Tuesday, 29 October 2013

RCGP Hon Secretary Amanda Howe reminds CSA examiners to behave.

Today I received the most distressing message from my female IMG GP trainee who was reduced to tears by her new GP trainer on her extension, a CSA examiner. The CSA examiners were, 'keen to slag you and your course and your blog'. The GP trainee wrote how she felt 'sick and disgusted' to have to listen to them speak unprofessionally. 'I told them proudly that I attended your course and found it very useful.' Where others would sit in silence and hide the fact that they had attended my course, she bravely spoke out to defend her teacher. She had remembered her Hippocratic Oath. She is now so worried and stressed with her exam looming next month...

You read of her life story earlier on my blog on June 17 2013 and when I read this, I reached out and offered her a free place on my CSA course. She was born to be a doctor just as Paul Potts was born to sing. Let me remind you of who this wonderful good-hearted compassionate GP is...

'I was 9 years old when I decided to become a doctor, my mum used to have recurrent miscarriages...
my brother was born when I was 9 and I said I would love to be a doctor. When I was 12 years old, my sister was born and I became more determined I wanted to become a doctor...

I was like a mum to both my brother and sister, I cared for them while my parents were working full time as we were poor and needed the money...My dad used to be an alcoholic and spent his money drinking and used to argue often with my mum...I used to cry in silence...

Every time I had exams he would be drunk, break things and fight with my mum... I still managed to pass my exams with flying marks..I did not have a proper childhood, I was like a mum to my siblings and my only happiness was books...I went to medical school to fulfil my dream.. also I got a scholarship because I was one of the top students each year...

When I was on year 5 of med school, my sister who was then ten died suddenly... She fainted while playing outside and I was on my own, my dad had just gone to Greece that morning to find work as we were suffering financially..My mum was working a long shift...

I took my sister to a military hospital which was closer to my home, her heart was racing like mad...She had an ECG which showed severe arrhythmia... I was told to go to the main hospital... No transfer offered. I had to call my neighbour who had a car to take us to hospital...

All this on my own. My brother was staying with another neighbour, my mum was notified by work who would not allow her off till she finished at 10 pm.

When I finally got to the main hospital I told the A&E dr she needed intensive care, but they admitted her to a normal ward... The on call Dr was an old Dr and he was in a club drinking...

My sister was being cared only by nurses, it was Saturday night, not many staff...kept telling them she needed to be transferred to ITU, she was having chest pain and her face was soooo pale...

The nurses loaded her with iv fluids, I kept telling them no, as her heart was not right....
long story... But the next morning my sister 10 year old died from pulmonary oedema....

I decided to become a paediatrician and help kids... When I did my finals I managed to pass the entry exam for paediatric training...I had to leave my training in the last few months before becoming a consultant...I left Albania when I was 5 months pregnant when I came to the UK...
I worked so hard..And I have lots of experience, like paediatrics, derm, obs and gynae, GUM, general surgery. My interpersonal skills are excellent. Everyone compliments me for that.
In the last (CSA) exam I asked for a breakdown of the scoring, and I could not believe that in 3 stations, I had failed IP (interpersonal), when I thought I had done the best. There were stations where they had scored me as only 2/9.
...I have been 3 months without salary and I start my extension next week but my salary will be at the end of July, another month to struggle to feed my kids and pay the bills...'

This IMG who spoke English as a second language scored 82% in the GP applied knowledge test! She is a genius with a heart of gold. Allow this doctor a chance to sit a fair exam where she can show the world her caring doctoring skills. We call for an exam with real NHS patients and real illnesses, ie videotaping the GP in her work environment, treating ill patients, not a staged room with actors, hidden manuscripts and unchecked hidden biases behind closed doors with no videos for appeals.
I am sad that mere weeks before the next CSA exam diet commencing November 8, stressed and anxious IMG GP trainees facing their final CSA must be on the receiving end of 'badmouthing' of me by CSA examiners for speaking out and asking that all CSA actors and examiners be tested for 'unconscious racial bias.'
In 2010, I alerted the Chief Examiner Sue Rendel and RCGP Honorary Secretary Amanda Howe of specific instances in which GP trainees were sharing comments made in public by CSA examiners, running RCGP CSA courses, maligning my course, in particular. They both acted upon my concerns and gained my respect as female professional colleagues and holders of senior positions within the College.
'You are my saviour! Your teaching methods work without ANY doubt! I must add that previous RCGP courses that I had attended had also disapproved of your course! Absolutely outrageous and disappointing!'
'My registrars usually go and find out about your courses after hearing this. Those that have gone have given good reports, and passed csa. To be honest, consider it as free advertising,' Programme Director from Eastern Deanery.
'It is unfair for them to put your course down. I found it very helpful. I don't know what they are concerned about by people attending your course.'
'There is this one person who runs CSA courses and teaches you guys to say specific sentences which sound fake. We found that many candidates who went on HER course asked the same questions which doesn't make sense and hence they failed.' Witnessed verbatim testimonial from a GP trainee of an announcement made by RCGP CSA examiners running a RCGP CSA course. 
A GP trainee facing his 4th CSA named both Dr Paul Wilson and Dr Craig Kelly as the ones who announced at the start of the Croydon RCGP MRCGP Course attended by up to 60 GP trainees for the May 2011 sitting, 'Do not go on Una Coales course as the College does not approve of her teaching methods.'
The asian female GP trainee of Dr Paul Wilson sat down with this examiner and 'has been given reassurance that things are going to be resolved amicably. Hopefully we all can learn to be true professionals and do not bring our profession into disrespect.'
'Dr Craig Kelly was a Boston PD. The Boston pass rate is 20% this time. Certainly your pass rate is better.' GP trainee December 2010.
Dr Sue Rendel, Chief Examiner, contacted both Dr Paul Wilson and Dr Craig Kelly, and passed on their response (below) to me on December 22, 2010.

The General Medical Council code on working with colleagues states:

46. You must treat your colleagues fairly and with respect. You must not bully or harass them, or unfairly discriminate against them by allowing your personal views to affect adversely your professional relationship with them. You should challenge colleagues if their behaviour does not comply with this guidance.
47. You must not make malicious and unfounded criticisms of colleagues that may undermine patients' trust in the care or treatment they receive, on in the judgement of those treating them.
Sadly the blackballing of my CSA courses continued into 2011.
On May 3, 2011, a  London Deanery IMG male GP trainee facing his 4th and final CSA asked me 'not to tell anyone I have been on your course as there is a lot of pressure NOT to attend your course.' He had to hide the fact that he had attended my course from his GP trainer. He shared how his trainer bad-mouthed me and he had to interrupt her and say, 'I do not know this Dr Una Coales, but I see she has been made a fellow so why are you talking about her like this?' He explained that he had attended every other course but had come to me last because 'so many bad things were being said by examiners on the Croydon course about you and your course. They were actively discouraging people from attending your course and saying it was not just about passing CSA but about being a good GP.'

I commend Dr John Spicer Director of GP education and formerly Head of GP School at London Deanery (now called The London School of GP) for his acknowledgement and response to my concerns on behalf of GP trainees expectation of CSA examiners and trainers.

'Hi Una, What you describe is worrying. It's completely within any colleagues' rights to hold opinions about any provider, hopefully based on facts, but ill informed bad mouthing is not professional.

In fact we often (we being ARCP panels, senior trainers, etc) suggest to struggling trainees that one of the many courses out there (including yours) may be just what they need. Courses all have differing styles and one size does not fit all. I have heard positive comment from trainees of your work, as of others.

If there is a Deanery line, that is it. We can't be partial, but equally can't and should not criticise. I can't control the off-hand comments of all 600 educators in the network but I can say where I think we should be on it.'

Another GP trainee wrote me:
'One of the course organisers at Worcester VTS tried discouraging me from your course but she has not given me any feedback or organised any support for me.'
Fortunately this Oriental male GP trainee did attend my course against his course organiser's advice and passed his re-sit CSA May 2011 with a strong score of 80!
When I attended my Lambeth Locum Group meeting on May 11, 2011, I was equally surprised to hear from a newly qualified male Indian GP that he was 'surprised that the RCGP course examiners were speaking badly of you' and what 'surprised me even more, was that these were College examiners and I expected better behaviour from them.' He informed me he only knew of me from my revision books and it was a pleasure to finally meet me in person. He said 'they did not speak ill of any other course so was rather taken aback that they discussed you and your courses, and thought to myself, she must be a good course for the College to want to stop GPs from attending.'

In October 2011, I raised further concerns of unprofessional behaviour of a CSA marshall Dr Jim Bartlett to the College Secretary and Chief Examiner. His GP trainees informed me that he had called my course 'rubbish'.


Honorary Secretary Amanda Howe kindly sends an email reminder to all CSA examiners on my behalf


'Dear colleagues, I need to draw to your attention to some difficulties that have been raised recently concerning feedback from trainees and post MRCGP graduates that they have heard what they regard as inappropriate criticisms of different MRCGP course providers. I know it is a legitimate part of a trainer's role to advise AiTs on the option for MRCGP courses, and that you will have views on which may be best for them, but we rely on you to ensure that any recommendations you make are objective rather than personal. Some of this may be misinterpretation of remarks by trainees or others, but we do need to ensure that we acknowledge that all providers have a legitimate position in the market and that trainees can choose to attend any course which is available. Dr Sue Rendel has sent a similar email to the examiners whose concerns have also been raised. Many thanks for your reflection on this issue.' RCGP Honorary Secretary Amanda Howe, 14 October, 2011.

Doctors challenge unprofessional behaviour as per GMC guidance.

On 23/10/2013 at 01:12, I received a message from a white male London NHS GP, 'Hi Una, Clare Gerada (RCGP Chair) has started a thread regarding you on DNUK (doctors net) GP forum entitled 'Is it just me', quite distasteful and obviously seeking to distract from the recent CSA stories. Hope you are well.'

On 23/10/2013 at 14:19 a female Bristol NHS GP trainer wrote me 'Una - I saw the thread last night and I was really shocked at how unprofessional she (CG) was becoming. Now I don't agree with everything you say in your blogs but CG was obviously trying to rally people round to 'her side' by mocking you. I wrote on the thread saying that I felt I was in a school playground where one girl was trying to rally people around because she had been unpopular in the last few months. When I looked just now the thread had been pulled (by DNUK forum moderators) so clearly someone must have realised that it was unwise. Very poor behaviour in my opinion.'
It is now 2013, the CSA actors and examiners have still have not been tested for 'unconscious bias' with a test that have been available for free online since 2007, does not have a shadow observer examiner in each room, and the exam still does not allow GP trainees video access for appeals. All I ask is for a licensing exam that gives every GP trainee equal opportunity to show their doctoring skills so that they may continue to serve the NHS which is in desperate need of GP reinforcements.
This is not only about gaining membership into a Royal College but also about gaining a license to practice as a NHS GP, a career, a livelihood, the ability to support and raise a family as a GP! These doctors have given 3 years of dedicated service to NHS hospitals and GP surgeries and passed regular patient and trainer/supervisor assessments. In the US, family medicine residents may work as family practitioners upon completion of the 3-year residency programme without having to sit a board exam.
If the licensing exam could be reverted back to real patient videos, I would not have to read such sad messages as this:
'My husband is an IMG with post grad surgery and 20 years experience. He has been married to myself for 16 years. I have a Masters and I am a British UK graduate. His clinical skills are beyond reproach and his English perfect yet he still fails the CSA. The RCGP need to acknowledge Prof Esmail's finding and rectify this assessment - actors are NOT real patients. My husband even overheard one of the 'actors' saying to the examiner 'sorry I made a mess of that.' Stop ruining careers, marriages and families' lives.'

I commend a GP trainer who wrote me, 'I am a GP trainer in x. I have been asked to help a trainee who has been given an extension as he failed his CSA a second time. He is from X, but he is very good, and he is certainly patient-centred. I haven't got much time as just joined my practice and he is sitting his exam in November. I know it is a lot to ask but I was wondering if you could take him in your October course. I would like to come to observe with him. Thanks for your help even if you cannot accommodate us. Yours sincerely.' She was the first GP trainer who attended with her IMG GP trainee on extension earlier this month to learn first hand what exactly I did teach and how I renewed much damaged confidence in IMGs facing the actor CSA exam. She did not reduce her IMG to tears weeks before his CSA but gave him her full support and went out of her way to attend a CSA course with him to improve her GP trainee's unmet needs and her GP trainer's educational needs on CSA.
I commend the professional efforts made by RCGP Honorary Secretary Amanda Howe and Chief Examiner Sue Rendel. However in light of the upcoming Judicial Review, urge that they increase exam controls for bias by TESTING all CSA examiners and actors for unconscious bias and remove any extreme hawks or persons with strong bias from the CSA examiner and actor pool. All it takes is a 5 minute online valid Harvard Implicit Association Test to ensure the best impartial human judges in a subjective exam decide who becomes our NHS GPs to deliver safe, compassionate, nonjudgemental care to all Britons of colour, sex and religious creed.


If this blog article has touched you, please make a paypal donation to BAPIO (http://www.bapio.co.uk/contribute-towards-legal-challenge) so that they may raise £200k to bring this UK GP licensing exam to the Supreme High Court for full Judicial Review on behalf of the 100s of black, chinese, and Indian GPs who have been expelled for failing this CSA actor exam.