Racial discrimination in medicineBMJ 1995; 310 doi: https://doi.org/10.1136/bmj.310.6978.478 (Published 25 February 1995) Cite this as: BMJ 1995;310:478
Equity for patients is unlikely if we don't treat doctors fairly
There is now considerable evidence that people from minority ethnic groups are discriminated against at each stage of their medical careers.1 2 3 4 5 6 7 8 9 This week's BMJ carries two papers that point to continuing discrimination on application to medical school.1 2 McManus et al studied nearly 7000 students who applied to one of five chosen medical schools in 1991 and showed that similarly qualified applicants from minority ethnic groups were 1.46 times more likely to be rejected than their white peers (p 496).1 Esmail et al found a similar pattern among all applicants to medical school in 1992 (p 501).2 These papers add to the picture painted by the original reports by McManus's group on medical school applicants in 1981 and 19863 4 and to the report of the Commission for Racial Equality which showed discriminatory practices in the admissions procedure at St George's Hospital Medical School, London.6
Once admitted to medical school the problems do not stop. A recent report revealed that Asian students at Manchester University Medical School (mostly UK born) were more likely than white students to fail final clinical examinations despite good performance in their written exams.6
Once qualified the discrimination continues. Two surveys from the late 1980s concluded that, as a group, doctors from minority ethnic groups had more unsuccessful applications for jobs, were less likely to be able to pursue their chosen career, and were more likely to experience long periods of unemployment when trying to obtain a registrar post.7 8
That these difficulties are due, at least in part, to discrimination was shown by Esmail and Everington in 1993.9 They sent matched pairs of curriculum vitae—one bearing an English name and one an Asian name—in response to 23 advertisements for senior house officer posts. The applicants with English names were more likely to be shortlisted.
In the late 1980s and early 1990s there was a flurry of initiatives to combat discrimination in medicine. In 1989 the Universities Central Council on Admissions started monitoring the ethnic status of applicants. A joint task force was also set up by the Department of Health and the King Edward's Hospital Fund for London to report on how to achieve racial equality in selecting hospital doctors. It produced guidance for all those involved in selection procedures in 1990.10 The NHS Executive issued specific guidelines on equal opportunities in recruitment and selection procedures in 1991.11 But the papers published in this week's BMJ, the recent report from Manchester, and the fact that Esmail and Everington were still able to show overt discrimination in 1993 indicate that these measures were not enough. This is partly because the guidelines are voluntary but also because they have not been linked to any effective monitoring of their impact.
If we wish to eradicate a systematic problem we need a systematic approach. The Commission for Racial Equality has produced guidance to help employers to be more rigorous in their attempts at achieving racial equality. Their booklet, Racial Equality Means Business: A Standard for Racial Equality for Employers gives a step by step guide on how to develop strategies and monitoring schemes. It also goes further by showing how to monitor the impact of these strategies in areas of policy and planning; selecting, developing, and retaining staff; communicating the corporate image, corporate citizenship, and auditing for racial equality.12 There is a strong case for the commission's standard to be made mandatory across the whole NHS and in every medical school. This should be centrally coordinated so data across the NHS could be made available. It could produce information on applications, shortlisting, and success rates at interview for all groups who are discriminated against and tie these to a process of audit and development. It could identify where change is necessary nationally and locally.
Audit can yield dividends. McManus et al have used the ethnic monitoring data from university admission forms to identify areas where change could make medical school selection fairer. Similarly, the working party set up after the examination failures in Manchester has called for more structured marking in clinical examinations to cut down the opportunities for discrimination.6
The discrimination which is evident in medicine means that good students are denied places at medical school and good doctors denied their chosen careers. If we do not choose the best person for the job because of his or her ethnic background then the practice of medicine suffers from the wasted potential as much as the individual. The image of medicine in the eyes of patients is also damaged. From April this year the NHS is to undertake mandatory ethnic monitoring of all patients to increase equity of care, but we are unlikely to produce an equitable NHS for patients if we do not have the will to produce it for doctors.