Best of British: the NHS was celebrated at the Olympics Opening Ceremony. But is there still a white bias for doctors? Photo: Getty
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White GPs have a far higher exam pass rate than black or Asian ones

In his Health Matters column, Dr Phil Whitaker discusses how the Royal College of GPs came under attack for possible discrimination. 

The Royal College of General Practitioners (RCGP) was at the high court last month, defending itself against allegations of racial discrimination. At issue was the college’s clinical skills assessment (CSA) examination, which all doctors must pass in order to practise independently as GPs. Roughly 94 per cent of white British doctors pass the CSA first time, whereas for black, Asian and minority ethnic (BAME) British doctors the rate is only about 75 per cent. The statistics are even worse for international medical graduates (IMGs – doctors who qualified at medical schools overseas), with just over half passing at the first attempt.

A possible explanation for these stark discrepancies could have been racism. The British Association of Physicians of Indian Origin (Bapio), which sought the judicial review, argued that the way the CSA examination is conducted leaves it open to discrimination. Candidates are faced with a simulated surgery, 13 different ten-minute cases coming one after the other. The patients are actors who play out carefully crafted vignettes, designed to test specific aspects of good medical practice. However, there can be no precise script: the actors’ responses will vary according to the way each candidate conducts the consultation.

Performance is assessed by examiners who are experienced GPs. Bapio’s contention was that the actors, or the examiners, or both were biased against BAME candidates. The RCGP countered that its equality and diversity training guarded against such a possibility and cited the excellent results achieved by many BAME and IMG candidates as evidence that no discrimination exists.

The judgment went in the college’s favour, Mr Justice John Mitting ruling that the CSA was not discriminatory. However, he ordered the RCGP to investigate the reasons for the stark differences in pass rates. It seems likely that as a result the spotlight will turn from the CSA to shine more broadly on the way GPs are trained.

Two-thirds of the marks in the CSA are awarded for what might be termed the pure medicine: arriving at an appropriate diagnosis and formulating a reasonable plan of management. Any doctor sitting the CSA – which is taken towards the end of a three-year programme of postgraduate training in general practice – has already passed other written examinations that assess this academic knowledge. The other third of CSA marks reflects consultation skills, including exploring the patient’s ideas regarding the symptoms; understanding and responding to the impact the illness is having on the person’s life; and incorporating, where possible, the patient’s preferences into the management plan.

The CSA examines not just knowledge but also the doctor’s skills in applying that knowledge to “real-life” situations. This is the doctor as “knowledgeable partner” rather than didactic expert – no decision about me without me.

Such “patient-centred” practice is relatively new and requires highly developed communication skills to pick up the nuances behind what people say. Britain has been at the forefront of its development but around the world much of medical education is still very “doctor-centred”, with the expectation that patients will gratefully fit in with how their physician chooses to do things. IMGs, whose basic training is likely to have been in medical schools rooted in doctor-centred cultures, may find patient-centred practice profoundly alien; and this goes equally for British-trained BAME doctors raised in doctor-centred subcultures.

The CSA may be exposing a fundamental problem with GP training. Every trainee has an experienced trainer who oversees their development. Trainers are expected to conduct frequent workplace-based assessments of patient-centred consultation skills and to review progress every six months. Ultimately, if a trainee is experiencing intractable difficulties, the trainer is expected to report this for further action.

There should, in theory, be ample opportunity to remedy problems well before the CSA. The current discrepancies in pass rates suggest that this isn’t always happening.

This may indicate that grass-roots training hasn’t universally evolved to match the expectations of the RCGP or there may be more difficult issues. The relationship between trainer and trainee is forged over a relatively long timescale and many trainers find the collision of roles – friend, colleague, mentor, assessor and, ultimately, police person – to be uncomfortable.

Difficulties that have their roots in cultural differences and language skills are particularly sensitive and there may well be a reluctance to escalate them (the Bapio action illustrates how the spectre of racism allegations hovers over these issues). If a trainee is medically competent but is failing to consult in the expected manner, a trainer may find this too potentially explosive to raise, and rely on others to tackle the problem instead.

While finding for the RCGP, Mr Justice Mitting praised Bapio for bringing the action, saying that he believed it would ultimately benefit medicine. At present, some doctors are being failed by the system, which is ruinous to their careers and emotional health. In resolving this, a better, more open system of GP training and assessment must surely result.

This article first appeared in the 01 May 2014 issue of the New Statesman, The Islam issue

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The most terrifying thing about Donald Trump's speech? What he didn't say

No politician uses official speeches to put across their most controversial ideas. But Donald Trump's are not hard to find. 

As Donald Trump took the podium on a cold Washington day to deliver his inauguration speech, the world held its breath. Viewers hunched over televisions or internet streaming services watched Trump mouth “thank you” to the camera, no doubt wondering how he could possibly live up to his deranged late-night Twitter persona. In newsrooms across America, reporters unsure when they might next get access to a president who seems to delight in denying them the right to ask questions got ready to parse his words for any clue as to what was to come. Some, deciding they couldn’t bear to watch, studiously busied themselves with other things.

But when the moment came, Trump’s speech was uncharacteristically professional – at least compared to his previous performances. The fractured, repetitive grammar that marks many of his off-the-cuff statements was missing, and so, too, were most of his most controversial policy ideas.

Trump told the crowd that his presidency would “determine the course of America, and the world, for many, many years to come” before expressing his gratefulness to President Barack Obama and Michelle Obama for their “gracious aid” during the transition. “They have been magnificent," Trump said, before leading applause of thanks from the crowd.

If this opening was innocent enough, however, it all changed in the next breath. The new president moved quickly to the “historic movement”, “the likes of which the world has never seen before”, that elected him President. Following the small-state rhetoric of his campaign, Trump promised to take power from the “establishment” and restore it to the American people. “This moment," he told them, “Is your moment. It belongs to you.”

A good deal of the speech was given over to re-iterating his nationalist positions while also making repeated references to the key issues – “Islamic terrorism” and families – that remain points of commonality within the fractured Republican GOP.

The loss of business to overseas producers was blamed for “destroying our jobs”. “Protection," Trump said, “Will lead to great strength." He promised to end what he called the “American carnage” caused by drugs and crime.

“From this day forward," Trump said, “It’s going to be only America first."

There was plenty in the speech, then, that should worry viewers, particularly if you read Trump’s promises to make America “unstoppable” so it can “win” again in light of his recent tweets about China

But it was the things Trump didn't mention that should worry us most. Trump, we know, doesn’t use official channels to communicate his most troubling ideas. From bizarre television interviews to his upsetting and offensive rallies and, of course, the infamous tweets, the new President is inclined to fling his thoughts into the world as and when he sees fit, not on the occasions when he’s required to address the nation (see, also, his anodyne acceptance speech).

It’s important to remember that Trump’s administration wins when it makes itself seem as innocent as possible. During the speech, I was reminded of my colleague Helen Lewis’ recent thoughts on the “gaslighter-in-chief”, reflecting on Trump’s lying claim that he never mocked a disabled reporter. “Now we can see," she wrote, “A false narrative being built in real time, tweet by tweet."

Saying things that are untrue isn’t the only way of lying – it is also possible to lie by omission.

There has been much discussion as to whether Trump will soften after he becomes president. All the things this speech did not mention were designed to keep us guessing about many of the President’s most controversial promises.

Trump did not mention his proposed ban on Muslims entering the US, nor the wall he insists he will erect between America and Mexico (which he maintains the latter will pay for). He maintained a polite coolness towards the former President and avoiding any discussion of alleged cuts to anti-domestic violence programs and abortion regulations. Why? Trump wanted to leave viewers unsure as to whether he actually intends to carry through on his election rhetoric.

To understand what Trump is capable of, therefore, it is best not to look to his speeches on a global stage, but to the promises he makes to his allies. So when the President’s personal website still insists he will build a wall, end catch-and-release, suspend immigration from “terror-prone regions” “where adequate screening cannot occur”; when, despite saying he understands only 3 per cent of Planned Parenthood services relate to abortion and that “millions” of women are helped by their cancer screening, he plans to defund Planned Parenthood; when the president says he will remove gun-free zones around schools “on his first day” - believe him.  

Stephanie Boland is digital assistant at the New Statesman. She tweets at @stephanieboland