Ethnic Minority Doctors 'Held Back Throughout Their Careers'

Liam Davenport

February 14, 2020

Ethnic minority doctors in the UK face discrimination that means they not only experience racism at medical school but also suffer an attainment gap versus their white counterparts that leaves them lagging behind at all stages of their career, reveals a series of papers.

The papers form part of a special issue of The BMJ focused on race and its impact on health that highlights how the issue affects all aspects of medicine, from initial training through to specialty post applications and even the amount consultants are paid.

It follows a recent survey showing that, although almost a third of the NHS workforce is from an ethnic minority background, they are more likely to be bullied and scapegoated than their white counterparts, and are twice as likely to be referred to disciplinary investigations.

Guest editor of the issue Victor Adebowale, who is incoming Chair of the NHS Confederation, said that tackling these disparities and achieving racial equity will require "organisational transformation, and leaders with the courage and ability to shift the culture".

However, one doctor turned senior NHS manager who spoke to Medscape News UK suggested that real and meaningful change will be achieved only by looking beyond race and tackling nepotism and tribalism in all its forms.

The Appointability Gap

In 1993, Aneez Esmail, now professor of general practice at the University of Manchester, and Professor Sir Sam Everington, a GP in Tower Hamlets, showed, by submitting fake CVs to apply for senior house officer posts, that ethnic minority doctors were less likely to be successful in securing specialty training.

Unable to repeat the exercise for the current analysis, Prof Esmail instead looked at the proportion of applicants for specialty training posts who were deemed ‘appointable’ for the post.

In the UK, a doctor who has completed foundation training will need to be approved as ‘appointable’ to apply for specialty training posts, following interviews at regional recruitment offices or deaneries.

An individual may not be considered appointable due to their level of experience, competencies, examination results, or failure to attend an interview.

Examining data from the General Medical Council for the years 2016–2018, Prof Esmail found that 75% of 31,430 white applicants were deemed appointable compared with only 53% of 29,072 ethnic minority applicants.

In The BMJ, Prof Esmail described the results as "shocking", and noted how "they show a lack of progress" in the years since his original investigation.

He added: "I would have expected to see ethnic minority doctors achieving the same outcomes as white doctors, but that is simply not the case. It is very disappointing and, frankly, unacceptable in this day and age."

The Attainment Gap

The findings were echoed in a feature by Samara Linton, a junior doctor and writer, on differences in attainment between ethnic minority and white doctors in the same issue of The BMJ.

She points to recent data indicating that ethnic minority doctors are less likely to pass postgraduate examinations than their white counterparts.

While they are more likely to apply for consultant posts than white doctors, those from ethnic minorities are less likely to be shortlisted and less likely to be offered a post.

Moreover, one study showed that, when looking at basic pay, consultants from ethnic minority backgrounds are paid on average 4.9% less than white consultants.

This pattern of attainment difference, the article underlines, has been identified in other countries, including the USA, Canada, Australia, and the Netherlands, as well as across UK higher education.

Katherine Woolf, associate professor in medical education at University College London, writes in an accompanying editorial that: "Differential attainment appears at medical school and persists after qualification.

"As a result, ethnic minority graduates of UK medical schools have worse outcomes during recruitment for foundation, specialty training, and consultant posts; are more likely to fail examinations; and progress more slowly through training even when exam failure has been accounted for."

The Reporting Gap

But the issue does not begin only once an individual has become a doctor.

An investigation published in the special issue and conducted by The BMJ and the British Medical Association (BMA) set out to examine the degree of racism and racial harassment at medical schools in the UK.

Zosia Kmietowicz, news editor at The BMJ, reports that, of 40 medical schools in the UK, 32 responded to a freedom of information request but only 16 said they collect data on racism and racial harassment.

And those medical schools said that, since 2010, they have recorded a total of only 11 complaints.

This mirrors recent data reported by the Equality and Human Rights Commission indicating that, over a three-and-a-half-year period, UK universities recorded 560 complaints of racial harassment.

This was despite 60,000 students reporting that they had made a complaint.

Dr Olamide Dada is the founder of Melanin Medics, which supports students and doctors from the African-Caribbean community.

She told The BMJ: "As someone who has been in contact with a large number of medical students I have personally heard of many, many racial incidents, and I have also experienced them but have not complained."

Prof Woolf adds that, even if students make a complaint, many believe it will not be taken seriously.

"Racism and racial harassment are real issues, and medical schools often do not have the best supporting structures for people who want to make a complaint," she said in The BMJ.

"But they have a duty of care to all their students. It’s a tricky area that requires more conversations and more clarity."

In response, The BMA is launching a charter that offers best practice guidance for medical schools to:

  • Support individuals in speaking out

  • Ensure robust processes for reporting and handling complaints

  • Ensure that equality, diversity and inclusion are priorities across the learning environment

  • Address racial harassment at work placements

The papers also put forward a number of potential solutions to tackle racism along the medical journey and end what Prof Esmail calls the "waste of talent".

These include peer and mentor support, fairer workplace assessments and improvements in the learning environment, all backed up by research into the most effective interventions.

The Everything Gap

Nevertheless, the differential attainment seen on average among ethnic minority doctors is, in reality, experienced on an individual level, and may not be the same from one person to the next, both in terms of its impact and its underlying causes.

One doctor, who is now a senior manager at a London teaching hospital, believes that it is only by looking beyond solely race and recognising this plurality of factors and outcomes that meaningful improvements can be achieved.

The doctor, who wishes to remain anonymous, told Medscape News UK that "what the data absolutely shows is that there is a gap in attainment...between a certain group and another group, and some people label this as a manifestation of some sort of racism".

"My observation is I would go a bit wider than that and say it ‘can’ be. You can look at it in one context as conscious or unconscious attempts that basically reduce one group of people, or you can see it as conscious or unconscious attempts that elevate another group of people."

He continued that he would "ascribe much of what we are seeing to variations of what we could label as tribalism/nepotism...which is to take more interest and elevate those who we perceive as ‘more like us’ and less interest in those who we perceive to be ‘less like us’".

He explained that the "kind of dimensions of ‘are people like me or not’ are social, educational, racial...and I think we see all of that playing out and influencing the data that has been shown".

"What is clearly the case is when you have senior people who are teaching, who are interviewing, who are appointing to jobs, those people are predominantly of a certain racial and social type, and I think what we’re seeing is those people are inherently elevating and inspiring more people who are they perceive to be part of their ‘set’.

"So if you are a white, male, junior doctor and if the most senior leaders are also white males, you probably relate more to them; you might try harder to impress them because of that sense of belonging, you are likely to feel more confident in the environment and about your prospects...and I think we see those sets of feelings and interactions play out throughout people’s careers."

And when this "is about tribe, or how much this person is like me", he said, "ethnic elements of race may be trumped by cultural, geographical perceptions of race".

To give an example, he said: "Let’s take two types of people who are ethnically Asian. There’s one who went to school here and medical school in the UK.

"I think their experience could be completely different from someone who has trained in Bangalore and come over to the UK as a postgraduate student."

He continued: "One is likely to feel much more ‘in the tribe’ than the other, and if we start to split the data along those grounds, I think we may start to see two gaps," one of which "may be very small".

Echoing ideas alluded to in several of the papers, the doctor said that, as a manager, he prefers to talk about inclusivity and "helping everyone to be the best that they possibly can be".

He continued: "For our patients to receive the best care, we need all our staff to give of their best, so from that perspective you want to invest in everyone and give everyone the opportunity to maximise their potential and attainment.

"The behaviours manifest in tribalism, nepotism and racism can all count against that. It means you’re wasting talent, you’re wasting ability. Then, any grounds for not enabling and supporting people to be their best are a problem for me.

"That can be gender, country of origin, colour of skin, accent, sexual orientation: it can be any of those things."

But how can the problem be solved?

As was discussed in the papers, solutions involve more mentoring and nurturing of talent, "and, certainly, we need more senior people for students and trainees from minority groups to be inspired, motivated and championed by".

He said: "Of course, there is also some of what I would call aggressive, conscious efforts on the part of some people to marginalise individuals from certain minority groups. And we absolutely must acknowledge that and call it out for what it is.

"But, in the short term, I think we should really look at how some of these tribal or relational instincts can be used positively: so, where we have got clinical leaders from minority ethnic groups, let’s really encourage them to be more visible in mentoring and pulling through BAME students and trainees.

"Of course, over the medium-to-long term, we want an environment in which all our leaders feel able to connect to, relate to and inspire the diverse workforce we have."

No funding or conflicts of interest declared.

Racism in Medicine. The BMJ, 2020.


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