Diaspora psychiatrists

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

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  • 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 3. PMQ : Primary Medical Qualification IMG: International Medical Graduates EEA: European EconomicArea UK: United Kingdom 4. 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 5. Paper 3 Pass Rates by Country with Attempts & Gender 6. CASC Pass Rates by Country with Attempt s & Gender 7. 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% 8. 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) 9. 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 10. 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 11. 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. 12. 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. 13. 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." 14. 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 15. (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 16. 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 17. (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 18. 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. 19. 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 20. 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 21. 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 22. 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 23. ThankYou for listening Any Questions? 24. 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 Georges 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 Georges 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 25. 1994: Esmail and Everington showed that doctors from ethnic minorities were six times more likely than white doctors to be brought before the GMCs 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 MRCGPs clinical skills examination