Dr Pauline Foreman Interview: Restoring trust in the MRCGP

The RCGP's chief examiner took on the role at the height of a row over the fairness of the MRCGP. Dr Pauline Foreman talks to Neil Roberts about how she has coped.

Dr Pauline Foreman: 'We still have a traditional apprenticeship model, so we are very much involved with our trainees'
Dr Pauline Foreman: 'We still have a traditional apprenticeship model, so we are very much involved with our trainees'

Softly spoken amid the clatter and hubbub of the cafe at the RCGP's Euston HQ, chief examiner Dr Pauline Foreman's careful, considered answers to questions seem to reflect her interest in the pedagogical side of GP life.

Appointed in November 2013, Dr Foreman began a six-month shadow period alongside predecessor Dr Sue Rendall, taking over the role in April for a three-year term. She took on the leadership of the MRCGP at the height of an existential threat to both the exam and the college.

Following a series of research publications, including evidence published by the college itself, showing significant differential pass rates for international and UK black, Asian and minority ethnic (BAME) graduates compared with their white British counterparts, and a row over the causes, the British Association of Physicians of Indian Origin (BAPIO) launched legal action against the college in March 2013.

The college eventually won the case in April, with Mr Justice John Mitting ruling the exam was lawful and the college was neither discriminatory nor in breach of legal duties.

But the clinical skills assessment (CSA) does disadvantage minority ethnic candidates, the judge said, warning the college it must take action or risk losing any possible future legal challenge.

Legal battle

Why would a busy GP - Dr Foreman still practises at the same Hertfordshire surgery she's been at since the beginning of her 17-year career - voluntarily step into the middle of a legal battle? Dr Foreman describes it as a 'painful and difficult time' which was divisive for the profession and stressful for her. 'I had a few sleepless nights, I can tell you,' she says.

She describes her background in training and examining and the experience she brings to her role: before her appointment she was a member of the CSA's operational group, has worked as a GP tutor and appraiser, and is still programme director for the East of England deanery. Beyond this, there is a sense that she saw this battle to defend the exam as something close to a duty.

Her own research in 2013 looked at bias in role play - the issue at the heart of the accusations of discrimination. That assessment found the differentials did not seem to target any particular group of candidates.

She knew the exam was fair, she says, and had never seen any evidence of discrimination, pointing out it was RCGP research that showed the differential pass rates and recognised the problem.

There is a problem of education in general, not one caused by this exam or the college, she says. 'That doesn't mean it's not important and we shouldn't try to find out what's causing it and do everything we can to remediate it.'

The college has committed to working to identify international and BAME graduates at risk of failing and providing them with support.

Attainment

A project will begin in November with the Academy of Medical Royal Colleges to look in more depth at differential attainment rates in examinations. Working with other organisations will be key to tackling the problem, Dr Foreman believes.

But she is also keenly aware of the reputational damage the exam and the RCGP have suffered. Re- establishing trust with 'key stakeholders' is a central aspiration for her as chief examiner.

The college is also looking more widely at equality and diversity policies across all of its work and has set up a group, on which Dr Foreman sits with representatives from external organisations such as BAPIO and Stonewall, to advise on best practice.

Sitting in committee meetings, which she describes as the 'mundane' side of her three-sessions-a-week role, is not what Dr Foreman thrives on. It is developing the exam, which she describes as creative and exciting work that had been on hold while the legal threat was dealt with.

Assessment

Now piloting is under way for workplace assessment for the fourth year of training the college hopes will be given the green light by government. Areas being piloted cover quality improvement and leadership.

How do busy, pressured and harassed GPs find time to do the vital work of training and examining? Dr Foreman says she is lucky she can compartmentalise her roles, which 'keeps me sane'.

'I wouldn't say I had a perfect work-life balance,' she says, however.

'My children are always moaning about that.'

But while it is difficult for GPs to take on additional roles, she says, the centrality of training is deeply ingrained in general practice.

'It is very much a part of our culture,' she says. 'We still have a traditional apprenticeship model, so we are very much involved with our trainees. We have all had that personal experience of being, hopefully, in a very good training relationship, and we often seek to replicate that ourselves.'

She continues to see that commitment to training with young GPs, despite the pressures and changes the profession faces. 'It is still very much there. There is still a lot of passion for teaching and training.'

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