'Perfectly good trainees' lost as revamped GP exam deepens inequality, LMCs warn

Recorded consultation assessments (RCAs) brought into the MRCGP exam during the COVID-19 pandemic have deepened a long-standing attainment gap for minority ethnic GP trainees and threaten to cost the profession many 'perfectly good' doctors, LMCs have warned.

BMA GP committee executive team member Dr Krishna Kasaraneni
BMA GP committee executive team member Dr Krishna Kasaraneni

The RCA test requires trainees to submit 13 recordings of real consultations as part of a system set up to replace the CSA test early in the pandemic. The RCGP suggested earlier this year that the revamped system could be retained permanently.

But GPs at the 2021 UK LMCs conference backed a motion noting 'well documented and concerning historical differential CSA pass rates for British ethnic minority and IMG trainees' - and warning that the gap had 'not only persisted, but substantially widened with the introduction and evolution of the non-standardised RCA'.

Dr Paul Scott, from North Staffordshire LMC, told the conference that in more than 20 years as a GP trainer he had 'never been so disillusioned' with the mismatch between outcomes of the tests and the hard work of 'perfectly good trainees'.

GP exam

He said testing had become 'considerably worse and more discriminatory' under the RCA system - and that general practice was at risk of losing 'a large number' of trainees at a time when the profession is already chronically understaffed.

BMA GP committee executive team member Dr Krishna Kasaraneni told the conference that since the publication of the motion debated at the conference, the RCGP had been in touch to set up an urgent meeting to look at the issue as 'a matter of priority'.

Unfairness in the CSA exam is a long-standing issue of concern in general practice. A 2013 report commissioned by the GMC found 'significant differences in outcome' between trainees who were white UK graduates, and those who were black, Asian or minority ethnic (BAME) UK graduates or BAME international medical graduates (IMG).

The GMC-commissioned report found that BAME UK graduates were 'nearly four times more likely to fail the CSA examination at their first attempt than their white UK colleagues, while BAME IMG candidates are nearly fifteen times more likely to fail'.

Training

But Dr Scott told the conference the problem was now worse than ever. He said: 'I am a trainer. I have never in my long career - 20 years as a trainer - been so disillusioned with the system, and the mismatch between what we are seeing on a day-to-day basis with our perfectly good trainees and the trials and the time and the effort put into it.

'They are not training at the moment to be GPs, they are training for an artificial RCA exam, that initially we didn't really understand, but seems to be considerably worse and more discriminatory than the CSA.

'It's really serious. It's affecting real dense enclaves of trainees in certain areas where BAME doctors and IMGs are trying to train. It needs addressing. We are going to really lose a large number - we have a two thirds pass rate - if one third fail every time we are going to lose a load of trainees and we can’t afford that.'

Speakers highlighted concerns that in areas where a large proportion of patients did not speak English as a first language, trainees able to carry out consultations in other languages could be disadvantaged - because consultations submitted for their RCA portfolio must be English-only.

Responding to the LMC vote, RCGP chair Professor Martin Marshall told GPonline that the college had 'always been transparent about differential pass rates between candidates taking the MRCGP and is committed to identifying and addressing the underlying issues for them'.

He pointed to a 2013 judicial review that found the MRCGP assessment was ‘lawful and fair’ and a 2017 review that found the CSA and AKT were fit for purpose and fair.

Professor Marshall said there was 'no systematic evidence so far that differential attainment is a bigger issue for the RCA than the CSA, but we are monitoring the data carefully'.

Dr Kasaraneni said there was 'an element of deja-vu' around differential attainment in exams that had persisted despite being an issue raised repeatedly in recent years - and said it would be looked at urgently.

Read the motion backed in full by LMCs:

NORTH STAFFORDSHIRE LMC

That conference with regards to the RCA portion of the MRCGP exit exam:

(i) notes the well documented and concerning historical differential CSA pass rates for British ethnic minority and IMG trainees

(ii) is disappointed that the differential pass rate gap has not only persisted, but substantially widened with the introduction and evolution of the non-standardised RCA

(iii) recognises the negative impact this is having on trainees' mental health and well being and that of their trainers and TPDs

(iv) urges that all pragmatic alternative options for fair assessment need to be considered as a matter of serious urgency including submissions from trainers/ educational supervisors

(v) urges the nation GPC executives to address this as a top time-limited priority with the RCGP and all related stakeholders including the GMC

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