Racism in medicine
BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7301.1503 (Published 23 June 2001) Cite this as: BMJ 2001;322:1503All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Response to: Racism in medicine
Discrimination in medicine
As a female physician who has grown up in the UK and a male
sociologist in US medical training, both of Indian origin, we are
compelled to comment on the current debate about racism in the NHS. We
wonder whether the lack of progress made is related to the failure to
create an environment in which we can have constructive and open debate.
There is clearly racism within the NHS and other institutions but racism
cannot be considered as an isolated issue as we have both experienced
different forms of discrimination outside of race.1, 2 This has often been
at the hands of ethnic minority men who want equality for themselves on
the basis of race but are unprepared to give the same courtesy to others
with differences.
As Bhopal states antiracism is best seen as a component of the
struggle against oppression.3 Until we do that and work towards creating
equality on all fronts (including gender, age, religion, disability and
sexual orientation), each group of minority or vulnerability will forward
its own case without necessarily leading to the kind of broad culture in
which equality is a given. However, much we may try to separate out these
forms of discrimination, they are interlinked at an institutional and
societal level.
At Leicester University, The Human Diversity module component on race
and cultural diversity, (other components include sexuality and gender,
religion and disability) has been shown to be effective in helping
students to address personal prejudices early and to start challenging
their views of all kinds of people.4 There is a need to acknowledge that
we all have prejudicial views of one sort or another before the impact of
these views on professional practice can be addressed. A key to the
success of this module has been the willingness of staff to broach
sensitive issues and engage students in such a crucial dialogue. In the
module, cultural awareness is not about denigrating the majority
perspective, but about learning that we all need to have an awareness and
sensitivity to cultures different from our own.
There is clearly a need for debate and action, at all levels,
including personal and organisational. It is, however, important not to
oversimplify the complexity of institutional oppression by focusing
exclusively on one strand of this process.
Dr Nisha Dogra BM DCH MRCPsych MA
Senior Lecturer and Honorary Consultant in Child and Adolescent Psychiatry
Mr Niranjan Karnik BA, MA
MD/PhD Candidate
Visiting Fellow
Greenwood Institute of Child Health,
University of Leicester,
Westcotes House,
Westcotes Drive,
Leicester
LE3 0QU
Email: nd13@leicester.ac.uk
1 Coker N.ed. Racism in medicine: agenda for change. London: King’s
Fund, 2001.
2 Carvel J. Secret government report finds racism flourishing in NHS.
The Guardian, 25th June 2001, A1, 4.
3 Bhopal RS. Racism in medicine: the spectre must be exorcised. BMJ,
2001; 322: 1503-4.
4 Dogra N. The development and evaluation of a programme to teach
cultural diversity to medical undergraduate students. Medical Education,
2001; 35(3): 232-241.
Neither one of us has any competing interests.
Competing interests: No competing interests
Dear Sir,
Professor Bhopal's editorial is timely and makes the very important
point that no further evidence of racism in the NHS is required: we know
its there, what we now need to do is to find ways of getting rid of it. As
overseas doctors, our personal experience in this country would mirror
that of thousands of other Asian and African doctors. Before we came to
Britain, all we knew was that we would have to work hard to prove
ourselves. The extent of overt and covert racism was a rude shock. We got
used to it, learnt to expect it even, all the while hoping that once we'd
''proved'' ourselves, it would stop. Obviously, we were naive. We carry
on, disillusioned, but for how long?
What should the NHS do? Equal Opportunities policies may help, or
just become an exercise in futility. How many non-ethnic minority doctors
will actually read Professor Bhopal's artcle, we wonder. No lasting change
can occur until people stop believing that they are better simply because
they belong to a particular race.
Competing interests: No competing interests
EDITOR--There has been little attention to sex based reservations
during recruitments to different positions in International Organizations.
To add insult to injury, the WHO, like others who believe in
discrmination, would select an ordinary or even below average female and
reject an outstanding male. To expect, the international organizations to
help elderly professionals with their visa problems or immigration
clearance would be asking for much too much.
One might agree for a second that there was gross discrmination against
those from Asia, Africa or Latin America. Would it ever be possible for
any scientific journal published in those nations to discuss the favours
being showered on the kith and kin of innumerable government officials,
politicians or even friends of film stars or sport personalities:
definitely not. Obviously, British Medical Journal needs to be
congratulated for such an extensive coverage of the topic.
Furthermore,
one is able to offer one's viewpoint during discussions in the Western
system of education. Any difference of professional opinion between a
junior and senior, if expressed before others, implies a death warrant for
the junior in many parts of Asia, Africa? The senior can never be
imperfect or wrong. Certainly, that would be unlikely in the British
Isles.
Yours sincerely,
Subhash C Arya, MBBS,PhD
research Physician
Centre for Logistical Research and Innovation,
M-122 Greater Kailash- Part 2,
New Delhi- 110048, India
Email subhashji@hotmai.com
Competing interests: No competing interests
Dear Sir,
In the NHS, there is endemic racism every where, not the
least during the appointment process. I believe the efforts
by B M J, such as writing " Equal opportunities employer "
are at best lip sympathy / eye wash because it is never
followed up. The monitoring forms are filled but does any
authority check them ? I believe there is absolutely
nothing equal in opportunities. Shear hypocricy. If they
were really sincere in finding out, one of the ways forward
is to force health authorities to publish the exact numbers
of people from all races applying for any / all SPR jobs,
then the numbers of the same shortlisted and then the exact
number of them selected. Over a period of 11 long years, I
have observed that for good jobs viz. type I SPR now, the
visitors are either not shortlisted at all or are very very
rarely given the jobs, citing funny/stupid reasons.
A number of actual cases can be quoted on this. It is more
of a hype, than an intention to improve.
Yours sincerely,
bob
Competing interests: No competing interests
I read with interest the article by Dr. Raj Bhopal : 'Racism in
Medicine'. I have been training in Medicine for the last three years in
General Medicine in a DGH in UK. It is easy to take sides in this story
and only too difficult to maintain a neutral perspective. May I take this
opportunity to reflect on some experiences that overseas doctors face
while working in the NHS.
Firstly, on the rigors of the PLAB test: you are required to go
through this unless you have obtained your undergraduate medical degree
from an EU country. This exam can be attempted only on passing the IELTS
exam which tests linguistic proficiency and communication skills. On
passing the PLAB, overseas doctors may be offered Limited Registration, if
they are selected for a training post. Obtaining a visa for appearing
for the PLAB itself is very often laborious and has been known to
degenerate into detailed interrogation regarding possible ulterior motives
for training in the UK and even enquiries into financial stability and
family property in the home country.
Being an EU citizen automatically renders one eligible for Full
Registration with the GMC without going through any of the above
exertions. The comfortable assumption must be that being born and trained
in any of the EU states automatically bestows one with proficiency in
medicine and the English language. I will desist from insulting the
readers' intelligence by elaborating on the chasm that exists between
reality and the above perception.
Most of the candidates who seek medical training in the UK are
initially unaware of the difficulties in getting training posts for non-UK
trained medical graduates. Still the GMC seems intent on fervently
conducting PLAB tests almost every month in multiple centres all over the
world and churning out overseas doctors seeking work in the UK in
burgeoning numbers. Perhaps it would be kinder to offer some form of
counselling to overseas doctors on actual career prospects prior to
embarking on the long and tortuous road in the NHS, which starts with the
PLAB. Arguably such an open approach has significant financial
implications for the GMC. Ensuring that all non-UK doctors who aspire
for training within the NHS have to pass the PLAB test, regardless of
their genetic lineage and ethnic derivation will go a long way in
addressing the blatant disparity in the treatment meted out to the
overseas doctors.
"You are over-qualified", "You do not have enough experience in the
UK", are some examples of favourite phrases used freely by interview
panels throughout UK to explain overseas candidates’ failure to obtain an
initial training post. Surely this must be evident from their application
forms and CVs well before they were short-listed for interviews. It leads
one to politely wonder whether some of these shortlistings are merely
efforts to bypass the so-called ‘equal opportunities monitoring’ process
in a politically correct manner. The worst offenders come out with
patronising quips like "You should consider it fortunate that you attended
an interview for a post in this hospital" and "Candidates like you would
be better off applying for smaller jobs in DGHs rather than in our
(teaching) Hospital". Non-possession of MRCP part – I is another negative
point that is frequently quoted as criteria for selection even for first
jobs.
I know about a complaint from a patient who was indignant that ‘all
the doctors who examined her child – the Senior House Officer, the
Registrar and the Consultant – were all Asians or non-whites’.
Regrettably the whole medical team was asked for written explanations!!
I still remember the anguish at made to wait outside a door in a
prestigious London Hospital for 6 hours, before I could see someone with a
request for a clinical attachment, which was curtly turned down. Already
in the throes of hypoglycaemia, I was offered a ridiculous explanation
that reeked of prejudice and ignorance about medical training elsewhere in
this wide world. I have come across many sad stories of prejudice against
overseas doctors all over the UK. Many of them are perhaps more worthy
of being aired via a tabloid than in the BMJ. In a majority of cases, no
efforts are made to react to these episodes or complain to a relevant
authority (if there is any).
This may well reflect a growing mistrust, disillusionment and eroding
faith in a system which is comfortably ensconced in its own self-
righteousness or maybe simply not bothered to address sensitive issues
like racism in an open and healthy fashion. On the other side, there is
also the real danger that genuine criticism aimed at poor performance or
even gross negligence may deliberately be misconstrued or even cited as
examples of racist behaviour, which is as bad or even worse.
I consider myself fortunate to work in a DGH that has consistently
encouraged overseas doctors to join their training scheme. The
consultants have taken sincere efforts to help me at work and I have
received excellent training. I am confident that there are numerous
similar experiences elsewhere in the UK. There is an enviable lot to be
said about medical training in the UK and it is only too easy to get
carried away either way.
However, having completed 3 years in General Professional Training,
deep in my sinking heart I know very well that it will be difficult to get
an SpR post, however good I may be in my chosen field of interest. I
will probably be forced to consider the prospect of as a NCCG (“Staff
Grade”) doctor - that growing breed of overseas doctors with little hope
of career progression - to survive.
Yours sincerely
Dr. A D Vellore
St. Leonards-on-Sea
Competing interests: No competing interests
I read this article with interest and with some feelings of guilt. I
fully agree with the article. I feel ashamed and frustrated at racism
within our community and I fear within the health service and our
profession.
Are things improving and if so will they continue to improve? I do
not know but I hope so.
Competing interests: No competing interests
Excellent writing, revealing most of the overseas doctors' thoughts
and feelings.It's true that most of the overseas graduates spend our time
and energy in applying for training posts.
Even if you are lucky and attend interviews, the presence of a local
graduate at the same place, makes it certain that the job isn't yours,
however well you perform in the interview. The response from them for not
giving the post is very vague. I cannot see why the other person gets the
job, except for the colour factor.
I have seen local graduates who trainied with me as an SHO already hold a
number without any Publications or Research experience or National
presentations. But, if it comes to overseas doctors all the above matters
and leads to the reason for not being successful for the job.
I agree that they should advertise clearly if it is open to overseas
doctors as well, rather than make us spend a long time in completing
these lengthy application forms.
Competing interests: No competing interests
Over 16 years of medical practice in the U.K., I can recall very,
very few social interactions that left me with an after-taste of racism.
By and large, this is a society where race is much less of an influence
than in most other cultures. Problems may arise occasionally, principally
because of communication 'difficulties' on all sides and an inadequate
understanding of other cultures, but I think (at the most) very rarely
with racial intent. Patients, I think, could not be bothered less about
the doctor's racial origin -- they are looking for a caring medic who will
sort out the problem quickly and efficiently. I cannot recall a single
interaction with a patient that has made me wonder about racial factors
playing a negative role. However, I feel strongly that the NHS must have
robust and transparent mechanisms of evaluation in place to 'prove beyond
doubt' that the system is not racist, in order to be able to respond
effectively to criticism.
Competing interests: No competing interests
Sir,
At last it is official that racism is part of NHS. Some parts of racism
are unintentional and some are not perceived by the perpetrators.
Overseas doctors who contribute nearly 40% of the service requirements
of the NHS are also most marginalized. The problem starts from the
immigration officials. Overseas doctors are eligible for 4 years' of
permit free training in the UK. But they are not given the visa for full
four years at once. You need to have a job first to get a visa and it is
accorded only until the period of job contract. Overseas doctors do not
have a choice over where they work. Those with some postgraduate
qualifications back home, will apply for posts in the same field whilst
freshers apply for at least two to three specialties. One has to apply
for all posts advertised in the BMJ every week because you are not sure
where your luck is. It takes a lot of time, effort and money. On an
average, overseas doctors apply for more than 50 posts before their
first job. They hardly ever get in to rotation posts and in to tertiary
teaching hospitals. Their chance of getting a job is maximum in the
months of July and January because they are the left over ones. They in
effect compete against themselves but not with the local graduates. In
the end they take up whatever job comes their way because they cannot
get visa extension without the next job. It is a norm for an overseas
doctor to criss-cross the country every six months. When they apply for
spR posts, their CV stands poor, having worked in only District General
Hospitals in deprived areas. They expect you to have publications and
research experience. They do not recognize your overseas experience. It
is understandable that overseas doctors should not be given jobs at the
cost of locals. Then there should not be the "equal opportunities"
slogan. It should be made clear that in the event that local candidates
cannot be found for the post, overseas doctors will be appointed. It
will save the time and money on unnecessary application. Some
consultants say they cannot assess the quality of overseas experience
(read in third world countries), but why then PLAB test? GMC is also
culpable in opening more centers and test places overseas for its PLAB
test, giving a false hope to overseas doctors.
For people like me who came to this country, with the aim of getting a
specialist training after post graduation back home, it takes a while to
realize that NHS wants us to fill up the service gaps such as trust
doctors or staff grades. By the time you realise it is too late. You
shed sweat so that local graduates can train in the spR grade to become
your boss. Otherwise why there is not a credible alternate system to
type 1 training for overseas doctors who wish to get specialist training
and go back to their country?
Sincerely,
Satya Hegde
Competing interests: No competing interests
Disablism in medicine -the spectre is not even recognised
Bhopal`s editorial (1) makes sobering reading and it is surely the
duty of all medical practitioners to address racism in themselves and
society. Inequality as a civil rights issue needs to be tackled under
whatever guise it arises, whether that be in terms of race, gender,
culture, or disability. However, the latter is one major aspect of the
social justice agenda that hasn`t been generally acknowledged in medicine
or society.
To understand the effect of disablism try, in Bhopal`s editorial,
substituting words to do with disability for words to do with race.
For example, "Disablism is the belief that non-disabled people are
superior to disabled people, which is then extended to justify actions
that create inequality." Or "..institutional disablism is `The collective
failure of the health care system to provide an appropriate and
professional service to people because of their impairments.`" Or
"Disablism causes death in epidemic proportions, as in Nazi Germany.."
But UK law does not afford full protection to disabled people. The
Disability Discrimination Act 1995 is not an anti-discrimination act,
because it lays down the circumstances under which it is legal to
discriminate against disabled people. For example, employers with less
than 15 employees (who are the majority of employers) are exempt from the
employment part of the Act; education and transport are exempt from the
provision of goods and services part (2). British Sign Language, used
by around 60,000 Deaf people in the UK, is not recognised as an official
language, unlike minority oral/aural languages, and not usually included
in discussions about interpreting services (3).
Disability exists because society does not take account of people
with impairments and thus excludes them from mainstream life (4). The way
to address disability is therefore through addressing the barriers in
society that exclude disabled people. In order to do this, hearts and
minds need to be won over. Adapting the final sentence of Bhophal`s
editorial, "The noble profession of medicine should seek to be in the
vanguard of the historical and global struggle against disablism.".
References
1. Bhopal R. Racism in medicine. British Medical Journal 2001;322:1503-40
2. Disability Discrimination Act 1995. Code of practice. Rights of
access. Goods, facilities, services and premises. Department for
education and employment 1999. The Stationery Office.
3. Carter JM, Hare-Cockburn K. Breaking down language barriers. Sign
here, please. British Medical Journal 1998;317:817 (letter)
4. Oliver M. Theories of disability in health practice and research.
British Medical Journal 1998; 317: 1446-9.
Competing interests: No competing interests