The IMG and the SCA.

The RCGP published its SCA performance interim report at the end of last year. It showed, among other things, that the IMG pass rate in the SCA stood at 51.5% and the UK Graduate at 94%. To put this into context, 1 in every 2 IMGs fail the SCA.

But why is this the case? I have noticed the following recurring issues in IMG colleagues

1. Lack of structure: colleagues with a clear structure tend to cover all bases well and finish their consultation in good time. They tend to start management early and so don’t have to rush towards the end, avoiding losing key marks in the relating to others and management bit. They’re also more likely to pass even stations they don’t know just by having a solid structure. They are a joy to watch as the flow is good and there is no ‘stalling’. I am yet to see a single colleague with a structure fail the SCA.

2. Not knowing the exam: the SCA is misunderstood by many. It is a communication exam that looks at the level of a day 1 independent GP. It is not a knowledge exam. I often hear IMG colleagues call it a subjective exam but I disagree. You can almost always tell who is going to pass and who isn’t. From the standpoint of an IMG, it is just particular exam. It needs to be learnt. Once learnt, it will easily be passed.

3. Being an hospital doctor: most of us have backgrounds as hospital doctors. I have huge respect for our hospital colleagues. Having worked in various specialities, being a GP is different. The GP is the ultimate risk taker and holistic clinician. You do the clinical bit without the resources of hospital colleagues. You don’t just treat the medical condition. You treat the illness. You address all the issues surrounding the patient and the community. You want to know how the disease has affected them in all facets of life and also how it can affect their family, work, personal life, sleep, comfort and ability to perform their responsibilities. You then want to bring those highlighted points to the management bit and address every part of life where the disease process has been felt.

4. Not being a good service provider: imagine a customer meets me in a shop wanting to buy milk but I hand them sugar. The ‘customer’ needs to be happy that what they come for has been addressed and if not realistic, talked about and a middle ground reached. They want to have clarifications made to what they think is happening to them and what they’re worried about, considered and discussed. They want to go home knowing clearly what the next steps in their care are and when to seek further help. Their ideas, concerns and expectations need to be sought in a conversational and non-formulaic way such that the very inner thoughts of their minds are uncovered and dealt with.

5. Not communicating with the examiner: the SCA requires a doctor to not just speak with the patient but also, indirectly, the examiner. Imagine asking a patient with suspected gastritis if they take OTC medication versus saying something like ‘just because some medications can do this to you’ do you take ibuprofen OTC? Who would the examiner think knows what they’re doing? The examiner needs to be able to tell what the doctor is doing at all parts of the consultation. The differentials need to be excluded in a back to back fashion rather that a wide questioning of all related symptoms that makes the examiner wonder if the doctor actually meant to exclude those differentials or only wanted to ask all related symptoms and ‘shoot their shots wide’. Nailing questions need to be used to exclude/include differentials in a clear way and organised way.

6. Not being a scientist: a doctor is a scientist first. Everything done in a consultation is in keeping with scientific principles. A doctor gathers information from history, looks at the patient notes, examines the patient and use all information gathered to make a diagnosis and proceed to manage the problem. Nothing is imagined or assumed. A male who has followed the male patient to their consultation isn’t automatically their brother. They can be a friend, father, cousin, neighbour or even wife/husband! Only issues factually established are taken as face value and built upon. Diagnosis and differential are made based on evidence gathered from the history or doctor’s brief. A diagnosis or at the very least, a working hypothesis must be established. It is the very foundation that the management is built upon. Expressed ideas of the patient have to be refuted or reinforced based on facts gathered.

There are a few other minor reasons for failure but the above are by far the commonest reasons I come across and the issues I spend the bulk of my time addressing with colleagues who previously failed. Once corrected,colleagues typically go on to pass with significant score jumps.

Disclaimer: the above mentioned points are from personal experience helping over 120 IMG pass the SCA especially colleagues with previous fails. Dr Ola Fajinmi.

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