Abstract
This chapter has two main aims. First, it holds a spotlight to the ongoing discrepancy between observed and expected scores for Black, Asian, and Minority Ethnic (BAME) candidates in this exam – and the actions the RCPsych is taking to address this. Second, it describes the challenges specific to graduates of non-UK medical schools taking the RCPsych CASC, offering them pertinent practical advice. Our hope is that this chapter will empower such candidates, as well as senior clinicians who would like to support them. The information provided here has been gathered from previous international medical graduate (IMG) CASC candidates, CASC tutors, and personal experience.
This chapter has two main aims. First, it holds a spotlight to the ongoing discrepancy between observed and expected scores for Black, Asian, and Minority Ethnic (BAME) candidates in this exam – and the actions the RCPsych is taking to address this. Second, it describes the challenges specific to graduates of non-UK medical schools taking the RCPsych CASC, offering them pertinent practical advice. Our hope is that this chapter will empower such candidates, as well as senior clinicians who would like to support them. The information provided here has been gathered from previous international medical graduate (IMG) CASC candidates, CASC tutors, and personal experience.
The Current Climate
Recent figures from the General Medical Council (GMC) have shown that on average, 49.2% of IMG candidates (defined by the GMC as any candidate who studied outside the UK and European Economic Area) passed the CASC in 2019, compared to 92.2% of UK graduates. A breakdown of pass rates by ethnic group is not publicly available for the CASC in isolation; however, across all RCPsych examinations in 2019, white graduates of UK medical schools were 15.7% more likely to pass than BAME graduates of UK medical schools. Disappointingly, such significant discrepancies in Royal College clinical examination pass rates have been well documented across many specialties over several years.1
In 2014, the British Association of Physicians of Indian Origin (BAPIO) sought to challenge by way of legal review the continued use of one particular Royal College specialty clinical examination, the Royal College of General Practitioners’ Clinical Skills Assessment (CSA).2 BAPIO (the claimant) argued that the low pass rates of South Asian, Black, and minority ethnic doctors reflected discrimination (whether directly or indirectly), and therefore the examination was unlawful per the Equality Act (2010). The defendants were the Royal College of General Practitioners (RCGP), as those who carry out the examination; and the GMC, as the body responsible for its regulation. The High Court did not find that the examination was unlawful, but Justice Mitting noted in his judgment that unless existent wide-ranging recommendations from investigations on the matter were implemented by the RCGP in a timely manner, they might be found in breach of the law by a subsequent judicial review. He referenced several reports, including one commissioned by the GMC in 2013 and written by Professors Aneez Esmail and Chris Roberts. This report made wide-ranging recommendations, including the following:3 the RCGP should make IMG candidates aware of differential pass rates, the RCGP should make specific provisions for IMG candidates, the RCGP should endeavour to provide a less ethnically narrow range of examiners and mock-patients, formative feedback to candidates should clearly describe any weaknesses and how to address these, and the GMC should commission further research into whether examiners’ scoring differs when applied to candidates whose ethnicities differ from their own. The outcomes that provoked the legal challenge were not unique to the RCGP, and as such, the legal judgment in 2014 had clear ramifications for other Royal Colleges (including RCPsych). The RCPsych has indicated to us that they recognise the pattern of differential attainment and that they take their responsibilities in this regard seriously. They have advised us that they are still working on specific advice for IMG candidates, which they intend to publish on the RCPsych website soon. It is also currently compulsory for any RCPsych CASC examiner to undergo specific equality and diversity training.4
The authors of this book, including multiple second-generation immigrants, are highly sympathetic to the extra challenges faced by both IMG and BAME candidates when sitting the CASC. If you feel that you have been a victim of discrimination in relation to an examination, the RCPsych encourages you to bring this to the attention of the chief examiner so that appropriate action can be taken. This can be done either by email (examinations@rcpsych.ac.uk) or by post:
FAO Chief Examiner, Examinations Unit
Royal College of Psychiatrists
21 Prescot Street
London
E1 8BB
Recognising the Extra Challenges
The CASC by its nature is an exam likely to favour UK medical school graduates, who will have gained many years of experience interacting with British and Northern Irish patients (with all their specific cultural and social quirks) in language typical of the CASC examination. Additionally, many UK medical school graduates will have been examined even during their undergraduate training in a format similar to the CASC, and most will also be very familiar with the CASC-appropriate treatment options (i.e. those supported by NICE and utilised by the NHS). These advantages are not available to IMG peers.
Despite these extra challenges (which we hope this book will help you overcome), IMGs represent a group with a monumental potential benefit to psychiatry in clinical practice. Amongst this diverse group, there is a wealth of cultural knowledge and experience that will hugely benefit patients.
Challenge One: Simulated Patients
The CASC is based on the ‘Objective Structured Clinical Examination’ format utilised in UK medical schools, which may be entirely new to some IMG candidates. The defining feature of this type of exam is the use of simulated patients (portrayed by trained actors) rather than ‘real’ patients. This difference often causes much consternation amongst IMG candidates (and indeed all candidates) who worry that an exam using this format might not allow them to engage naturally with patients as they would in usual clinical practice.
The use of actors in the CASC has advantages over using ‘real’ patients, particularly relevant to BAME and IMG candidates. Patients (unlike actors) are not trained to give a fair and uniform experience independent of their underlying personal biases. You are protected from any such biases by the equal application to all candidates of one set script for actors, one identical controlled environment, the same guidance for all examiners, and their use of a single mark scheme.
However, the CASC format may present some unexpected challenges. For example, simulated patients may be instructed to withhold information unless the candidate specifically asks for it, even when a ‘real’ patient might reasonably be expected to volunteer this information in a normal clinical setting. We have incorporated this into our practice stations, so that the adaptive behaviour of asking explicitly rather than assuming can become more natural for the exam.
Another challenge is that any simulated ‘medical students’ would also be played by actors. Tasks in these ‘medical student stations’ (such as Station 4.3) might involve seeking their opinion on a patient’s condition or educating them on a particular topic (such as the interpretation of some test results). In the simulated format, the use of a collaborative approach where the student is encouraged to think for themselves (appropriate in clinical practice) may leave your actor confused and apparently disengaged. Similarly, asking for the student’s opinion on the patient’s diagnosis could result in a frustrated ‘I don’t know’. It is important to realise that this strange artificial behaviour is designed to provide a fairer examination. If the actor could choose to volunteer information spontaneously, they might not do so equally for every candidate. Here, the trick is to remain calm and to be slightly more directive: ‘OK, well, let me explain…’ This book will help you to become familiar with these challenges of the format.
Despite all the artificial aspects of the CASC, your aim should still be to offer a realistic (if brief!) consultation, that is, to be yourself. The examiners don’t set up any tricks or traps in these stations, so please don’t second-guess yourself and offer advice or treatment that you wouldn’t offer in your real clinical practice. Ultimately, they just want to know that you are a safe clinician.
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