwrenching narrative of a 42-year-old Indian male GP who failed his CSA actor GP exam three times by 1 mark and was then expelled even though he had completed his 3-year UK GP training programme with an average NHS patient satisfaction score of 4.8/5 seeing 40 patients a day and is now resigned to working as a junior foundation year hospital doctor and taking SSRI antidepressants as he will never be able to work as a GP, I have decided to share my tutorials with the world so that the 100s of ethnic and black GP trainees who face their CSA exam resits next month, at least stand a chance of passing and learn how ethnic minority and black GP trainees may and have passed CSA first time or last time with extremely high scores.

How to pass the Royal College of GPs actor CSA exam as an ethnic minority or black GP trainee

Ethnic minorities and IMG doctors have long served as the backbone of the NHS. If the CSA exam keeps failing huge numbers of GP recruitments for the NHS, the NHS will collapse faster and be fully privatised as early as April 2014. To retain independent contractor status of GP partnerships, we must fight to ensure not only our white UK but also our British ethnic minorities and IMG GPs complete their UK GP training, pass their exit exam and fill locum posts or vacant GP partnerships immediately to replace GPs who have taken voluntary retirement or emigrated. It behooves you all to help your BMEs pass CSA. With a national shortage of GPs hastened by the lack of GP recruitment, comes the demise of general practice, followed by the closure of NHS hospitals, followed by the end of the NHS and the fulfillment of privatisation.

What is unconscious bias? Watch Yale Professor of Psychology Banaji and Washington University Professor Greenwald explain unconscious preference for whites (good) over blacks (bad), as they demonstrate the Harvard Implicit Association Test to determine degree of unconscious racial bias in a white civil rights lawyer and a white schoolteacher who are unaware they have strong unconscious hidden racial bias!

I gave a presentation to 40 London Deanery Programme Directors in October 2012 to raise awareness of the possible effects of blues eyes, brown eyes and unconscious bias in the CSA exam and suggested they each took the Harvard IAT test but this time swap the photos of the white and black persons with a blonde female doctor (good) and an asian male doctor (bad) and see how they fared when the blonde female doctor was associated with the word (bad) and the asian male doctor with the word (good) and showed them these random photos. I was met with hostility from the audience! And one female Asian CSA examiner PD in the audience exclaimed, 'If I met you in CSA with your 6 inch heels and face full of make up, I would be intimidated!' She had revealed her strong unconscious bias as I was not wearing 6 inch heels nor did I have a face full of makeup but her hatred came to the surface publicly in front of 39 other GP programme directors and it is not surprising that the CSA pass rate for a 'chinese IMG' like myself (Korean IMG) is the worst at only 25%. And indeed a chinese male IMG (who had been a fellowship examiner in oral dentistry prior to changing careers) was kicked out after failing his 5th CSA (a 5th sitting granted with support by his Dean) by one mark.

Now do the free online Harvard Implicit Association test yourself for hidden racial bias. It only takes 5 minutes as you whizz through the 7 online tests to determine whether you have a 'strong' preference, a 'slight' preference or 'no automatic' preference (ideal for judges, examiners, interviewers, assessors, police, teachers one might argue) for one race over another. I scored slight preference for whites over blacks myself (got one cross in just one of the 7 tests). I had asked the RCGP repeatedly to test the CSA actors and examiners with this free online Harvard IAT test and remove those who scored extremely high or 'strong' preference for one race over another.

What other biases may be at play in CSA?

Outcome bias - because the pass rate is so low for IMGs, IMGs must be bad.
Priming - examiners may be primed to find flaws in IMGs so they found them.
Intraobserver bias - one examiner assessing the IMG may be influenced by how others, ie white GP trainees perform in the same case.
Flaw of law of small numbers - CSA judges an IMG based on 13 CSA actor role plays over 3 hours vs 3.5 years of the IMG consulting and treating 2,000 real NHS patients safely.
Illusion of validity - that to assess an IMG in an artificial CSA setting over 3 hours, the forecast of success of a GP in real life may be argued as no better than a blind guess vs regular feedbacks from educational and clinical supervisors and GP trainers over 3.5 years.

To read the full tutorial, please purchase my book Dr Una Coales's MRCGP CSA book sold exclusively on


I wrote all my tips to control foreigner/ethnic/black bias in my 2nd edition of Dr Una Coales MRCGP CSA book in hopes of ending the huge failure rate among ethnic (Indian, Chinese) and black GP trainees in CSA, to stop good doctors of colour sinking into a dark hole and ending up on antidepressants with their lives as GPs terminated because they could not pass a subjective actor CSA exam with inadequate controls for unconscious bias.

My tips have helped 100s of ethnic and black GP trainees finally pass CSA. Many came to me first and passed their first attempts.  These tips to control subjective unconscious bias against ethnicity ie race, raised CSA marks from 55 (fail) to 85 (pass), 78 (fail) to 87 (pass), 67 (fail) to 91 (pass) and allowed ethnic GPs to score 106 as a female Asian and 101 as a male Asian.

If you can pass as a posh Brit Asian in each of the 10-minute observational assessments by 13 stranger white British actors and 13 stranger British examiners you have improved your chances of passing CSA from 15 times more chance of FAILING to 4 times more chance of failing, okay not perfect but it has helped many a black and ethnic GP trainee finally pass their CSA to continue to work as a NHS GP in the short 18 months they are given to pass the actor CSA GP exam.

Until Judicial Review changes the GP CSA actor exam and puts in place adequate controls for bias, you must change to pass CSA especially if you are a doctor of colour or IMG who has failed repeatedly and face the end of your career as a NHS GP next month!

I leave you with the actual narrative of Indian GP Dr Ram and dedicate this blog article to him and the many 100s of Indian GPs out there who face the end of their NHS careers because of this CSA exam. I am sorry I could not reach you all in time. Please share this blog article with any ethnic or black GP trainee facing CSA.

'I have appeared for CSA three times, each time failed by 1 mark. After my 2nd failure I worked very hard. I practiced lots of consultations and was seeing 40 + patients every day. At times I was the only Dr available and patients and practice staff were very impressed by my commitment. My PHQ score was 4.8/5 above UK average. I diagnosed numerous conditions like bowel and lung ca, type 1 DM & coeliac, P.E, HSV encephalitis, depression, PCP pneumonia in HIV and many more & felt proud to have saved lives. In my 3rd attempt at CSA the actor gave me wrong findings and was corrected by the examiner in the real exam!!! Also in telephone consultation the sound quality was very poor. Unfortunately I failed by 1 mark. I raised the above issues in my exam with the RCGP who sent me a letter stating that they cannot do anything now but are happy to give me an additional chance at the exam if my deanery supports my application. Well the deanery unfortunately refused to support the application and now I am kicked out of training. I was at home for 3 months without a job and now an FY2 locum in A & E. I am currently also taking antidepressants and trying to salvage my relationship from falling apart. I have spent about 20,000 pounds for CSA. (This includes 8 CSA courses with the college).

I think I did everything I could to pass this exam. I feel the exam lacks objectivity and depends on role players and actors. Why don't they use some real patients?? The actors mistake ruined my life/ my career.

I have not gone to the practice since being out of GP training, too embarrassed. Staff and patients will be shocked that I can never work as a GP for them. I was the best. Can anyone advise me regarding my career development?? I am 42 years old. Thank you, and God bless you all, ram.'

When an Indian GP on the BMA sessional GP subcommittee asked me, 'why do you help these Indian doctors? Do you have an Indian relative?' I replied, 'I have no Indian relatives.' And my answer to all of you is, 'I do this, because it is the right thing to do.'



On October 25, 2013, the British Medical Association announced their full support for BAPIO's High Court challenge against the CSA exam and will provide an impact statement for Judicial Review.

On November 8, 2013, the British Medical Association donated £25,000 towards BAPIO's High Court Judicial Review of the CSA exam and asks GP trainees to click the email link on their website to share their CSA experiences for the impact statement for Judicial Review and hosts the link to BAPIO's paypal donation page.

On November 13, 2013 a male IMG who just sat his 3rd CSA writes me, 'I feel my life will end if I fail the CSA...My wife is trying to console me in vain.'

Many BMEs/IMGs have told me they have resigned membership of the RCGP once they have passed their CSA and gained their CCT or CEGPR or their FRACGP in Australia. It may be worthwhile for the College to implement changes to the exam like videotaping of stations for a fair appeals process, 2 examiners per station to reduce observer bias and testing of all actors and examiners for unconscious bias, ie unconscious racial preferences and selecting those with no preference for race. Continued membership to the RCGP is optional and not mandatory to work in the NHS as a GP once you have your CCT or CEGPR.

UPDATE November 2014: One of the Indian male GPs in a photo in this blog article has now packed and is taking his young family to Australia, leaving behind the 'socialist' NHS for freedom to practice medicine.


In April 2014, one white posh High Court Judge deemed the CSA a fair exam and stated he did not believe in unconscious bias. This means the exam continues without testing of actors or examiners for unconscious bias and male BMEs/ IMGs still write me that they keep failing CSA by 1-2 marks. Now even after passing AKT and CSA, one educational supervisor may decide not to sign off a GP trainee at the end of training! My advice at this stage would be to consider legal representation if this is an employment matter or simply go into private practice without MRCGP or a CCT. CCT is mandatory to work as a NHS GP but not as a private doctor. Some doctors go straight into private practice with an MBBS after completing their foundation years.

Please consider carefully whether as an IMG or BME, you wish to embark on GP training as you are sitting an exam which fails 15x more IMGs than white British, which does not record stations for fair appeals, has a marking system in which one extreme hawk may score you 0-1 marks out of 9 which may skew your overall marks to a fail, and examiners may not be scrutunised in a formal college appeal.

If released your options are:

The GP specialist application advises:

'You are eligible to apply for a CEGPR if you have completed a period of at least six months specific training in general practice.

An application for a CEGPR is both time consuming and costly so we encourage applicants to read all the published guidance first, and to consider very carefully whether they have some prospect of success before deciding to pursue this route. Please be advised to read the Specialty Specific Guidance. Page 5, paragraph 7 deals specifically in relation to your situation.

We also suggest to applicants who have trained in the UK that they should not simply provide evidence of their training programme and the failed assessment. It is important to show that they have improved their performance and rectified the deficiencies, keeping in mind the requirement to demonstrate that they have achieved the standard of the CCT and the general practice curriculum. This might be through further learning and validated, objective assessment since release from training but there are no prescribed ways of doing this. Some doctors have considered applying for training outside the UK and returning to apply for a CEGPR, others focus on evidence of learning in current clinical work. Again, there are difficulties with the latter as the doctor is no longer working in general practice.

I hope this advice is of some help in deciding whether to make an application.

Yours sincerely,

GP Specialist Applications Team
30 Euston Square
Tel: 020 3188 7656'

Or you can just go straight into private practice like Dr Chiara Hunt with MBBS (the RCGP cofounder's granddaughter) or Dr Leah Totton MBBS, as you do not need MRCGP or GP CCT (certificate of completion of training) outside of the NHS. You may wish to join the Independent Doctors Federation for annual appraisals and revalidation.

Update 2016

CSA continues to prevent some junior doctors from becoming NHS GPs. Please take this into consideration if you decide to apply for GP training.