Commentary (on Ragg et al.)

There has been much interest and discussion within the medical education community about the differential rates of achievement in postgraduate medical assessments between UK qualified trainees and those who have qualified overseas. This differential resulted in a judicial review of the Clinical Skills Assessment (CSA) after a highly publicised legal challenge from the British Association of Physicians of Indian Origin (BAPIO) in 2013 against the RCGP and GMC. In the judgement, Mr Justice Mitting exhorted the GMC and RCGP to review the situation and take action to support doctors from other cultures who may be disadvantaged by the present situation. [1] One response has been to consider how best to support those whose performance has given cause for concern and to set in place an analysis of communication issues within the exam itself. The paper from Eleanor Ragg and colleagues [2] in this issue takes a different approach, considering which general factors associated with the candidates training appear to relate to success in the exam. The work builds on a short report published in 2013 considering the characteristics of trainees who pass the MRCGP on their first attempt. [3] There is considerable concordance between the two studies; both described strong benefits from supportive relationships allowing honest constructive feedback to trainees. The early identification of the challenges allowing trainees to take responsibility and plan their study within an organised educational framework was perhaps not a surprising outcome. Insight into the trainees’ own learning needs, the ability to maintain self-discipline, be organised, positive and proactive and the need to formally learn communication skills might all have been expected. But the strong emphasis on supportive, trusting relationships and methods such as joint teaching surgeries is an interesting finding common to both studies. As Eleanor Ragg and colleagues state, barriers to ‘an impressive level of openness and trust’ allowing a ‘willingness to share perceived personal weaknesses and deficiencies’, need to be researched further. We need to consider not just the way that trainees relate to their patients, but also the way that supervisors work with trainees to develop their communication skills and knowledge about General Practice and the consultation. We have always recognised that when it works well the apprenticeship model in ST3 is capable of producing highly effective change and educational benefit, but perhaps we have not previously analysed why this model of teaching is fit for purpose in the modern context. What is it about this key supportive relationship that allows the efficient transfer of the complex skills exhibited in every successful consultation? The management literature has long considered the factors which allow the maximisation of the communication of knowledge and skills within organisations. McAllister writing in 1995 [4] set out a framework which developed the concepts of cognition-based and affect-based trust between colleagues. These concepts have been refined and developed subsequently in many different areas, with similar results. Broadly, it appears that while respect for professional abilities and problem solving (cognition-based trust) allows professional association and the transfer of explicit knowledge, it is affect-based trust that allows emotional openness without vulnerability and the sharing of tacit knowledge, that is the subjective, deep knowledge we use for key strategic decisions. This type of communication is usually face to face and corresponds to the ‘know it when I see it’ recognition that is required for the CSA. [5] What then is the impact of culture on the development of affect-based trust within a professional educational relationship? An interesting perspective on this is the impact on creativity in professional relationships demonstrated in some novel work from Harvard. [6] Experiments with groups of managers in multinational