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Rapid Responses: Rapid Responses published:
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More analysis is needed
- J M Bland (23 October 1998)
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Experience at the Bar suggests that urgent self-initiated changes are essential
- Wai-Ching Leung (28 October 1998)
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Discrimination in selection for medical school
- Neil Bradbury (30 October 1998)
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Paper is misleading about St Andrews
- C Michael Steel (30 October 1998)
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Racism in medical school admissions
- J J L Mann (30 October 1998)
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Discrimination in medical school
- Kirsten Reed (30 October 1998)
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A few questions from Dundee University Medical School
- Parratt (5 November 1998)
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Selection of medical students
- A J Crisp (5 November 1998)
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Re: A few questions from Dundee University Medical School - The published results were correct
- Wai-Ching Leung (6 November 1998)
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Untitled
- S D McCabe (9 November 1998)
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Selection of Medical Students
- Simon Paterson Brown (10 November 1998)
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Selecting Medical Students
- J D Beard (12 November 1998)
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"And I am black, but O! my soul is white"
- S Patel, A Singleton (17 November 1998)
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Untitled
- Raman Bedi (25 November 1998)
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J M Bland, Prof of Medical Statistics St George's Hospital Medical School
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There are some fundamental omissions in Prof McManus's analysis, which may be no fault of the author but which, in my opinion, invalidate the research. GCSE grades and predicted A level grades are not included. These are among the main factors which influence selection for interview at St. George's and no doubt elsewhere. This is rather like trying to investigate the causes of stroke without taking blood pressure or cigarette smoking into account. In a past analysis of applications to St George's (1988-90) there was a clear difference in O level scores between European (mean 21 points, n=1882) and Asian (mean 19 points, n=845) applicants without A levels, for whom O level results would be the main indicator of academic attainment. These are not representative samples of the ethnic groups. The proportion of university applicants applying for medicine is much greater among applicants from ethnic minorities than among European applicants. We thus may not be comparing like with like. We are not dealing with representative samples of Europeans and Asians here, but with the extreme upper tails of the distribution of academic attainment. The greater proportion of applicants for medicine from ethnic minorities may imply that this group of applicants contains more relatively weak applicants than the European group. The O level scores described above support this view. Do the adjusting variables explain any of the difference between ethnic groups? The author mentions many variables which do not explain the difference in offers by ethnicity, but does not show us whether the different ethnic groups differ in these variables. Only the adjusted odds ratio is given, without the un-adjusted odds ratio with which it could be compared. There is no frame of reference. Does this phenomenon applies to medical schools only, to the Universities as a whole, or to other sectors with high applications per place, such as Oxbridge, old universities, other high demand subjects? The analysis applies only to applicants in medicine. It seems unlikely that staff concerned with admissions to medical schools are universally racially prejudiced whilethose in other university sectors are not. We should also admit that everybody is prejudiced, including ourselves. The language of this paper, which refers consistently to the `disadvantage' experienced by applicants from ethnic minorities, prejudges the issue, for example. In every walk of life we should guard against predjudice, but we should not assume that a difference in success rate is in itself evidence that this is the explanation. |
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Wai-Ching Leung, Senior Registrar in Public Health Medicine Northern Region Public Health Training Scheme
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In her commentary on the legal implications of McManus’s findings that applicants from the ethnic minority groups were disadvantaged in their applications for entry to medical schools, Demetriou (1) focused on the legal rules which would be applied if an individual seeks compensation for alleged racial discrimination. However, the enquiries into her own profession and the Bar’s vocational course between 1993 to 1995 could throw further light on the issues. Like the current state in medicine, racial discrimination occurred at every stage in one’s career at the Bar a few years ago. In 1993, Dame Barrow conducted an enquiry into complaints about racisim at the Bar’s law school. (2) Besides allegations of racial discrimination in its selection of students, the failure rate for ethnic minority students on the Bar’s vocational course was almost three times that of white students. Although no conclusive evidence for direct discrimination was found, students from the ethnic minorities were found to be significantly disadvantaged. Ethnic minority barristers were also disadvantaged in seeking pupillage and tenancy. (3) Although direct discrimination was not proven, these findings initiated a wide-ranging agenda for self-reform to tackle the issues by both the Bar’s law school and the Bar Council. (4) Access to the Bar Vocational Course was broadened through a scheme to allow institutions other than the Inns of Court School of Law to teach it. To illustrate the legal principle of proving indirect indicrimination, Demetriou stated that an applicant from an ethnic minority group might show that medical schools placed significant weight on A level predictions when deciding whether to offer, and that applicants from ethnic minority groups received lower predictions than white applicants. However, judicial review may be an easier and more realistic legal option. In 1994, the Bar law school proposed to introduce new selection methods, which included A level results and a written “critical reasoning” examination paper, but completely ignored the degree results. More than 50 students sought judicial review against the Bar law school, and the new selection methods had to be significantly revised. (5) The Bar law school applicants were only required to show that the selection methods were unreasonable. Similarly, the applicants to medical school could argue that using predicted A level grades as selection criteria is unreasonable if they have poor predictive value. Irrespective of the details of the legal analysis, experience of the Bar's law school suggests that after the publication of McMannus’s results, urgent self-initiated changes are essential if the Deans at the medical schools wish to avoid legal challenges. Reference 1) Demetriou M Some legal aspects arising from the study BMJ 1998;317:1111-1117 ( 24 October ) 2) Gibb F. Bar school to tackle racism;Law The Times 4 May 1993 3) Gibb F. Unequal before the law. The Times 14 November 1995 4) Goldsmith P, Beloff M. How to attract the best to the Bar; Law The Times 16 May 1995 5) Gibb F. Law students threaten Bar school with action, The Times 23 April 1994 |
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Neil Bradbury
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Dear Sir I read with interest the paper by McManus and editorial by Abbasi on this sensitive subject. The conclusion of both authors is that medical school selection discriminates against people from ethnic minorities. This conclusion was reached despite no data being available on past or predicted examination results, textual statements made by applicants and referees or the interview procedure. These, of course, are the major dicriminators used to select applicants to medical school and this is another example of garbage in garbage out! In addition, Abbasi's own figures clearly state that 6% of the U.K. population is Asian and 21.7% of Asian applicants are offered a place at medical school. These articles are not science - they are politically correct nonsense and I am very sorry that you feel they merit publication. Neil Bradbury FRCS |
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C Michael Steel, Professor in Medical Science University of St Andrews
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Readers of Professor McManus¹ paper (23rd October) might be misled into believing that, in 1997, it would have been unwise for a prospective medical student from an ethnic minority to apply to St Andrews. The reality is that for those who met - or were predicted to meet - our clearly published academic entry requirements, the chance of receiving an offer was 98.5% (compared to 97% for comparably qualified white applicants). It is doubtful whether these offer rates were equalled by any other UK medical school. Why the difference between perception and reality? Several factors are relevant. First, Professor McManus based his calculations on achieved A level or Highers grades whereas, for the former at least, medical school selection has to be based largely on predicted grades. At St Andrews, and probably elsewhere, the relationship between predicted grades and likelihood of an offer is far from linear but shows a marked threshold effect, offer rate below the threshold being effectively zero. Second, for those applicants attempting to achieve the required entry grades at a second or third sitting, we take account of achieved grades at previous sittings and at GCSE, which were not included in Professor McManus¹ dataset. There are other deficiencies in Professor McManus¹ approach. It may be, however, sufficient to note that fewer than 50% of ethnic minority candidates met our academic threshold, (compared with over 70% of whites), that ethnic minority applicants who were re-sitting had correspondingly weaker academic credentials when GCSE and first sitting A level results were assessed and that overall, the simple odds ratio for receiving an offer from St Andrews (ethnic minority vs white applicants) corresponds exactly to the odds ratio for meeting our academic entry requirements. Finally, though the number of applicants from different subgroups taking up places in particular medical schools measures student choice as well as the schools¹ selection procedures, it may be worth recording that the proportion of St Andrews entrants in 1997 who were from ethnic minorities exactly matched the proportion who applied. The difficulties inherent in digesting and analysing limited and incomplete data are properly emphasised by Professor McManus but, given that this is by no means the first publication to address the issue of equity in selection for medical school places, it is unfortunate that more time was not taken to ³dig deeper into these data², to analyse other evidence and to draw more reliable conclusions. In conclusion, the important point to remember is that the evidence clearly confirms that the University of St Andrews¹ approach to applications is driven by purely academic criteria. C MICHAEL STEEL Professor in Medical Science DAVID JACKSON Admissions Officer Medical Science DAVID W SINCLAIR ProDean Medical Science STEPHEN R MAGEE Director of Admissions |
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J J L Mann
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Dear Sir or Madam I am an ethnic minority student who would like to take a gap year. It is a great pity that you published this information about prejudice only after I and many other students had already sent off our UCAS forms because of the early Oxbridge closing date. My name does not reveal my ethnicity, but it is something I wanted the university to be aware of and I mentioned my cultural background on my form. I didn't want to be accepted at a college which was prejudiced against ethnic minorities. I am relieved to see that two of my choices, the Royal Free and Newcastle hold good in both fields, the gap year and anti-racism. But your new information poses a problem for black students who are yet to apply. Should they aim for all the colleges who are not prejudiced, thereby increasing pressure on ethnic applications, or should they hope that the shamed colleges will respond swiftly to your revelations? Next years results will be telling. Yours sincerely Jack Mann 42 Duchy Rd Harrogate N Yorkshire HG1 2ER |
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Kirsten Reed
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Editor – The study by McManus1 strongly indicates that students are discriminated against, directly or indirectly, in the process of selection for medical school. I applaud the attention given by the BMJ to this important area23 and suggest that it is crucial more research be carried out into discrimination suffered by students not only in the selection process but also within the medical school environment itself. Whilst an undergraduate in a London medical school in1996-7, I was involved in a student-led initiative in which we set out to explore students' concerns regarding, and experiences of, equal opportunities related problems. We carried out a research project4 in which 48 fourth year medical students from a total year group of 116 completed a questionnaire. In it we invited them to outline personal experiences of discrimination based on gender, race/ethnicity, religion/culture, sexuality, parental status and socio-economic background, and to indicate how they would approach such problems. We found that 50% of our sample felt they had been discriminated against in one or more of the above areas whilst in the clinical environment. 75% would be unlikely to make a complaint or report an incident in which they felt they had experienced discrimination to academic or clinical staff within the medical school, 29% stating as an explanation for this that they would fear repercussions in terms of grades, examination results or future career prospects if they were to voice their concerns. Our main conclusion was that despite experiencing considerable discrimination, students feel isolated, unsupported and often unable to make their worries known to the medical school. While this was a small, financially unsupported research project, we feel that the issues it raised, along with previous data5, indicate that there is an urgent need for more research to be carried out into this important area. Kirsten Reed House Surgeon University Hospital Lewisham Lewisham High Street London SE13 6LH Graduate of King's College School of Medicine and Dentistry, July 1997 1 McManus I C. Factors affecting likelihood of applicants being offered a place in medical schools in the United Kingdom in 1996 and 1997: retrospective study. BMJ 1998;316:1111-6.(24 October) 2 Esmail A. Commentary: League tables will help. BMJ 1998;316:1116.(24 October) 3 Abbasi K. Is medical school selection discriminatory? BMJ 1998;316:1097 -8.(24 October) 4 Reed K, Cowley K, Blackwell B. ‘Consultants don't like ethnic boys without public school accents': an investigation into medical students' experiences of discrimination and harassment. Presented in poster form to the Association for the Study of Medical Education Annual Conference, May 1996 (unpublished) 5 McKenzie K. Racial discrimination in medical school. BMJ 1995;310:478- 9[editorial; comment] |
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Parratt , Senior Lecturer Ninewells Hospital & Medical School, Dundee
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We refer to the study by McManus on factors affecting admission to medical
schools.1 We have many reservations about this paper, particularly as to
its methodology which we believe is flawed. However, there appear, to us,
to be discrepancies in the presented data which are misleading.
We refer to Table 2 in the paper and its comparison with Figure 3 which
deals with the possible deleterious effect of ethnic origin on admission
to medical schools. In Table 2, Dundee University Medical School is "black
-spotted". Table 2 results are described as "combined" from the 1996 and
1997 UCAS data. Although it is not clear how such a combination of data
has been achieved it would be reasonable to assume that the mean odds
ratios (OR) from Figure 3 have been used.
If our assumption on this is correct we reason that an error may have
occurred. The mean OR for Dundee is 1.80 and this is awarded the "black
spot" in Table 2. However, Aberdeen (OR=1.85), Belfast (OR=4.0), Oxford
(OR=2.15) and Glasgow (OR=2.0) all have greater mean OR's but are
displayed in table 2 as free from ethnic minority bias.
We would ask the author to address this paradox or to explain to us the
derivation of the data in Table 2 in more detail than is contained in his
paper. It hardly needs to be stated that if such an error exists the
validity of the whole content of Table 2 has to be questioned. Given that
the Table has been recommended to applicants and their advisors in schools
and colleges as a kind of "Which" guide as to where it is best to apply,
the consequences are serious.
We are confident that our own admissions policy is fair. Our internal
audit of 1997 applications using predicted examination data and personal
achievement scores for all applicants shows an OR of 1.12 for "whites"
versus "ethnic minorities". It would seem to us that contrary to what is
displayed in Table 2 of the McManus paper, ethnic minority applicants
would be well advised to consider applying to Dundee.
Finally, Figure 1 in McManus' paper seems to indicate that, overall, ethnic minorities are disadvantaged in respect of offers made. Can this be the case when the data in the Figure is based on actual examination results and not the predictions which most of us use when making our offers? We, like our colleagues in St. Andrew's2, find that a higher proportion of "ethnic minorities are rejected because of poor predictions than is the case for "whites". There may be a disadvantage, but it is not of the making of the medical schools. Excluding Highers from the analysis is also inappropriate and we have many reservations about the validity of the McManus paper in respect of Scottish Medical Schools. We are of the view that an independent analysis for Scotland is needed. We would, however, reiterate that ethnic minority candidates should not be deterred from applying to Dundee. Yours sincerely. Professor DA Levison, Dean Dr D Parratt, Convenor of Medical Admissions University of Dundee Medical School, Ninewells Hospital and Medical School, Dundee DD1 9SY. References. 1. McManus IC. Factors affecting likelihood of applicants being offered a place in medical schools in the United Kingdom in 1996 and 1997: retrospective study, BMJ 1998;317:1111-1116. 2. Steel CM et al. Paper is misleading about St Andrew's. 1998. http://www.bmj.com/cgi/eletters/317/7166/1111. |
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A J Crisp
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McManus's conclusion that the current system of medical student selection is flawed is welcome. (1). The remedy will not follow from "breast-beating" about the profession's conscious or unconscious biases but from a radical reform of the selection process. Head teachers' eulogies, predicted A level grades and students' personal statements are feats of creative writing but are not hard data on which to base life determining decisions. Medical schools effectively demand that 15 - 16 year olds obtain so called "work experience" in a medical or paramedical environment but this is intrusive to patients, unacceptable and subject to unverifiable hyperbole. Many suspect that there is a significant inter-board variation in GCSE standards and question whether a clutch of A* should be the main criterion for an offer. How often has one expected to meet Einstein, Nightingale and Botham reincarnated in one 17 year old after reading the UCAS form, only to meet a pleasant, average teenager? Selection should occur after A level results so that assessors will have more relevant and objective data to consider. All prospective medical students should be required to spend the period between post-A level selection procedures and the start of the course (one year post-A levels) in some worthwhile activity such as auxiliary nursing, laboratory work or community service to demonstrate their motivation, develop their humility and to grow up. Documented evidence of perhaps six months' experience would be required before entry to the course. It is doubtlful whether those who are lukewarm about medicine through lack of motivation or excess of parental pressure would demonstrate this level of commitment. No selection system will ever be perfect but medical students are selected at present on "too few data to reach a valid conclusion" and that allows our prejudices to intrude. Dr A J Crisp Consultant Rheumatologist Addenbrooke's Hospital Cambridge CB2 2QQ (1) McManus I.C. Factors affecting likelihood of applicants being offered a place in medical schools in the United Kingdom in 1996 and 1997: retrospective study. BMJ 1998; 317:1111-7. |
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Wai-Ching Leung, Senior Registrar in Public Health Medicine Northern Region Public Health Training Scheme
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I read with interest the electronic response from Levison and Parratt (1) to McManus’s paper. (2) I found McManus’s description of how the results in Table 2 were derived from the 1996 and 1997 UCAS data in Figure 3 extremely concise and clear, and that his methodology was sound. He stated in his “Significance testing” subsection of the “Method” section that “...A straightforward solution for avoiding inflation (type I error) treats as significant only results nominally significant in both years, defined as a nominal significance level of <0.01, or <0.05 on one occasion and a geometric mean less than 0.01 for example, P=0.05 and P=0.002”. Levison and Parratt objected to the fact that Aberdeen, Belfast, Oxford and Glasgow were not blacklisted. However, from Figure 3, it is clear that the 95% confidence interval for the odds ratio include unity for Oxford in 1996, and for Belfast and Glasgow in 1997. Since p>0.05 for Oxford, Belfast and Glasgow for one occasion, the combined result was appropriately judged to be not significant. For Aberdeen, the lower 95% confidence limits for the odds ratio just exceed unity in both 1996 and 1997 (i.e.. p value is just below 0.05 for both years.) Although one cannot definitely conclude from the figure that p<0.01 without analysing the original data, it is at least highly credible that the combined results are not significant. The methodology is much more appropriate than that suggested by Levison and Parratt. To use the mean odd ratio alone would have ignored the fact that a high mean odd ratio may result from random variations if the small sample sizes in one or more of the ethnic groups were small. In recent years, secondary school teachers and student teachers are increasingly made aware of the dangers of self-fulfilling prophecy if the academic potential of subgroups of students were underestimated. Levison and Parratt suggested that teachers tend to underestimate the A level performance of ethnic minority students compared to Caucasian students. If this were so, it is important to communicate this findings to the teaching profession and institutes running initial teacher training courses. More vigorous studies on the factors which influence the accuracy of teachers’ predictions of academic performance are needed. Reference 1) Levison and Parratt A few questions from Dundee University Medical School eBMJ 5 November 1998. http://www.bmj.com/cgi/eletters/317/7166/1111#EL7 2) McManus IC Factors affecting likelihood of applicants being offered a place in medical schools in the United Kingdom in 1996 and 1997: retrospective study. BMJ 1998; 317: 1111-1117 |
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S D McCabe, general practitioner Portree Medical Centre, Isle of Skye
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The problem with any article which seeks to demonstrate discrimination is that to some extent we are all guilty of bias. To this extent it is perhaps worth recounting my own (n=1) experience. When I was applying to medical schools in the early 1980s I was told in no uncertain terms by at least 3 English medical schools that they could not offer me a place on the basis of Scottish Higher qualifications alone (despite them being good enough to merit an unconditional offer from Edinburgh). How many applicants were admitted to English medical schools on the basis of Highe results alone? McManus fails to tell us. Could this be because such disrimination no longer exists or does it reflect bias on the part of the author? Perhaps what is required is a randomised controlled trial of glasshouses and stones! |
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Simon Paterson Brown
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Dear Sir, The recent study of McManus (1), along with the associated commentaries (2,3), leading article (4) and 'How to do it' paper (5) have confirmed what many have suspected for some time - that all is not well with medical student selection in the UK. Inspite of the plethora of previous studies and publications on this subject by McManus and others, there remains no data to support the suggestions put forward by Powis in his 'how to do it' article on medical student selection. Until we, as a medical profession, identify the criteria required to be a good doctor, rather than simply to pass through the medical school curriculum, the current state of affairs will continue. What sort of message are we sending out to prospective medical students when there is no agreement on the role of the interview and the involvement of non- clinical staff, the advantages of a 'gap' year and the essential academic requirements? Medical students and junior hospital doctors today are faced with a vastly more complicated medical curriculum and intensity of work than their predecessors, in addition to the need for making career decisions at a much earlier stage. What remains clear to all trainers are the following three facts: first, some of the best doctors did not obtain straight A grades at ''A'' level; second, a gap year provides many school leavers with the the time to mature before starting the long and arduous trek through medicine; and third, perhaps the most important requirement of all, the need to have interests outside medicine which will help contribute to a balanced view on life during the years ahead. Yours faithfully Simon Paterson-Brown MS MPhil FRCS Consultant Surgeon and Postgraduate Surgical Tutor Royal Infirmary Edinburgh EH3 9YW Tel: 0131 536 3819 Fax: 0131 228 2661 |
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J D Beard
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EDITOR-In his important paper on the selection of medical students (1), Professor McManus makes the throwaway remark that 'It is naturally desirable that factors such as medical parents.... do not become significant predictors of shortlisting or interview success'. What evidence does he have that this is not a useful attribute? Children of doctors usually understand the huge personal demands made by a medical career and its impact on family life. Such individuals may be more likely to complete their medical education and continue working as doctors. It should come as no suprise that many children of doctors wish to pursue a medical career. The same is true of most other professions and trades. Entering the same profession simply because 'Mummy or Daddy was a doctor' seems a poor reason for selection. However, a young person who has already 'experienced' medicine and who appears genuinely motivated at interview should be encouraged. The 28% of medical school applicants who are asian may be partly explained by the large numbers of asian doctors who were originally attracted into the NHS. I agree with the article on how to do it by Powis (2) that ' A true selection procedure should match applicants with the course of study to maximise the chance of successful completion and to produce a competent and effective graduate professional'. I do not suggest that children of doctors should receive positive discrimination but this fact must not be discounted during the selection process. And before you ask, I have no competing interest as neither of my parents worked as doctors! J D Beard Consultant Vascular Surgeon and Surgical Tutor Northern General Hospital, Sheffield, S5 7AU 1 McManus I C. Factors affecting likelihood of applicants being offered a place in medical schools in the United Kingdom in 1996 and 1997: a retrospective study. BMJ 1998; 317:1111-6. 2 Powis D. How to do it-select medical students. BMJ 1998; 317: 1149- 50. |
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S Patel , A Singleton
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The Editor, BMJ BMA House Tavistock Square London WC1H 9JR 17th November 1998 Editor, "And I am black, but O! My soul is white" (1) McManus' article highlights the complexity of exposing "racism, discrimination and disadvantage" (2). Given this context we should remember that selection is discrimination, currently sanctioned if based on academic ability, but not on gender or race. However, none of these attributes stand alone: their importance lies in the deeper characteristics that they are considered to reflect. Attributes of a successful candidate are not only determined by selectors' notions of "good doctors", but also by their notions of successful people. Selectors are not immune from societal influence nor from a scientific discourse that reduces societal norms into measurable attributes. These can then be neatly aggregated to construct the ideal candidate as "white, female, an academic high achiever, and single-minded" (3). Deeply embedded in the medical system is a complex mixture of modern white American-European values uncritically adopted as the norm. Modern medicine has propagated the dichotomies of 'normal' and 'abnormal' and linked them to others such as 'healthy' and 'diseased', 'good' and 'bad', 'white' and 'black'. So for the black doctor or black patient, their colour is an assumed handicap - in the words of Franz Fanon, "When people like me, they tell me it is in spite of my color. When they dislike me, they point out that it is not because of my color"(4). The discrimination against non-white doctors continues to this day.(5) Cultural bias in medicine lurks far deeper than the ethnic constitution of its practitioners. Selecting only those non-white students with the most "white" characteristics as determined by their probability to meet the "white requirements" of biomedical training can still support the negative stereotype of black doctors. Equalising the selection of non-white students will not address the very real problem of a health service that is unable to meet the needs of non-white people if those students have to become "white" in the process. That process embodies cultural assumptions implicit in perceptions of a "good medical student" derived from the idealised notion of a "good doctor". We must deconstruct that notion to effect change at a level which tackles rather than hides the cultural bias underpinning institutional racism. To use a biomedical metaphor, this research has highlighted a symptom of a serious disease - it has pointed out the pallor, now is it not negligent merely to correct the anaemia and ignore the cancer beneath? Sangeeta Patel. GP/Clinical Lecturer Andrew Singleton. Research Scientist. Department of General Practice and Primary Care, St George's Hospital Medical School. London. SW17 0RE. Fax: 0181 767 7697 e-mail: sangeeta.patel@sghms.ac.uk. References: 1 Blake,W "The Little Black Boy" in "Songs of Innocence" 1789. 2 McManus IC. Factors affecting likelihood of applicants being offered a place in medical schools in the United Kingdom in 1996 and 1997: retrospective study. BMJ 1998;317:1111-7. 3 Abbasi, K. Is medical school selection discriminatory? BMJ 1998;317:1097 -8. 4 Fanon F. The Fact of Blackness.Black Skin, White Masks. London. Pluto Press. 2nd ed. p116. 5 Esmail A, Everington S. Asian doctors are still being discriminated against. BMJ. 1997;314:1619. |
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Raman Bedi
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Dear Sir, The debate on potential discrimination of minority ethnic applicants to medical schools has a disturbing déjà vu feel about the research and subsequent comments on its impact for the medical profession 1-2. Esmail is right in asking why exploration of the data has been delayed for nearly a decade 2. In addition, the criticisms that variables such as predicted grades, interviews, etc. were not taken into account (despite not being made available to McManus) are reminiscent of the debate earlier this year on the investigation in allocating consultant merit awards 3-4 . Esmail's commentary on league tables is limited in its approach 2. Discrimination is only one factor the NHS has to consider as significant numbers of the minority ethnic community enter the health care profession. Factors such as workforce mobility, attitudes towards health care professionals (complaints and violence) from certain sections of the public, the effect of culture, religious background, gender and family expectations are complex and can have significant impact on career choice and employment mobility. The implications of minority ethnic individuals forming such a large part of the NHS workforce should not be simply focused upon discrimination. Positive achievements have been made in promoting and developing minority ethnic individuals in the NHS. Some fine-tuning is clearly needed and an authoritative group should be established to consider these issues to plan and promote for an inclusive and positive workforce who feel valued and their specific needs are being catered for. However, the idea of an authoritative group also has a déjà vu feeling 5. Yours Raman Bedi Competing Interests: none References 1. McManus IC. Factors affecting likelihood of applicants being offered a place in medical schools in the United Kingdom in 1996 and 1997: retrospective study. BMJ 1998; 317:1111-7. 2. Esmail A. Commentary: League tables will help. BMJ 1998; 317: 1116. 3. Esmail A, Everington S, Doyle H. Racial discrimination in the allocation of merit awards? Analysis of list of awards holders by type of award, speciality and region. BMJ 1998; 316: 193-5. 4. Bedi R. Racial discrimination in distinction awards. NHS monitoring of discrimination should be more transparent. BMJ 1998; 316: 1977-8. 5. Bedi R. Overcoming racism in the NHS - an authoritative central body would help. BMJ 1997; 314(7098): 1906-7. |
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