Abstract

Background
Reasons are unclear for differences in candidate performance in medical examinations by attributes such as ethnicity. Such ‘differential attainment’ is also found in written computer-marked multiple-choice examinations such as the Membership of the Royal College of General Practitioners (MRCGP) Applied Knowledge Test (AKT) where differences are found by ethnicity and country of primary medical qualification. We aimed to investigate causes of differential attainment in the AKT by candidate ethnicity using cognitive interviews.
Methods
We used a qualitative design employing cognitive interviews; a purposive sample of 21 GP specialty trainees (GPSTs) including white British/Irish UK trained doctors and BME doctors trained in the UK or overseas International Medical Graduates (IMGs). We used Grounded Theory to analyse data from ‘think aloud’ interviews of GPSTs while answering up to 15 AKT questions.
Results
Four linked themes were identified. ‘Theoretical versus real-life clinical experience’: participants reported difficulties recalling information and responding to questions from theoretical learning compared to clinical exposure; rote learning helped some IMGs recall rare disease patterns. Recency, frequency, opportunity and relevance: participants reported greater difficulty answering questions not recently studied, less frequently encountered or perceived as less relevant. Competence vs. insight: some participants were over optimistic about their performance despite answering incorrectly. Cultural barriers, for IMGs including differences in undergraduate experience, lack of familiarity with UK guidelines, and language barriers overlapped with the other themes.

Discussion
IMGs face additional difficulties centred on experience, familiarity and language impeding AKT success in specialty training which are potentially amenable to additional training support.