Hot Burning Coales, the enigmatic London GP who has for a time been a thorn in the side of the Royal College of GPs, is showing signs that she is about to start hammering at them like a pneumatic drill. She is alarmed by the absurd pattern of results from the College’s Clinical Skills Assessment, the ‘exit’ exam for trainee GPs. Her concern is that white British candidates go through on the nod, while Asian International (non-UK medical school – IMG) graduate candidates are systematically failed, on the grounds that they are not ‘one of us’. Certainly the raw figures appear to back up the suggestion that there is a case to be answered. The College’s own statistics (page 28 here) largely (she has skimped a bit on the detail) confirm those reported by HBC: 96.1% of white UK graduates pass on their first attempt, while the figure for Asian non-UK graduates is 36.9%.
The crucial question, of course, is whether this striking difference arises because many Asian IMGs really are ‘not one of us’, and so properly should fail because they have not sufficiently adopted British ways to be safe to practise, or whether they are merely casually but nonetheless prejudicially seen by College examiners as ‘not one of us’, when in fact they are safe and competent to practise. HBC’s latest post pokes the tip of her pneumatic drill sharply in the eye of the College, and gives it a hammering, accusing it of forcing ‘debt, destitution, and despair’ on harmless, indeed capable, Asian IMG candidates by repeatedly failing them, of inflicting ‘suffering multiplied several times over’. To add insult to injury, serial failers risk GMC referral based on their exam performance, for alleged ‘safety reasons’, despite the fact no live (or dead) patient has suffered. The whole shooting match, which is pretty much what it amounts to, is, HBC suggests, rank discrimination. The fish in the barrel never had a chance.
The College, for its sins, already has a red face over discrimination. Still smouldering in the coals of the news archives is the Clouseau case. A hapless French porter employed by the College is said to have received a five figure payout for sexual discrimination and harassment after a tribunal found other College employees had repeatedly taunted and harassed Monsieur Basile. When not calling him Basil in manner of Sybil, they dubbed him Clouseau. At other times they would make Gallic gestures, or enquire after the well-being of his bâton. A picture emerged of a College very happy to share jokes, but rather less competent on the caring front. A parallel claim for racial discrimination was disallowed, not because it was unproven, but because it was out of time.
As it happens, Dr No has himself had occasion to question the efficacy of GP assessments. Some years ago, after a spell out of general (but not clinical) practice, he agreed, under a degree of duress, to apply – the process was competitive, because their were more GP returners than there were places available – for a period of refresher training. Not only did he find the MCQ, which was aimed at junior doctors fresh off the acute wards, quaintly impossible to answer – it had no questions that could assess the cumulative experience of decades of practice, he also fell badly foul of the clinical assessment, and almost landed himself a GMC referral to boot.
The assessment, like the College’s current CSA, required the candidate to act out a scenario with an actor-patient. The scenario invariably has some sort of forked stick embedded in it, on which it is hoped hapless candidates will fall. Despite knowing this, Dr No, having been helpfully told to ‘do as he would always do’ in an identical real consultation, did what he, and just about every other experienced doctor he knows, would have done (which involved keeping the patient on side rather than blindly following orders, and tanking the patient in the process) in the exam, only to end up with a stick stuck through his chest, with a label saying ‘Fail’ on one end and another saying ‘GMC referral’ on the other. Dr No did manage to extricate himself from the GMC referral, but the experience left a bitter taste in his mouth, and a conviction that GP assessment was more than a few fries short of a happy meal – or worse. Another refresher – and so mature – candidate who faced the same dilemma, and reluctantly chose the ‘dumb’ but ‘correct’ solution, remarked afterwards that she ‘came out feeling that it was the worst consultation I had done in my life’.
The Clouseau affair and Dr No’s ejection from any prospect of returning to general practice are themselves isolated incidents, but taken together they suggest the necessary but not sufficient requirements – xenophobia, and a curiously narrow-minded approach to assessment, an assessment that rewards ‘the worst consultation…in my life’ and penalises a doctor for doing what any experienced doctor would do – exist in the College to allow systemic discrimination on unacceptable grounds against Asian IMGs. Whether that discrimination is given real effect, we do not yet know: it may still be that more Asian IMGs should fail, because they lack sufficiently British-nuanced clinical skills. What we do know is the published results are stark, and there is a question to be answered. Like IMG Clouseau coming back to haunt Chief Examiner Dreyfus, this is a question that is not going to go away until satisfactory answers are provided.
All my classmates that came over to England to sit MRCP,FRCS, MRCOG & MRCPsych (4 of us)all passed first go. Strange that or may be not.
SFD went through one of her neurotic phases (OK more neurotic) and felt somewhat inadequate having never been offered the choice of MRCGP when she did her Summative Assessment. It seemed strange that all new GPs had MRCGP but she didn’t, despite running a successful single handed practice on her own (a fortunate lady!)
Despite having no local tutoring (no one in North Wales available at the time) she paid £3000 and completed her 34,000 word iMAP portfolio. Went to the viva for “just a chat” as she was led to believe and was given a roasting by a pair of old duffers who were very condescending and patronising, treating her as if she were a junior partner, and had no idea of the stresses and strains of a single handed GP – e.g. why I couldn;t take a session off every week just to study. Also why did I bother to do SaO2s on admitting a patient with exacerbation COPD? “Errm because the hospital usually ask (and its in NICE guidelines)” “But they should take your word as a GP!” – what planet did they practice from I asked myself.
The killer was when they asked “Why did you prescribe Difflam for a sore throat? It’s not cost effective for the NHS!” To which I replied “It makes the patient better and its not my money is it?” Game over.
Never again will SFD darken the doors of this crappy outdated institution unless dragged kicking and screaming. I pity new GPs who have to deal with these people.
Hi there,
Love your blog, consistently superb and a welcome break from the drivel we are being fed from the industrial medical machine. I am currently a GP ST3 about to sit CSA in Feb 2013.
As it stands the exam is a bit of a farce really and our preparation is geared towards this completely false situation for half of our final year in GP. Thus yet again a medical exam that fails to prepare people for the real world.
The other main point i have to make is that their seems to a constant drive for homogenisation in modern society and in GP it is no different. This is reflected in the pass rates mentioned above and also in the method of training which is almost exclusively based around consultation styles and effective communication to the detriment of other key areas – ie clinical decision making and clinical knowledge which at the end of the day is still of paramount importance.
Thanks again for the wonderful blog.
Anon – Dr No thanks you for your kind generous words. He couldn’t agree more about vital clinical stuff being squeezed out by all that caring and sharing malarkey. At the end of the day, clinical competence is the only vital skill – the rest is nice, useful, not to be sniffed at, but, as one of the gang of four first time passers and others regularly point out, if our doctors lack clinical competence, we are stuffed.
On the assumption you are not in fact Dr Who here on a timely visit, Dr No has taken the liberty of making a one character alteration to your comment.
SFD – all a bit reminiscent of trial by sherry. ‘Just a chat’ are three of the most chilling words in the English language, perhaps only exceeded by ‘just a little chat’. The messaging is the same: in some shape of form, they are going to ‘let you go’.
Dear DN,
What on earth is going on with this GMC referral business?
On what grounds would that be done?
OT: I was having a little chat with one of our Associate Deans at a recent trial by sherry. She was rather perturbed by the high failure rate of the GPVT IMG candidates, the question was why were these results so different from the ARCPs which have a strong emphasis on communication skills? Something rotten in the state of Denmark methinks.
Happy Christmas one and all!
Boots
Boots – Dr No could publish the tawdry emails from the GP goons who threatened him with pre-revalidation GMC referral. Perhaps he should. Perhaps he will. Or perhaps he wont. Frankly, Dr No has had his Rhett Butler moment, and that was that. But he never forgot Burke (attr.), which is why he is here.
Forgive my sticking my patient’s oar in as I have done in the past. I have no idea whether you’re technically competent from the perspective of someone playing with textbook stuff, but I don’t think that’s what matters most.
Forgive me also if I tell you something close to my heart. My GP told my best mate she had indigestion and she had a cardiac arrest shortly afterwards. Oops! So why is he still my GP? Because he cares and I trust him and there’s more to being a damn good GP than being perfect according to the unreasonable judgement of a tabloid or a bureaucratic beancounter.
Keep fighting the tickbox assessors. There are plenty of us out there that don’t want tickbox doctors.
As an occasional examiner of candidates at medical examinations, and interviewer for umpteen jobs, I have heard some pretty stupid answers. It has never occurred to me to do more than fail the candidate, I am genuinely shocked to hear that in this sort of context it is thought appropriate to refer to the GMC.
Perhaps I will get referred for expressing the view that revalidation is a pile of pants. I cannot see how we escape this insane control freakery.
Keep those emails to yourself, and raise a glass to that tormentor of the GMC, “she who must not be named”.
Boots – you are right to be shocked, because it is shocking. The pattern of behaviour by the Establishment here has much in common with that seen in the Dr Scot Jnr affair, in which, as you will recall, again no patients were harmed. In fact, they weren’t even involved in the slightest.
Dr No expects we will see the control freaks given new licence to meddle, interfere and generally mess up other people lives as the carnage of revalidation gets under way. The control freaks, busybodies and other toxic elements of the profession will naturally gravitate to Responsible Officer positions. Despite the sham dance of objectivity, when all is said and done, revalidation is a subjective non-evidence based assessment by a control freak. If he/she doesn’t like the colour of your shirt or the cut of your jib, then it’s ‘Good bye Doctor.’
Anon 1:05 – Thanks for your contribution – badmed doesn’t get as many comments from patients as Dr No would like, so he is all the more appreciative when patients do contribute. Much as it pains him greatly to say it, medicine isn’t about doctors, it’s about patients, and so the patients’ views matter. You highlight two points which Dr No agrees are important.
The first is how do patients lacking medical knowledge assess technical competence? It is a bit like asking Dr No whether a dress is well made. He might be able to say whether the dress looks good or not, but whether it is well made? He wouldn’t have a clue.
The government has a crazy notion that releasing a few summary stats will change all that. What they forget is that when you do performance management and league tables, people game the system. The flip side of this is what might be called the Savage Attack Principle. Some time ago, a bunch male obstetricians at a London teaching hospital ganged up on a young radical female obstetrician. Revalidation hadn’t been invented, so they had to use rather more old fashioned methods to get rid of her. They cited her five worst cases. Just about any doctor, even the best of doctors, judged on their five worst cases, looks pretty dreadful. Wendy Savage was duly suspended. It look a public outcry to get her reinstated, but by then the damage had been done.
The second point you raise (why you are still with your GP) is also close to Dr No’s heart. You are still with him because ‘I trust him‘. Real trust by its nature is intangible, perhaps even ineffable. Why do spouses trust their partner (when they do)? Have they obtained 360 degree feedback from the neighbours? Have they sat down and reviewed critical coital incidents and marital CPD? Like Hell they have. At the risk of freezing and shattering the Tao of trust, Dr No wonders if trust may have something to do with believing that the other has your best interests at heart. Or should that be knowing? But how can one know? All said and done, trust is an act of faith, something one believes when it is impossible to know. Quite how revalidation will improve trust is utterly beyond Dr No. In fact, he thinks it will achieve the opposite (posts passim). Patients (and some doctors, Dr No included) trusted Wendy Savage because they believed she had her patients’ best interests at heart, despite her five worst cases.
‘Thanks for coming in today’? It’s what toxic consultant psychiatrists say to detained patients seen on the ward round. As if the patients had any choice. Dr No suspects many of those invited in for ‘just a chat’ will be greeted with ‘Thanks for coming in today’. The remark will start a ‘chat’ that will end with ‘Good bye, doctor’ ‘Au revoir?’ ‘No doctor, good bye.’