GP exam 'unfair to minorities'
- 19 October 2013
- From the section Health
UK ethnic minority doctors are four times more likely than white candidates to fail their clinical GP exam, the General Medical Council has found.
The review into 5,000 candidates was ordered after ethnic minority students complained the exam was unfair.
Prof Aneez Esmail, an expert on racism in the NHS who led the investigation, said "unconscious bias" could explain the findings.
But the Royal College of GPs, which sets the exams, denies they are unfair.
RCGP chairwoman Dr Clare Gerada said the college took equality and diversity issues "extremely seriously".
She added that the college: "strongly refutes any allegations that the exam is discriminatory in any way".
The Clinical Skills Assessment (CSA) - introduced in 2010 - is a practical test in which trainee GPs are assessed by an examiner while they treat actors in a mock-surgery setting.
They have up to four attempts to take the test which they must pass before they can practise as a GP.
During the six-month review for the GMC, Prof Esmail analysed data on more than 5,000 candidates who sat the CSA exam over a two-year period.
He said he could not exclude racial discrimination as the cause of the findings.
He told BBC One's Breakfast: "Many of us who do work in this area describe the problem of unconscious bias.
"So I think that what might be happening, especially with the white British graduates compared to the ethnic minority British graduates, is that - without realising it even perhaps - they may be assessing it in a different way."
"So I don't think that it's the examiners saying 'oh we don't like ethnic minorities' - it doesn't work like that anymore," he added.
"It's all this unconscious stuff that goes on which we need to be aware of."
He said all British doctors, whether white or from ethnic minorities, had "gone through medical school and passed all that and so we're not talking about people who aren't as good as - they're exactly the same".
He said the test was "a relatively new technique that's being used and it's bound to improve as time goes on".
He has made a number of recommendations to try to combat bias in the exam including having more examiners and actors who are from ethnic minority backgrounds.
But the RGCP's Dr Clare Gerada said the review found "no evidence, either through the examiners or through the actors, or through the process of the examination, of discrimination".
She added that, "in fact, what it showed was that it was probably preparedness for the exam that was a factor".
"We already take comprehensive steps to ensure that the exam is fair and equitable to all candidates," she told BBC News.
"This exam is designed for doctors to practise independently; it is not an exam that has to be passed by everyone. I think that is a very important issue.
"Of course we cannot be complacent and we continue to make sure the exam does not have bias built in."
The review also found that trainee GPs from abroad were 14 times more likely to fail the CSA exam than white British doctors.
"We also know that eventually they pass," Dr Gerada said.
"We also know that this is a culturally specific exam - it stands to reason if you are born and brought up in this country, within the NHS, that you have an advantage," she added.
"If I go to India and sit an exam designed for doctors to practise in India, I will be at a disadvantage."
GP Una Coales, meanwhile, said that, "because they use predominantly white actors, even the white actors may not even be aware that they have hidden bias against foreigners".
"So if they hear an Indian dialect, for instance, they might pretend that they don't understand them and they might subconsciously withhold vital clues," she said.
She said the actors could "give away the agenda or the concern right away if he happens to like you or can withhold it for eight minutes of a 10-minute exam".
Organisations representing ethnic minority doctors have threatened legal action against the RCGP.
Dr Ramesh Mehta, president of the British Association of Physicians of Indian Origin (BAPIO), said: "Hundreds of doctors' careers have been damaged because they have repeatedly failed the CSA exam.
"They are facing institutional bias and are unfairly failing the exam despite extensive training and knowledge."
BAPIO has been given permission to launch a judicial review against the RCGP and the GMC over the exam.
The General Medical Council said it took the findings of the independent review seriously.
"We agree with Prof Esmail that there is no room for complacency - we want to work with him and all those involved in this area," chief executive Niall Dickson said.
"We are duty-bound to act where there is evidence of a problem and his report and recommendations make a powerful case for action."