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.