The conference overwhelmingly agreed that the pass rate disparity was a concern, raised questions on the validity of the exam and demanded immediate improvement in feedback. Various organisations of international medical graduates (IMGs) especially BAPIO (British Association of Physicians of Indian Origin) already have been concerned enough to take up the issue with the RCGP. Many from the training community have been worried especially for those trainees who are deemed competent and safe by trainers but struggle with either the CSA or AKT. However, sadly the college has refused to budge.
The efforts from the GP training subcommittee of BMA to highlight the issue are laudable but the issue is more complex than it looks. So, what needs to change?
Recruitment needs review
Corrective steps should start with the review of recruitment and entry into GP training so that it is robust enough to weed out any candidates who are likely to struggle and be released from the training. Various tools that have predictive value, for example MCQ assessment, need to be used proactively. Current statistics need highlighting to potential applicants at the entry level so that they can make an informed decision as otherwise it is unfair on not only the trainees but on the taxpayer and public at large which funds the training. There are serious implications for funding for extension of training as well as patient safety due to worsening recruitment problems. This becomes vital in light of the new plans to increase the number of GP training places.
Just in my training scheme, it appears that up to 25% of trainees have failed AKT/CSA and may need an extension.
What trainers can do differently
Many training schemes and deaneries are already starting to provide extra training/support at various levels for those likely to face problems. They surely deserve credit especially at times when many funding streams are disappearing. Some trainers are also making laudable efforts at individual level. Not only we need to review what appears to be effective but also innovate to look at any measures that may reduce the discrepancies in pass rates in both AKT and CSA.
There is need to urgently provide guidance to the trainers so that the support for the groups likely to struggle is standardised and socio-cultural aspects are taken into account. IMGs are a very diverse group with very diverse needs. The way feedback is given and then perceived by IMGs is different. Pendleton’s model of feedback may not work for them. These issues need to be debated and experiences be shared.
What trainees can do differently
The CSA requires lot of practice with patients and fellow trainees. IMGs should try to form practice groups with local graduates and this should be encouraged at the deanery level. This should be encouraged at the scheme/deanery level. Use of audio and visual media may be helpful to gain more confident understanding of the language.
Amidst all the attention being focussed on CSA, issues around the AKT appear to have been forgotten where ability to speed-read has come into focus. Interestingly, MRCGP International appears to take this factor into consideration by allowing three and a half hours instead of three for AKT. This indeed should be applicable to IMGs taking the same exam in the UK.
A good grasp of statistics certainly increases the chances of passing the AKT.
What the RCGP must do
There needs to be an immediate review of the data by the college with BMA, BAPIO and other interested parties. A national task group needs to be formed to address the issue, which should work in close liaison with the deaneries and provide guidance to the trainers and trainees alike. The CSA should be videotaped and a feedback group be established to provide more personalised, specific feedback that is worthwhile despite concerns around disclosing all potential scenarios.
There has been perceived variability in actors/examiners during the CSA. The RCGP needs dedicated avenues where candidates who notice anything of concern, can report such issues without any fear of retribution.
But, we need action now.
All this will need some time but the current trainees are still being exposed to a system that by designs is flawed, as it is disadvantageous to certain groups especially based on ethnicity whereby even UK Asian or black graduates are likely to fare far worse than a Caucasian graduate.
BMA and other interested organisations including BAPIO must go back to the negotiating table and make a concerted attempt to make some progress.
Firstly, the college must increase the number of attempts for CSA and AKT to six. Though only a temporary measure, it will go a long way to reduce the stress on current trainees. This will stop the haemorrhage of those trainees who have passed two of the components including workplace-based assessment (marked competent by trainer) and have struggled with either CSA or AKT. I strongly urge the BMA and BAPIO to support these interim measures while solutions are worked out.
Secondly, the college should also consider going back to its pre-2010 CSA marking methodology where candidate outcomes are determined by number of stations passed rather than total marks.
There needs to be an alternative route of obtaining the MRCGP especially if the candidate is having problems with the AKT or CSA. One size does not and can not fit all.
Time is running out and so is the credibility of our training system and the organisations.
This must stop now.