Ethnic minority staff and patients: a health service failureBMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l2226 (Published 21 May 2019) Cite this as: BMJ 2019;365:l2226
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Kmietowicz refers to disparities affecting ethnic minorities across the health service .
It is widely accepted that race is a social rather than biological construct used to explain cultural differences, and as such ethnicity is rarely used to guide clinical practice. Indeed, some studies demonstrate that there is more genetic variation within a race than between races . However, new clinical trials should make us reconsider whether being racially blind can also be harmful when deciding on treatment. Currently, the preference for calcium channel blockers over ACE inhibitors in the treatment of hypertension in Afro-Carribean patients represents one of the only concessions to racial differences represented in the national guidelines. There is surmounting evidence from clinical trials suggesting that ethnic minorities do not respond to recommended treatment in the same way as Caucasian patients, to the point that certain populations may not be being treated at all. Where treatments are largely guided by national guidelines, can we really treat individuals in a multicultural population in the same way?
A 2018 meta-analysis of randomised control trials comparing response to alendronate in East Asian and non-East Asian post-menopausal women found that although bone mineral density increased in both groups, the statistically significant risk reduction of vertebral fractures seen in non-East Asians was not seen in East Asians . The difference in response is supported by the broad genetic variation found between Caucasian and Asian populations that suggest Caucasians are more likely to have a positive response to bisphosphonate therapy . Current treatment guidelines favour Caucasian populations by recommending bisphosphonates, such as alendronate, as first line primary prevention of osteoporotic fragility fractures . Furthermore, bone mineral density is used as a measure of drug response but results from this trial imply that the correlation between bone mineral density and fragility fractures is not as robust in East Asian women. These findings are limited by a small sample size, but it does question whether the current approach is leaving East Asian women at greater risk.
Ethnic minorities may be at increased risk of adverse effects from standard doses of anticoagulants and antiplatelet medications.
A genetic study in 2019 revealed that Asians often have lower warfarin requirements compared to Caucasians . This difference may be due to genetic variation between CYP450 enzyme in ethnic groups, as mutations in these genes changed the average daily warfarin dosing requirements. The dosing of warfarin is notoriously complex. However, aggressive dosing of warfarin in the initial phase exposes patients to increased risk of bleeding, which can be catastrophic if it occurs in the brain or the gastrointestinal tract. This study suggests that East Asians may be overdosed on warfarin in the initial phase. However, the generalisability of this trial is limited by its small sample size, which is itself limited to patients in the city of Los Angeles.
A 2019 meta-analysis of seven randomised control trials suggested that the dosing of dual antiplatelet therapy , which has been optimised for a Caucasian population, may be inappropriate for the treatment of East Asian patients. The standard dose of aspirin and clopidogrel led to an unacceptably high bleeding risk in East Asian populations (hazard ratio [HR], 2.843). By contrast, although the non-East Asians had a slightly higher risk of cardiac events compared to East Asians (1.8% vs. 0.8%), there was no significant increase in the rate of bleeding. As the first tenet of medicine is “to do no harm,” it may be appropriate to lower the dose or shorten the duration of DAPT in East Asians in order to optimise the risk ratio between bleeding and ischaemia.
Ethnic minorities are underrepresented in clinical trials and as a result written out of treatment guidelines. It is the responsibility of clinicians to ‘provide effective treatment based on the best available evidence’ , and this should encompass evidence about treatments for different population groups. By ignoring these differences, we are failing 14% of the country  by prescribing ineffectively or even causing harm.
1. Kmietowicz, Z., Ladher, N., Rao, M., Salway, S., Abbasi, K. and Adebowale, V. (2019). Ethnic minority staff and patients: a health service failure. BMJ, p.l2226.
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4. Olmos, J., Zarrabeitia, M., Hernández, J., Sañudo, C., González-Macías, J. and Riancho, J. (2010). Common allelic variants of the farnesyl diphosphate synthase gene influence the response of osteoporotic women to bisphosphonates. The Pharmacogenomics Journal, 12(3), pp.227-232.
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7. Kang, J., Park, K., Palmerini, T., Stone, G., Lee, M., Colombo, A., Chieffo, A., Feres, F., Abizaid, A., Bhatt, D., Valgimigli, M., Hong, M., Jang, Y., Gilard, M., Morice, M., Park, D., Park, S., Jeong, Y., Park, J., Koo, B. and Kim, H. (2018). Racial Differences in Ischaemia/Bleeding Risk Trade-Off during Anti-Platelet Therapy: Individual Patient Level Landmark Meta-Analysis from Seven RCTs. Thrombosis and Haemostasis, 119(01), pp.149-162.
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Competing interests: No competing interests
I wholly agree on the systematic racism that exists within the NHS. I also believe much of it is largely unintentional, unconscious bias. Having only just completed a year in a district general hospital that serves a largely deprived, BAME population that also boasts a high proportion of BAME doctors one would think cultural understanding would also ensue and translate into better treatment.
Unfortunately what often ends up happening is that BAME staff who are keen for professional respect and courtesy are often less sympathetic to patients from a background they share, in what I believe is their effort towards acceptance that they crave from their colleagues. The desire to be accepted is undoubtedly a natural one and as the article suggests those who are not feel bullied and are overlooked professionally. Unfortunately, I have seen this comes at the cost of the patient.
I have to admit, even for myself, it is a conscious battle not to belittle the concerns of a BAME patient. One has to question why that is? I think a large part of it is language and a learnt description of symptoms from medical school. We are often oblivious to the fact we are being taught from a certain perspective, Questions and revision material only add to this by testing candidates on typical scenarios, often racially driven. Are we properly equipped at medical school for the cultural diversity of the NHS?
There are well known stereotypes such as Bibi syndrome or Begum syndrome which are often colloquially used to describe South Asian patients with non-specific complaints. These only serve to undermine patients and as this article points out contribute to health inequality.
The issue is multi-faceted, I am glad data gathering is taking place to identify the issue. So much needs to be done in working toward ensuring the NHS is a service to all.
Competing interests: No competing interests
I look forward to this special issue, in particular further information regarding attitudes towards NHS staff in terms of complaints which can be arbitrary and dependent on bias (conscious or not).
A cursory look at the results of a google image search for the term “doctor” reveals a disparity between expectation and reality. Of the first 10 healthcare professionals that appear, every single one appears to show a someone who seems to be from a white background.
Of course, we have to bear in mind that the image search is likely to include a high proportion stock images where advertising companies use photo models to portray doctors. Nevertheless, such imagery is pervasive throughout our society, whether it is online, on television or in advertising.
Is it therefore surprising that when patients do access healthcare, their preconceived image of what a doctor should look like can be very different from their actual experience? Do mismatches between expectation and reality increase the likelihood of a complaint?
Perhaps even more pernicious is the effect such imagery could be having on potential medical school applicants who may feel they have to conform to such stereotypes to gain access to the club (or not bothering to apply at all).
Competing interests: Blogger at https://unexaminedmedicine.org/
Checking the Government website today (www.gov.uk), it gives this overview of the duty of equality across public services including the National Health Service (NHS):
"The public sector Equality Duty (PSED) requires public bodies to have due regard to the need to eliminate discrimination, advance equality of opportunity and foster good relations between different people when carrying out their activities."
Poorer quality care for patients from ethnic minorities has been documented in many British institutions. In this letter I will focus on the inequalities experienced by clinicians from Black and Minority Ethnic groups (BME). A wise colleague (and fellow teacher) told me this starts long before BME professionals are in practice. So I began by looking just one step before professional practice. To qualify in the UK, clinicians all spent extended periods in higher education. Recent research in two multi-disciplinary London universities by AdvanceHE  was driven by the same need to enhance diversity at the top of organisations described in this Editorial. Discrimination is already present in academia. However, participants in a Diversifying Leadership programme reported “that using diverse role models and speakers can help convey the message that leadership can take many forms and can incorporate different identities and cultural backgrounds.” Equality of recognition and promotion came up as sensitive issues for many BME staff. Over the year of the Diversifying Leadership programme, ratings of “My formal appraisal/performance review is useful/ valuable” improved significantly.
Here are three recommendations for developing new academic leaders, that might also apply to the NHS:
a. Pay particular attention to the advertising strategies employed for senior posts, identifying ways to increase the breadth of the audience reached.
b. Initiate discussions with BME staff to explore what barriers they face to progression and leadership within the institution and more broadly.
c. Implement equality impact assessments as a standard accompaniment to all decision-making agenda items.
Actually, these recommendations are a Duty.
1. Kmietowicz Z, Ladher N, Rao M, Salway S, Abbassi K, Adebowale V. Ethnic minority staff and patients: a health service failure. BMJ 2019;365:l2226
2. Fook J, Archibong U, Kim T, Aldercotte A. Cracking the concrete ceiling: Tracking the impact of the Diversifying Leadership programme. London, AdvanceHE, 2019.
Competing interests: No competing interests
It would be interesting to see what the special issue turns up.
I have always classified myself in questionnaires from the DHSS, from the local authorities, etc, as merely Homo sapiens and crossed off the dozen or so boxes asking, in effect, whether one is a green man or blue.
Census forms? I treat them the same - with contempt.
I am sure that the health service has sometimes attributed to me an “ethnicity” without consulting me.
Just in case someone wishes to gift to me the tartan of the Clan Annand or Anan - I will accept it with thanks, but I would like to clarify that my ancestry does not include any Scottish chromosomes. As far as I know.
Competing interests: No competing interests