The MSRA: Is this really how we want to choose the anaesthetist of the future?

How we select the next generation of anaesthetists has always been a question of much debate. What qualities make a ‘good’ anaesthetist? How do we identify these qualities in a group of already highly qualified doctors? In an ideal world we would assess the merits of each applicant to ensure that we have a fair recruitment process. However, as the number of applicants increases each year without any increase in the capacity to assess them, the Royal College of Anaesthetists (RCoA) and NHS Workforce, Training and Education (NHS WTE) have had to explore more ‘efficient’ ways to appoint from thousands of applicants. Their answer to this has been the introduction of the Multi-Specialty Recruitment Assessment (MSRA) to Core Training applications in 2021.

Introduced under controversial circumstances, there is confusion regarding this exam with unclear explanations from the RCoA and NHS WTE as to the evidence behind its introduction and ongoing usage. This controversy reached a nadir this year, when industrial action limited numbers of available interviewers. The MSRA threshold was subsequently raised in order to reduce the number of applicants that progressed to interview. This resulted in many with scores that in previous years would have put them in the top 20% nationally not being offered an interview. Given this concerning precedent, we, the authors of this article, want to pause and review the evidence and utility for this exam and what it means for the future of recruitment in anaesthesia.

What is the MSRA?

The MSRA is an exam set annually by the NHS Work Psychology Group. The MSRA is a Multispecialty Recruitment tool developed since 2013 and was originally based on the GP selection exam (Table 1) [1]. It consists of two parts – a Professional Dilemmas (PD) paper and a Clinical Problem Solving (CPS) paper [2].

The PD paper is a ‘Situational Judgement Test’ and assesses a candidate’s response to a challenging professional scenario. It assesses 3 core competencies: Professional Integrity, Coping with pressure and Empathy and Sensitivity and consists of two question types - ranking scenarios and multiple choice scenarios (Figure 1). The scenarios are set within the context of the Foundation Programme and are written by what NHS WTE describe as ‘Subject Matter Experts’ (SMEs). NHS WTE does not provide any description of the SMEs only describing them as a ‘well-established team of trained item writers’.

The CPS paper is an assessment of clinical knowledge and decision making. Its ‘Target Domains’ are described in Table 2. Example questions are shown in Figure 2. NHS WTE state the questions are all relevant to the Foundation Year 2 Training Programme. There is no written syllabus to aid applicants in their exam preparation.

The MSRA does not have a ‘maximum’ mark so candidates are ranked by their performance (regardless of specialties applied for) and scored on a bell curve. Each specialty that uses the MSRA as part of its selection process utilises a candidate’s score differently. GP allocates training places purely based on MSRA score whilst other specialties use it as a cut off to inviting applicants to interview.

Anaesthetics currently ranks applicants by their MSRA score and invites a set number to interview. The applicant’s interview score makes up 85% of their total application score with the MSRA making up the remaining 15%. In the most recent 2024 recruitment round, only 727 applicants were invited to interview from an estimated 3000 applicants. The MSRA has now become the main barrier to securing a training place.

Analysis of the MSRA

This exam was initially introduced with limited evidence, to understand if it could lighten the workforce required for the prior recruitment methods. Three years on, it looks it won’t be going anywhere.

The justification for its continued use is that a high MSRA score correlates with success in the Primary FRCA. The held data on this has not been published for public analysis and scrutiny. We would encourage the RCoA to publish their data as a matter of transparency to alleviate the concerns of applicants. Ultimately, all this correlation shows is that we recruit people who can pass exams (any exams). Differential attainment (specifically for sex and ethnicity) is a significant issue in the world of medical training, and is reflected in significant inequities with regard to Primary FRCA pass rates [3]. Unfortunately, the world is not a meritocracy. It is widely known that ability to pass an exam is hugely dependent on a number of non-merit based social factors. This is illustrated

well by an analysis of the pass rates of the American Board of Surgery exams. For this exam, partnered men with no children have the highest likelihood of passing. Interestingly, their partnered female counterparts have a far reduced likelihood of success. Married women with children have almost 30% less likelihood of passing in comparison to their male counterparts [4].

A recent review also recommended the entire Structured Oral Exam (SOE) be removed entirely [5]. Therefore, are we choosing anaesthetists based on their ability to pass an exam that will soon be irrelevant?

Additionally, passing the Primary FRCA is just one element of anaesthetics training and if we go back to our initial question of ‘What makes a good anaesthetist?’ I doubt it would feature on many current anaesthetists’ list. Doctors by nature have become adept at navigating ever-changing goalposts and will tend to succeed at whatever is asked of them – particularly exams.

As per the most recent 2023 GMC workforce report [6], anaesthesia has the least ethnically diverse trainee population with over 70% white anaesthetists in training (average 49.6%). The MSRA risks exacerbating this significant issue. Furthermore, the RCoA’s statement that the MSRA demonstrates ‘small differences in scores due to ethnicity and gender’ have been proven inaccurate with Black, Asian and minority ethnic applicants scoring on average lower compared to White applicants [7].

The introduction of the MSRA has counterproductively led to a sharp increase in the number of applicants to the specialty (Figure 3). Introduced to try and solve the issue of recruitment workload, it has instead increased competition. It should also be noted that while the length of the interview has also been halved, the capacity to interview has certainly not doubled.

Given that the MSRA is valid for application to multiple other specialties, it has encouraged many applicants (previously not seriously interested in anaesthesia) to apply for many specialties in one application round. As competition ratios for all specialties grow, this practice becomes increasingly common. With most specialties using the MSRA as a cut off to interview this leads to the same pool of applicants with high MSRA scores being interviewed for multiple specialties.

Despite application numbers doubling, the number of training places has actually decreased by 10% since 2016. The RCoA has not commented directly on this application trend but continues to state that anaesthesia remains an attractive specialty.

Box 1 ‘Experience from other specialties has been considered, including the robust evidence in place to support the use of the MSRA for shortlisting for CT1 recruitment. Over 50% of all Foundation doctors applying to core training sit the MSRA which has been found to have high reliability, small differences in scores due to ethnicity and gender, and good predictive validity in respect to subsequent scores at interview and performance in training. Approximately 20% of CT1 anaesthesia applicants sat the MSRA as part of applications to other specialties in 2019 and 2020; analysis of this data indicates that the MSRA would work well as a method for shortlisting CT1 anaesthetics recruitment since there is a strong association with subsequent scores at interview and appointability.’ [8]

Suggestions

So, if the MSRA is not the answer to the current recruitment issues, then what is? Ultimately, applicants want a process that is fair and rewards those with a dedication to anaesthesia. Furthermore, an increase in training places will continue to be a core part of the solution.

However, even if this was to occur this does not solve the issue that we currently lack the resources to appropriately assess all applicants. It seems there is a lack of the significant numbers of senior anaesthetists needed to engage with the recruitment process. Whether this is due to inability to be freed from clinical duties, significant workload of being part of recruitment, or lack of engagement with the recruiting bodies themselves, we do not know

How might one improve engagement? Could the answer lie in the recent RCoA Extraordinary General Meeting (EGM)?. Resolution 6 outlined a strong case for regional rather than national recruitment (Figure 4) and was passed with a majority of 88.73%. This process is likely to be fraught with complexities, but some proposed benefits may include:

• Reduction in application numbers - Only applicants with a previous interest in anaesthesia would likely apply
• More relevant recruitment policies - Departments can set recruitment policies that would be specific to anaesthesia e.g. CV/portfolio-based
• Increased senior anaesthetist engagement - They would be working with and training the applicants they are assessing
• Increased competition and standards - It would put the onus on departments to maintain high training standards to attract applications

It is important to point out that both Australia and the USA (popular destinations for UK medical graduates to move to) choose their anaesthetists via regional/local assessment.

However, regional/local recruitment is not without its problems. Nepotism and discrimination have often been cited as reasons against this and there would need to be significant initial work to ensure that regional recruitment policies are fit for purpose. This is not something that can be feasibly implemented in the near future, but a strong EGM result means that it should certainly be discussed.

Conclusion

Eight million operations per year will be cancelled by 2040 due to our future predicted staff workforce shortage [11]. At a time when we should be making it easier to become an anaesthetist, we are making it significantly harder

The introduction of the MSRA has arguably heightened competition ratios, worsened applicant experience, narrowed our specialty’s diversity, and excluded some dedicated and talented doctors from becoming anaesthetists. Its continued usage is based on data which proves MSRA pass only reflects an individual’s ability to pass an exam. This data has still not been seen by anyone other than those who hold it currently.

We must ask ourselves what qualities we want in our future specialty workforce and how we as an anaesthetic community can facilitate a recruitment process that is both fair and efficient. As a specialty with an already high number of notoriously stressful and high stakes exams - the last thing we need is the addition of another before we even embark on our anaesthetic journey

The way we recruit our future colleagues not only guarantees a talented workforce but sends a signal to aspiring anaesthetists that we will treat them fairly, reward dedication and talent, and allow them to thrive in their career. We fail them, and ourselves, by doing anything that does not do this strongly and unequivocally.

Allan Xu, Elected Member, Association of Anaesthetists Trainee Committee
Stuart Edwardson, Chair, Association of Anaesthetists Trainee Committee

References

• 1. Medical Hub. Taking the MSRA. https://medical.hee. nhs.uk/medical-training-recruitment/medical-specialtytraining/multi-specialty-recruitment-assessment-msra/ taking-the-msra/overview-of-the-msra (accessed March 26, 2024). 
• 2. Medical Hub. What's in the MSRA. https://medical.hee. nhs.uk/medical-training-recruitment/medical-specialtytraining/multi-specialty-recruitment-assessment-msra/ whats-in-the-msra/professional-dilemmas-paper (accessed March 26, 2024). 
• 3. Lumb A, Snook N. Differential attainment in curricular components of the FRCA - An Observational Study. 2017. 
• 4. Yeo HL et al. Association of demographic and program factors with American board of surgery qualifying and certifying examinations pass rates. JAMA 2020, 155(1): 22-30. 
• 5. FRCA Examination Review Group. FRCA examination review report of the examination review group, 2023. 
• 6. GMC. The state of medical education and practice in the UK, 2023.
•  7. Watson SA, Wong DJN. Anaesthetic recruitment interview performance and ethnicity. Anaesthesia 2023; 78: 1412–3. 
• 8. Medical Hub, 2023. Competition ratios. https://medical. hee.nhs.uk/medical-training-recruitment/medicalspecialty-training/competition-ratios/2023-competitionratios (accessed March 30, 2024). 
• 9. The Royal College of Anaesthetists. Anaesthetics specialty recruitment, 2021. https://www.rcoa.ac.uk/news/ anaesthetics-specialty-recruitment-2021 (accessed March 30, 2024). 
• 10. Extraordinary General Meeting of the Royal College of Anaesthetists Member Briefing, 2023. 11. Royal College of Anaesthetists. The anaesthetic workforce: UK state of the nation report 2022.