1. Adapted from work by Celia Roberts Professor of Linguistics at Kings College, London

2. Cause for concern: the under performance of minority ethnic candidates Can social theory help us understand these complex factors? Simulations Linguistic capital : Examples of problems Evaluation of failed candidates Conclusions

3. Ethnicity Pass rates for white candidates 93.6% Pass rates for ethnic minorities (all) 68% Country of Graduation UK 91.6% EEA 72% Non European 56.9%

4. Ethnicity White 93% Asian 74.1% Black 64.5% Country Of Graduation UK 90.9% EEA 65.2% IMGs 70.3%

5. It isnt as simple as command of English Self-reporting of first language other than English is surprisingly low Place of graduation packages up many factors all of which may inter-relate

6. Pierre Bourdieu Concept of habitus Products of early opportunities and constraints, particularly early socialisation within the family. Cultural, social and linguistic capital Those in power have more of this symbolic capital The fish in water

7. Overseas graduates least likely to have acquired it British working class and ethnic minority groups are less likely to be socialised into this form of linguistic capital. Those whose habitus has prevented them from acquiring the dominant linguistic capital will have less feel for the game. Its harder to be a fish in water

8. Du Bois notion of Double Consciousness among minority ethnic professionals: compartmentalisation, maintaining distinct cultural spheres Impact on simulated consulting

9. Additional pressure on those who have relatively less linguistic capital and so less feel for the game The double consciousness of IMG candidates – where have a double simulation, particularly in those areas of sensitivity and empathy which are crucial to being successful in the CSA. Those with a feel for the game will have the capacity to be hyper –real in order to play to the examiner. It is possible that the CSA puts more pressure on non middle class EM candidates and those who graduated abroad than the old style consulting skills exam of real consultations

10. Over-modelling Result of required ideological shift and lack of support to do so Recipe –like, formulaic, the bones showing through the flesh

11. Over direct and/or formulaic, very little mitigation or hedging D: Did you know why we did the X-ray? Too much direct questioning to elicit expectations/concerns D: Is there anything particularly worrying you ? (When the patient has already expressed her worries) No immediate listening to patients concerns P: Ive had heart problems and I was told to come in to-day D: Just going through your medical records, you have been hypertensive for some time.

12. Patient given bad news that may have cancer And how does that make you feel? Patient shakes his head and shrugs his shoulders What do you think about it, are you happy for me to refer you? I dont feel happy about anything What are you not happy about?

13. Overly Categorising this is a high risk pregnancy without mitigating the bad news – (no sunny pairing ) Lets talk about your obesity

14. 1. Does not develop appropriate management plan. (Unsurprising since the development of management plan draws on the whole consultation) 2. Does not develop shared management plan 3. Does not identify patients agenda/preferences or make use of cues 4. Does not recognise the challenge 5. Too Dr-centered 6. Does not use relevant and understandable explanations 7. Disorganised and unsystematic gathering of information

15. Frequent comments about the evidence of weak candidates interpersonal skills: Eye contact Didnt ask open questions Being formulaic and interrogative Unable to explain effectively But none of these in isolation account for the way the whole interaction is going. They are often proxies for more subtle features

16. Not easy to categorise why CSA so challenging for this group Need to find ways of helping students to develop an appropriate habitus and linguistic capital at the undergraduate and training levels Develop an analytic language and ways of supporting those on preparation and re-sit courses by working on the detailed ways of realising the positive generic indicators. Emphasis on listening, relating and a more organic mode of interacting Background the models Acknowledge the challenges of the double simulation for many minority ethnic group candidates and provide opportunities for plenty of practice.