Presentation from the International Congress of the Royal College of Psychiatrists 24-27 June 2014, London

1. Diaspora Psychiatrists, RCPsych and
Global Mental Health

2.  What are the issues facing IMGs?
 ForTrainees
 For Consultants and SAS grades
 Initiatives from RCPsych and Diaspora Committee
 What are the remedies?
 Academic
 Legal
 Pragmatic approach

4. ▪ PMQ : Primary Medical Qualification
▪ IMG: International Medical Graduates
▪ EEA: European EconomicArea
▪ UK: United Kingdom

9.  Total percentage of IMGs in Psychiatry is over 40%, but
disproportionate spread amongst grades
 Most non-Consultant grade doctors (probably >80%) are IMGs
 Under-represented at Consultant level
 Paucity of IMGs at high-ranking posts in NHS, Academia and RCPsych

10. Paper 3
Pass
Rates
by
Country
with
Attempts
& Gender

12. CASC
Pass
Rates
by
Country
with
Attempt
s &
Gender

17.  PLAB and UK graduates’ performance on MRCP(UK) and MRCGP
examinations: data linkage study
McManus, BMJ 2014; 348 - GMC commissioned UCL study)
 PLAB (Professional and LinguisticAssessment Board) exam marks good
predictors of future performance in MRCP and MRCGP exams
 IMGs lagged behind UK trained examinees – equivalence would be achieved by
raising PLAB pass mark by 13-20%

18.  Academic performance of ethnic minority candidates and
discrimination in the MRCGP examinations between 2010 and 2012:
analysis of data
Esmail, BMJ 2013; 347 (RCGP commissioned study)
 After controlling for age, sex, and performance in the applied
knowledge test (AKT)
 BME examinees (UK-trained) 3x more likely to fail in clinical skills exam
 IMGs 14x more likely to fail clinical skills exam but this was accounted in part for
by poorer performance in AKT (machine marked)
 Examiner bias suggested but disproven by analysis (?methodology)

19.  Annual Review of Competence Progression (ARCP) performance of
doctors who passed Professional and Linguistic Assessments Board
(PLAB) tests compared with UK medical graduates: national data
linkage study Tiffin, BMJ 2014, April 2014
 IMGs more likely to have poorer outcomes in ARCP
 Predicted by poor PLAB scores and IELTS scores
 Ethnicity data not consistently reported
 In Psychiatry majority are likely to have failed ARCP on account of failure in
MRCPsych

20.  IMGs in Psychiatry more likely to face suspensions and referrals to
regulators
 IMG trainees in Psychiatry more likely to fail formative and summative
exams
 Predictors include PLAB scores and IELTS performance

21. Analysis of 244,153 hospitalizations in Pennsylvania found that patients
of doctors who graduated from international medical schools and were
not U.S. citizens at the time they entered medical school had
significantly lower mortality rates than patients cared for by doctors
who graduated from U.S. medical schools or who were U.S. citizens and
received their degrees abroad.

23.  “The first, and by now uncontroversial, issue is whether or not the
public sector equality duty applies to the Royal College and the GMC.
The GMC has always admitted that it does and the Royal College
(RCGP) is prepared, for the purposes of these proceedings, to accept
that it does. Both concessions are right.”

24.  The public sector equality duty is set out in section 149(1):
 "(1) A public authority must, in the exercise of its functions, have due
regard to the need to —
 (a) eliminate discrimination, harassment, victimisation and any other conduct
that is prohibited by or under this Act;
 (b) advance equality of opportunity between persons who share a relevant
protected characteristic and persons who do not share it;
 (c) foster good relations between persons who share a relevant protected
characteristic and persons who do not share it."

25.  “The public sector equality duty cannot require the Royal College to
consider exercising public functions which it has chosen not to
exercise, or even to require it to consider exercising those functions”
 No requirement to run CASC courses, for example

26.  (2) For the purpose of attaining the aforesaid objects but not further or
otherwise the College may exercise the following powers:
 (a) to encourage and promote amongst its members and others the exchange
of knowledge, information, experience and ideas relating thereto and to
related subjects, sciences and disciplines;
 (b) to encourage and promote amongst its members and others working in
allied and related sciences and disciplines the achievement and maintenance
of the highest possible standards of professional competence and practice;
 http://www.rcpsych.ac.uk

27.  “Accordingly, in my judgement…….. If the Royal College were not to
consider taking steps such as those, it might well be that it would not,
as of now and in the future, discharge its duty under section 149”
 “Such measures have, however, not been the target of this claim. Its
target is the Clinical Skills Assessment itself.There it may be on weaker
ground”

28.  (2) For the purpose of attaining the aforesaid objects but not further or
otherwise the College may exercise the following powers:
 (a) to encourage and promote amongst its members and others the exchange of
knowledge, information, experience and ideas relating thereto and to related
subjects, sciences and disciplines;
 (b) to encourage and promote amongst its members and others working in
allied and related sciences and disciplines the achievement and maintenance of
the highest possible standards of professional competence and practice;
 http://www.rcpsych.ac.uk

29.  Thus the Royal College is empowered to encourage the Deaneries to
address the fact of underperformance by South Asian and BME
candidates in the Clinical Skills Assessment by, for example, providing
training to familiarise and equip them to deal with the assessment or
to provide remedial training for those who have failed at the first
instance.

30.  Key message from McManus study- raise PLAB pass mark but asTiffin
(BMJ,April 2014) himself acknowledges to attain true equivalence the
pass mark will have to be increased to unrealistic levels
 Raise IELTS requirement – but again even a score of 9 would still leave
IMGs with a 50% higher chance of failing
 Provide more UK-based experience

31.  Appoint IMG Champions to create awareness of IMG issues at all levels
of training pyramid
 Work with LETBs (Deaneries) to ensure creation of a system that
enables early identification and remedial processes for IMGTrainees in
difficulty
 Work with Diaspora Groups to establish a culturally sensitive
educational leadership
 Improved examiner and Clinical Supervisor training to help recognise
unconscious biases (accents, manner etc.)
 Improved recruitment processes (ensuring commitment and suitability for
psychiatry)
 Good feedback to trainees in difficulty with appropriate remedial support

32.  Establishment of Diaspora Committee
 Initiation of a mentoring scheme nationally
 Relooking at the revalidation process to identify problems and
remedial actions early
 Raise cultural awareness in the organisations
 Establishing a hotline to capture concerns and distress
 Focussed training in key areas of leadership & management skills

35.  Acknowledge the problem
 DiasporaGroup
 IMG ScopingGroup
 External Review of MRCPsych Exams
 Diversity and EqualityTraining for CASC examiners
 Diaspora Sessions at International Congress- Friday 27th June 2014
 Establishment of MTI Scheme
 Establishment of a sub-Dean post for IMG trainees
 Conference for IMG trainees on 23rd September 2014

37.  ThankYou for listening
 Any Questions?

38.  1976: Community Relations Commission examined possible discrimination in career progression being
faced by doctors from ethnic minorities
 1984: Joe Collier and Aggrey Burke, two senior lecturers at St George’s Hospital Medical School, showed
that some medical schools in London were consistently admitting fewer students with African, Asian, and
Arabic names than were other schools
 1986: Collier and Burke discovered that a computer program used to help select students at St George’s
Hospital Medical School had been downgrading non-white applicants, and informed the Commission for
Racial Equality of the situation
 1987: Commission for Racial Equality showed that doctors from ethnic minorities who had trained in the
UK faced barriers to securing senior medical posts
 1989: A study showed that ethnic minority candidates were 23% less likely to be accepted into medical
school than would be expected on the basis of their academic achievements
 1990: Evidence found for discrimination in competition for training posts
 1993: Aneez Esmail and Sam Everington showed that medical job applicants with Asian names were less
likely than equivalent candidates with English names to be shortlisted for interview

39.  1994: Esmail and Everington showed that doctors from ethnic minorities were six times more likely than
white doctors to be brought before the GMC’s ConductCommittee
 1997: Esmail and Everington showed that candidates with Asian sounding names continued to be less
likely to be shortlisted for interview than equivalent candidates with English names
 1998: Esmail and colleagues showed systematic differences across ethnic groups in the allocation of
distinction awards
 2000: Plymouth Hospitals NHSTrust agreed settlement with two consultants who alleged racial
discrimination
 2003: Esmail and colleagues showed systematic differences across ethnic groups in the allocation of
discretionary points awards scheme
 2011: Researchers showed that ethnic minority doctors who trained in the UK perform less well in
undergraduate and postgraduate examinations than do white candidates
 2013: Esmail and Roberts concluded that racial discrimination may be behind the high failure rate of UK
ethnic minority doctors taking the MRCGP’s clinical skills examination