Discrimination in the UK’s postgraduate examination in primary care

BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f5765 (Published 27 September 2013) Cite this as: BMJ 2013;347:f5765
  1. Patrick T Dowling, professor
  1. 1Department of Family Medicine, University of California Los Angeles, Los Angeles, CA 90095-1683, USA
  1. pdowling{at}mednet.ucla.edu

Cannot be ruled out

Increasing globalization means that up to 230 million emigrants now live in countries around the world. Wealthy English speaking industrialized democracies such as the United Kingdom, United States, and Canada have long relied on immigrants, and their descendants, to fill voids in their healthcare workforces. A linked paper by Esmail and Roberts (doi:10.1136/bmj.f5662) raises questions of fairness and equity in the way this important group is served by our selection and training processes, and what this might mean for the quality of healthcare in multicultural populations.1

The question is timely and important. Exactly half a century after Martin Luther King made his landmark “I have a dream” speech on racial justice and equality in 1963, the US remains tethered to the world’s most wasteful and unequal healthcare delivery system. It costs almost twice as much per capita as any other health system in high income countries, yet 50 million US citizens have no health insurance, and 70 million live in designated shortage areas for primary care. Yes, we can cure disease in ways past generations never dreamt, but we still haven’t ensured that everyone has access to basic care.2 3 In the UK too, there is evidence that the founding principles of the NHS—universality and equity—have become eroded over time.4 5 6 7

In a later speech in 1966, Dr King stated: “Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane.” Yet many countries, including the US and UK, continue to struggle with racial and ethnic disparities in healthcare outcomes. The problem that is often raised is the possibility of unconscious bias by healthcare professionals who are not racially and ethnically concordant with their patients.8

The US, led by California, is rapidly transforming into one of the most racially and ethnically diverse countries in the world. More than a third of Californians (38%) are Hispanic, 7% are black, and 14% are Asian. The physician workforce looks very different: just 5.5% of California’s doctors are Hispanic, and 3.5% are black, whereas Asians and non-Hispanic whites are over-represented (24% and 63%, respectively).9

Nearly a quarter of the doctors in California are international medical graduates, and a quarter (27%) of Californian’s population is also foreign born, more than double the national average. Almost seven million people in the state have a limited proficiency in English. Accordingly, both linguistic and cultural barriers to effective healthcare are common. Communication and trust can become problematic when providers are of different backgrounds and culture from the population they serve. Equitable access to healthcare is more than simply a patient seeing a doctor. Rather, it includes sharing of information, thoughts, and feelings; and, most importantly, building trust.

We try hard to select and train a physician workforce that better mirrors our population, but we face many of the same challenges discussed by Esmail and Roberts. In the US, black and Hispanic medical students generally score lower on standardized tests, similar to the applied knowledge test and clinical skills assessment in Esmail and Roberts’ study, than do non-Hispanic whites and Asian Indian students. This current study is therefore of interest to medical educators and work force planners well beyond the UK.

Esmail and Roberts’ study was well designed and clearly reported. The authors’ interpretation and conclusions are warranted. International medical graduates and UK graduates from black and ethnic minority communities are significantly more likely than white UK graduates to fail the clinical component of their postgraduate examination in primary care (clinical skills assessment). The difference is important. Candidates who fail cannot become primary care practitioners after years of investment in training, and ethnic differences in failure rates may exacerbate existing imbalances in diversity between doctors and patients. The current study is strengthened by analyses that adjusted for age, sex, deanery, and score on the applied knowledge test, which is marked by machine and therefore objective. Comparisons between different groups of doctors trained outside the UK were additionally adjusted for performance in compulsory tests of English language and clinical competence. In this subsample of international graduates, the difference in the failure rate between white candidates and others was no longer significant after full adjustment.

I arrived at the same conclusion as the authors—that subjective bias in the marking of the clinical skills assessment examination cannot be excluded. Such bias is difficult to measure, but it is a problem in the US too. We want our large immigrant and minority populations to be fully integrated into the broader society and culture. Having a well educated group of health professionals, who look like you and understand your culture, must improve communication and your trust in healthcare. Doctors from minority communities are also role models for young people who share their background.

Future studies exploring biases in the clinical skills assessment examination should include a substantial proportion of standardized patients (often actors) and examiners who are themselves from black and ethnic minority backgrounds. It would then be possible to see if they score a racially and ethnically concordant group of candidates differently from others. Researchers could also include standardized patients whose main language is not English, to see how they grade doctors who are language concordant and non-concordant. As we diversify further on both sides of the Atlantic, it must be in all our interests to educate doctors who can communicate well with all the populations they serve.


Cite this as: BMJ 2013;347:f5765


  • Research, doi:10.1136/bmj.f5662
  • Competing interests: I have read and understood the BMJ policy on declaration of interests and declare the following interests: I have served as an expert witness for the medical board of California and on medical malpractice cases. I am an an editor of the family medicine section of “UpToDate.” I serve on the board of the California Community Foundation and the executive board of the Charles R Drew University of Medical and Science. I am chairman of the Public Health Commission of the Los Angeles County Department of Health.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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