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.