Communication problems key for overseas doctors failing MRCGP

COMMUNICATION difficulties are a key factor behind higher failure rates amongst overseas doctors in the membership examination of the Royal College of General Practitioners (MRCGP), according to new research.

Doctors who qualified abroad were more likely to have trouble giving explanations to patients and sounded formulaic to examiners, it found.

Researchers from King’s College London investigated why international medical graduates (IMGs) had higher failure rates in the clinical skills assessment (CSA) part of the exam and looked at the role played by linguistic and cultural factors.

They analysed 40 video recordings of candidates sitting the CSA and reviewed examiners’ feedback and paperwork, excluding cases where there were clear and important clinical errors/mismanagement.

The amount successful and unsuccessful candidates both talked was found to be largely the same, but poorly performing candidates were more likely to have difficulties giving explanations to patients and to experience misunderstandings in the consultation. They also found it more difficult to repair these misunderstandings.

They also experienced “more moments of misalignment with the patient that would impact on the unfolding consultation” as well as sounding formulaic to examiners.

The reason for failure could not be attributed to one particular issue, the report stated, but was often “an accumulation of these small micro-level difficulties in communication”.

Researchers found it was challenging for candidates whose English is influenced by other languages, such as speakers of Indian English, not to sound formulaic due to their use of intonation and other patterns of speech which may differ from local English speakers.

When comparing white UK graduates and black and minority ethnic (BME) UK graduates, there were no obvious differences found in their communication styles in the exam. But there were “a small number of candidates who were not categorised as IMG but had some of the characteristics of talk and interaction which were observed in the failing IMG group.”

The report stated: “Some CSA candidates will have come to the UK to take up an undergraduate place but whose education and early socialisation were in another country. This may be a contributing factor in the somewhat larger number of BME UK graduates who fail as compared with white UK graduates.”

Interpersonal skills proved a particularly challenging element of the CSA for IMG candidates with evidence suggesting empathy and rapport, in particular, “may not be best assessed in a highly standardised exam of simulated consultations.”

Workplace based assessments with real patients would be the preferred setting, the report said, also suggesting that the interpersonal skills domain be changed to instead assess how clearly candidates communicated.

Researchers noted that there is no opportunity for candidates to be assessed consulting in a language other than English, or to show subtle cultural/language differences.

“This is an area where IMG candidates are likely to have particular strengths and recognition needs to be given to their skills,” they said.

“In addition, working in challenging consultations across language barriers is a competence that should be assessed for all candidates since the CSA licenses GPs to work throughout the UK, which is becoming an increasingly diverse society.”

Commenting on the findings, the lead author of the research, Celia Roberts, professor emerita in sociolinguistics at King’s College London, said: “The published report demonstrates that there are features of candidate performance associated with lower grades, but it is unhelpful to describe them as difficulties with ‘language’ or ‘culture’ in an undifferentiated way, set aside from discussions of fairness.

"There are also aspects of structured, simulated examinations which, unintentionally, contribute to the weight of the exam for the IMG group.”

Read the full research article on the King’s College London website