Friday, 6 December 2013

As Nelson Mandela dies, the actor CSA exam continues to fail African and Asian GP trainees after 3-4 years service for the NHS

How do we stop grown men weeping?




          "Any man or institution that tries to rob me of my dignity will lose" - Nelson Mandela

As the world mourns the death of a great anti-apartheid leader and past President of South Africa, I continue to receive heart-breaking emails from African and Asian GP trainees who have been failed in the November CSA actor exam and face expulsion after 3 years of NHS service in a UK GP training programme (family medicine residency). This has started a move for worldwide contributions, the latest from an American physician who is dismayed at the effects of repeated failures of an actor exam. The trauma these black and ethnic IMG trainees are experiencing from repeated CSA fails, ARCP panel referrals and interrogation, and outcome 4 expulsions has on doctors of colour is, in my opinion, verging on inhumane. Here are some of their testimonials that I continue to receive in shock that this unintentional apartheid still exists in 2013 in NHS GP training.

Young 'Nelson's' story:


'I am 31 years old, of Nigerian origin, came to the UK at the age of 10 years old, only child of a single parent mum, who worked her way up the ladder from doing 2 jobs to being a lawyer. I did my primary, secondary (GCSE English Grade B) and college education in London at the City of Westminster College.

My mum then sent me to the Ukraine to study medicine as she thought it would be good for me to break away from Hackney, become independent and as she also studied in Ukraine, she knew that their Universities were good. Spent 7 years in the Ukraine, did my medical degree in English. It was a challenging but an important life experience for me. Occasional you may experience discrimination but overall they were nice people and keen to adapt to International student needs even though we were not citizens. However there is no place like home and I was so happy to return to the UK in 2007 where I am a citizen, expecting to be treated fairly and ready to exhale. Unfortunately 1 month after my graduation, my mum (God bless her soul) died of ovarian cancer. As the only child, I had to pick up the pieces, dealing with funeral arrangements, solicitors, registry office and tax office. The first class care she received from her GP and my natural inter-personal skills made me decide to become a GP.

So like others, I did my PLAB/IELTS and FY1/FY2 training posts in Yorkshire and Hull. I then did my GP entry exam and got my second choice. Having spent 3 years of my life in GP training in Hertfordshire, excited about the future and playing my part within the community and done everything and more that they have asked me to do. Then to be told that I can NOT communicate or MANAGE a patient and further more I might be made unemployed in 6 months and referred to the GMC for not passing CSA. It is a miserable situation and outcome.

My trainer is herself a senior GP partner, white female CSA examiner and TPD and they had offered me a job which is now on BMJ awaiting another doctor to collect. I had also been offered another job elsewhere after a recommendation by a white OOH doctor and I had to undergo an interview with a panel of 5 white GP partners and was given the job the following day.

Only to be stopped on my tracks by the CSA exam and of course with the financial, psychological and social meltdown. It is like watching my life sip away from you, heart-breaking. I am the only black doctor in my training scheme and the only one that did not finish this August. Yet I was the one alone with a chinese doctor who did a 3 hour CSA teaching session to the ST1 which was supervised by two TPDs who only had positive comments and recommending becoming a trainer in the future.
Having read the above, the only QUESTION that remains is, if I can not communicate, how did I get to this stage in my life ???

I will of course be praying and trying to improve where needed, do sit-in's and during my personal study. I will be sitting in with my trainer to watch her consult new cases from scratch, so I can learn from her skills, an idea which I had suggested to the panel and they thought it was an innovative idea.


Having read your post 'CUM SCIENTIA CARITAS', I think you are first class and I am encouraged by your continued discovery of inner strength.
I will continue to fight for change but whether I stay to practice as a GP in the UK...it is clear that we are not all equals in their eyes.'

'I have a dream that my four little children will one day live in a nation where they will not be judged by the color of their skin but by the content of their character.' - Martin Luther King, Jr.



December 3, 2013


'Unfortunately, They failed me by 2 marks, even though I scored higher than previous and had no crosses on the clinical management. I just give up and don't know where to go from here. I am completely flat.

I have still got one more chance but I have no hope as am at their mercy. I have suffered so much. Just don't know what else I can do.'

He faces interrogation by his Deanery ARCP panel a week before Christmas 2014. Many IMGs are now being summoned to their panels to receive an outcome 4 'release from training'. It is a sad Christmas for him, his wife and their 4 month old baby boy as he faces joblessness, debt and the prospect of the end of his GP career due to an actor exam.



Weeping Mother Mary

His mother died of ovarian cancer and was well treated by the NHS, but this left him orphaned as a medical student. He has struggled to become a GP on his own. Allow him to fulfill his calling.

 'I am so low and practically crying in private every day. Simple things like looking at my thermometer or otoscope make me sad. I am still waiting for the panel appointment and trying to get permission from the College to reapply for the CSA exam. Even though I have only applied for the exam 3 times, it read that I have sat it 4 times on my e-portfolio because of the re-sit of an attempt when the college invited me to re-sit due to technical errors.'

US Physician donates to BAPIO after receiving a long distance call from his Indian brother weeping for the first time in his life after failing CSA again.


'I am a physician working in United States. I found your e-mail today after randomly surfing the web this afternoon. I will greatly appreciate if you would please advise me about my elder brother's situation.

He is an IMG from India. He moved to United Kingdom about 8 years ago. After working for several years under different positions he started GP training in year 2010. I was under the impression that he is doing well there as a GP trainee, till this afternoon when I received a call from him and for the first time in my life I heard him weep, which literally sank my heart. For so many years he kept it to himself that he has been struggling very hard for so many years and is under huge debt now. He is 39 year old, very hard working, sincere and honest.. He told me today that he failed the CSA exam for the second time today.  Apparently, there is a limit of four attempts per exam and he will be removed from training anytime now. He is on some kind of extension of 6 months.

As his brother, obviously this is a huge shock to me and I spent the whole day today surfing the net and found that a large number of IMGs are struggling in UK. I want to help my brother to the best of my ability. If you could please advise me on his situation.

I looked at BAPIO's website www.bapio.co.uk; will contribute $1000 and spread the word among my colleagues. I will probably donate another $1000 after a few weeks.

It appears too harsh to train a person for so many years and then just throw them out.

Thank you for all your work for the IMGs.'

Asian IMG GP trainees band together to donate between £500-£5000 to the BAPIO CSA Judicial Review scheduled for early 2014.


'Just to let you know that I practiced for the CSA with 4 other IMGs. It was our 3rd attempt. We all 5 passed by the grace of God. Today we got together and decided to donate £500 each to BAPIO. One of us will donate £5000. Thanks for supporting people in difficult times.

We all are from poor families. Doing locums every day in A/E since sat CSA. The one who is giving £5000 is also the sole earner in the family and still in debt but he strongly believes that CSA is an unfair exam and BAPIO should be supported at JR.'

Nelson Mandela was the greatest anti-apartheid leader! We must not let this actor CSA exam lead to an unintentional apartheid in our GP profession! Cum scientia CARITAS! And our profession may be severely lacking in caritas with the continuation of the actor CSA exam. Never before in all my years as a doctor both in the US and UK, have I ever come across so many depressed and suicidal black and ethnic minority doctors who weep as they cannot pass the actor CSA exam. Please, please give them a humane option such as video submission of NHS surgery consultations with real patients with real illnesses. The post traumatic stress, chronic anxiety and nerves make it virtually impossible for them to show their true abilities in an artificial setting with actors faking.

Update May 2014


Post the CSA Judicial Review in April 2014, our young 'Nelson Mandela' has passed CSA in May with flying colours! I am so glad that he may now dry up his tears and finally be recognised for the truly remarkable GP that he is and was born to be. His late mother in Heaven will now rest in peace. His diverse patients will be safe and well looked after.

'Dear Una,

How are you getting along? Just a thank you message for all your endeavours and support for myself and all IMG's. Sorry to read your blog about your difficulties before you resigned from the college. Be rest assured that there are a lot of BME trainers now and the trend will have to stop..it may take years...our children who will grow up in a more diverse society will bring about change too.

Finally, I am pleased to inform you that I have passed my CSA exam with flying colours!!! I only got 4 crosses across the whole board and a score of 92. To God be the glory.

Take care.'