Way Forward Finding Solution to CSA Issues

1. British Association of Physicians of Indian Origin British International Doctors Association Royal College of General Practioners Way ForwardFinding Solution to CSA Issues Meeting at RCGP 10 December 2012

2. Way ForwardFinding Solution to CSA Issues Issue: Significant Failure rate at CSA for IMGs Consequences: • Loss of career after 3-4 years of training for the individual with associated Professional, Psychological and financial impact • Loss of several hundred badly needed GPs to NHS • Concern about fairness of the system

3. Way ForwardFinding Solution to CSA Issues Objectives of the Meeting: • What can be done for those who have been released from Training • What can be done to support those who are in training

4. Audit of the perception of GP trainees regarding CSA Exam Oct 2012 British Association of Physicians of Indian Origin

5. Background Over last 2 year steadily increasing number of GP Trainees have been contacting BAPIO regarding Concerns about CSA

6. CSA Results 2010 - 11

7. The Survey • A questionnaire was sent to 195 GP Trainees whose email ids were available to BAPIO • All of them responded but the full questionnaire was completed by 160 trainees

8. Total complete responses 160 Male = 106 Female = 52 Did not state = 2

9. 88.7% of Drs in the survey passed AKT

10. Attempts at AKT 114 (58.5%) 1 attempt 45 (23.1%) 2 attempts 12 (6.2%) took 4+ attempts 7 (5%) trainees had to leave GP training due to failure in the AKT

11. CSA 153 (95.6%)Trainees in the survey had attempted CSA • 18.1% (29) had 4 attempts • 14.4% (23)had 5 attempts • 6.3% (10) had 6+ attempts

12. 46 (28.8%) GP trainees had to leave training due to failure in the CSA Factors that contributed to the CSA failures • Psychological (stage fright, Anxiety) - 63.1% (101) • Felt inferior to some GP trainee because their pass rate was higher- 70% (112) • Lack of GP trainer support to prepare for the test-58.8% (94) • Location of the test (very far)- 61.1% (109) • Bias of some examiners- 74.4% (119)

13. 46 GP trainees had to leave training due to failure in the CSA • Factors that contributed to the CSA failures - 2 • Examiner made his/her presence noticeable & it felt that they were not interested in your performance – 52.5% (84) • Bias of some actors (role players) – 66.9% ( 107) • Actor patients withholding information or giving information late- 68.1% (109) • General nature of test (1 examiner, no video recording use of actors)-83.1% (133) • Language and accent problem- 22.5% (36)

14. Overall 86.3% (138) felt that the CSA exam was unfair to overseas qualified doctors

15. Financial Pressure

16. Summary of Survey Findings • 88.7% in the survey passed AKT • 5% had to leave GP training due to failure in the AKT • 95.6% in the survey had attempted CSA • 40.52% had 4 or more attempts at the CSA • 28.8% GP trainees had to leave training due to failure in the CSA • 51.9% are considering another career/ specialty • 93.1% felt that the exam is very expensive • 92.5% would like to make the CSA exam a more fairer test

17. Some responses (randomly chosen) ‘stressful’ ‘Bankrupt’ ‘No real support but lip service.’ ‘It is a vague programme, with individuals left to work out the system’. ‘Poor induction programme, poor effort by the deanery to support the weak candidates- almost washing their hands off the candidates- as these IMG's were recruited through MMC- a big mistake. There is no structured educational programme’

18. Some responses (randomly chosen) ‘I have always been told that I am very good , good videos and good when doing role-plays with actors but failed repeatedly. My trainer and supervisor said I have good communication skill but not that is needed for CSA! The bias of the examiners and actors did not help.’

19. Some responses (randomly chosen) 'Have good references from 20 hospital Consultants, several GP trainers, 40 excellent MSF,100 PSQ- have been working for NHS for seven years, have seen at least three thousand patients in GP Surgeries, passed AKT with good marks-cannot pass my CSA , about to be kicked out of the programme. If I am not fit to practice why did my trainers not raise concerns, why are the RCGP actors taking centre stage ? Are they more genius than my Trainers, Consultants, Patients and colleagues?' The RCGP actors are deciding who is worthy to be a NHS GP!

20. Some responses (randomly chosen) ‘The GPVTS course did not prepare us for the biased exam. We were given 2 days of practice with the rest of the VTS group and I did not find any difference between the British qualified doctors and the international medical graduates.’

21. Some responses (randomly chosen) ‘This CSA and what they have done to my career has left me with financial trouble. I am in the process of selling the house too as we can't keep up with the mortgage and the credit taken’

22. Some responses (randomly chosen) ‘In the words of our trainer and the assistant dean "We train you to be a good GP and not pass the exam". Then how it is that after training to be good GP we can not pass the CSA exam? After going through the rigorous process of selection and then rigorous training and being stamped - unattainable. Is it justice???’

23. Actor Bias

24. ‘Actors bias-Very evident throughout the consultation(My experience from 3 CSA attempts and from many colleague mentioned the same). I work in a surgery with 92 % White middle class population. My trainer is happy with my consultation as he had seen many videos on my consultation many times before the exam” “My real patients are much different from CSA actors in communicating and information giving and making a rapport during the consultation and I never had any dysfunctional consultation’

25. Actor Bias ‘I felt actors were very vague and holding information unnecessarily” “RCGP asking for real empathy and emotions in an artificial environment and we have to assume certain things and act. I am a person good at these skills in real environment and I feel inside they are not real patients. I am not an actor!!!’

26. Actor Bias ‘No comparison with real surgery patients in terms of responding to our questions.(Verbal and non verbal communications)” “Time pressure, Uncertainty, Awareness of IMG failure rates, Huge sum of examination fee make us very tensed during the exam and impairing our real possible emotional outpouring impossible’

27. ‘Why I am depressed. I have no faith in this exam and I am not sure about my last and fourth attempt. My trainer and myself do not understand the real problem as feed back is general and wont give you anything to improve. I have no money as I have spent already 7000 pounds in total towards exam and preparation courses without any hope. My 3 exam score sheets not giving any consistent picture. I have felt actors bias throughout and found it difficult from real patient in my usual day to day surgery’

28. Some responses (randomly chosen) ‘No exam focus at all. VTS schemes need to take the CSA exam very seriously and as a part of their job. No specialty grade jobs in GP. Unlike other hospital specialties general practice has a dead end for significant number of IMGs. It ruins those doctors lives. I sincerely mean it!!!’

29. Conclusions • Exit exam (CSA) failing a significant majority of overseas trained doctors • No real support for doctors who fail the CSA exam • Concern over bias and subjectivity in the CSA exam • Overseas doctors mainly provide service in hospitals and GP surgeries but do not get proper training

30. Conclusions • Hundreds of Careers lost leading to psychological and financial trauma, ruining family life • Significant waste of tax payers money for GP training while there is GP shortage in the country • RCGP seems to have lost credibility with overseas doctors