Are medical schools turning a blind eye to racism?BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m420 (Published 12 February 2020) Cite this as: BMJ 2020;368:m420
Medical schools in the UK are ill prepared to deal with the racism and racial harassment experienced by ethnic minority students, an investigation by The BMJ and BMA has found.
Only half of medical schools collect data on students’ complaints about racism and racial harassment, a freedom of information request has shown. (Of 40 medical schools in the UK, 32 responded to The BMJ’s request, of which 16 said they collected the data.) And since 2010 they’ve recorded just 11 complaints.
The number of complaints documented by UK universities in general is also low: last year the Equality and Human Rights Commission reported that UK universities recorded 560 complaints of racial harassment over three and a half years, while 60 000 students said that they had made a complaint.1 Rebecca Hilsenrath, the commission’s chief executive, said the figures showed that some universities were “oblivious to the issue” of racism, and Julia Buckingham, president of Universities UK, described the results as “sad and shocking.”
It is against this background that the BMA has this week launched a charter for medical schools “to prevent and effectively deal with racial harassment” and guidance for students on tackling and preventing racial harassment.2
The issue of racism in medical schools is important because students from ethnic minority backgrounds make up 40% of medical undergraduates, nearly double the 22% in universities generally.3
And, perhaps more importantly, racial harassment is seen as a contributing factor to the gap in attainment seen between ethnic minority and white students and, later, doctors.4
In a foreword to the charter, Chaand Nagpaul, the BMA’s chair of council, says, “[Medical students from ethnic minority backgrounds] have worked hard to get to medical school and have big aspirations. However, their experiences once there may not live up to expectations, with some experiencing undermining, microaggressions, and racial harassment on campus and on work placements. Such behaviour damages self-esteem and confidence, affects learning, and contributes to an ethnic attainment gap that emerges through medical education and training. It is an unacceptable barrier to BAME [black, Asian, and minority ethnic] medical students achieving their full potential.”
Racism in medical schools was brought into sharp focus back in 2016, when a serious racist incident at Cardiff University medical school saw 32 students suspended and the ordering of an independent review (box 1).5 But four years on, the lessons learnt by Cardiff seem to have had no wider impact.
The Cardiff experience
In 2016 students at Cardiff medical school organised a review in which one of them blacked up and took to the stage wearing an oversized dildo to make fun of a lecturer. The event led to 32 students being suspended from clinical practice, a police investigation, and an independent review. Police decided to take no further action, but the review was damning. The students had portrayed the lecturer as “a stereotypical, hyper-sexualised black man” and had included other racist, sexist, and homophobic jokes, it concluded.5 The review panel heard that the school’s previous attitude towards diversity was “tokenistic.”
The review made 13 recommendations to try to heal rifts between students and staff of different ethnic backgrounds. It said that the medical school needed clear guidelines on how complaints from students should be reported and that the school should also consider having a dedicated staff member to offer immediate pastoral support to complainants. It added that the school’s initiatives on equality and diversity were difficult to understand.
The review also said its observations raised “some overarching issues about the apparent and disappointing lack of career progression of BME staff and their general negative perceptions in this regard” and said that the university should aim to increase the diversity of its staff (though admitting that this recommendation was outside the review’s remit).RETURN TO TEXT
Katherine Woolf, associate professor in medical education at University College London, says that students don’t necessarily think they can report racial incidents and that, even if they do, many believe their complaints won’t be taken seriously.
“Racism and racial harassment are real issues, and medical schools often do not have the best supporting structures for people who want to make a complaint,” Woolf tells The BMJ. “But they have a duty of care to all their students. It’s a tricky area that requires more conversations and more clarity.”
Olamide Dada, the founder of Melanin Medics, a group that supports students and doctors from the Afro-Caribbean community, said she was shocked at the low number of reported complaints.
“As someone who has been in contact with a large number of medical students I have personally heard of many, many racial incidents, and I have also experienced them but have not complained,” she told The BMJ. “Often these incidents are discussed in friendship groups and do not go any further. But this is something that really affects students, and by not reporting them we are making allowances for other people’s faults.”
A recent graduate recently told Dada about a whole string of incidents that had happened to her during medical school that she had been “harbouring for years, and the same is true for a lot of people,” she said (box 2).
Voices of medical students
The BMJ gathered comments from students at several medical schools during its investigation.
“I came from a predominantly white area and had lots of white friends, but when I got to medical school everyone went to join their ethnic groups. I felt really uncomfortable. We found ourselves becoming friends with people of the same colour, which was sad because it was not what I was used to.”
“Because I’m black, people assumed I was on the six year course, even though I wasn’t.” (Longer courses, apart from intercalated ones, usually imply a foundation year, often in the context of schemes to widen participation, which had been assumed here on the basis of race.)
“I was on a ward round when a student asked a consultant what a patient meant by saying that he felt under the weather. The doctor replied, in front of everyone, that that was exactly why it was really important for foreigners to get to know local expressions. The student was really offended. She wasn’t a foreigner. That expression just wasn’t in her culture. She felt too awkward to say anything.”
“People have made monkey noises at me [during a clinical placement in a very racially uniform part of the UK.] I tried to forget how that made me feel. I repressed it.”
The BMJ agreed to publish these comments anonymously.
Ololade Obadare, a third year student at Nottingham medical school, says she and many of her fellow students feel let down by the handling of complaints of racial incidents. “When you’ve complained three, four, five times and nothing has been done, there comes a point where you just give up and accept that this is my career from here on, that that is what I will experience. That is the truth and you just have to internalise it,” she told The BMJ.
The BMJ’s investigation also found that responsibility for handling complaints during students’ clinical placements was not always clear. Although most medical schools have a published protocol for dealing with students’ complaints about racial incidents that occur on university premises, this does not apply when students are in hospitals or GP surgeries. When asked about their policies for handling complaints from students who are off site, many medical schools directed us to documents held by third parties.
For example, the University of Oxford said that “placement sites will have individual complaints procedures which would be available to students who wish to raise a complaint.”
The response from Lancaster University was typical of many. “There is a Learning Development Agreement between Health Education England and the placement providers,” it said. “This is an HEE document and is not held by the university.”
Failure in responsibility
The BMA’s new charter asks medical schools to set clear expectations of placement providers in how they deal with racial harassment on work placements. It also asks signatories to support students who want to speak out, to have someone whom students can speak to confidentially, and to improve their complaint reporting and handling processes.
The BMA’s Nagpaul said that the Medical Schools Council, the GMC, and the NHS should require medical schools to have a systematic approach to training of staff and collecting feedback from students. “We need cultural ownership of this agenda by medical schools,” he said. “They need to say: can we afford not to? Or can we morally not want to make these changes?
“Medical students are the future of the profession. They need to know that they can expect an inclusive and safe environment at medical school and on work placements.”
Lack of staff diversity
The BMJ also asked medical schools about the ethnic makeup of students and staff. It found that while 40% of the UK’s medical students were from ethnic minority backgrounds, only 13% of teaching staff were.
There has been a major push for more students from ethnic minority backgrounds to enter medicine, with many helped by “widening participation” schemes. But The BMJ’s freedom of information requests show that only a third of medical schools have policies to improve the ethnic diversity of medical academics.
Third year medical student Obadare laughs when she recalls seeing the name of a lecturer whom she recognised as being black. “Me and my friends were so surprised and excited we all turned up to the lecture,” she recalls. “If you see people who look like you, regardless of background, you will feel inspired. You think, yeah, maybe that could be me.”
A junior doctor in Kent told The BMJ, “Fitting in at medical school was incredibly difficult. Even our weekly cohort teaching in the main lecture theatre was segregated. There was an obvious intersection between the various friendship groups, race, and societal class. People were incredibly judgmental: factors such as where you grew up, the schools you attended, your hobbies, and the way you spoke were dissected—sometimes explicitly (and embarrassingly) so. This had a profound domino effect on your entire learning experience. Particular social groups had access to concealed learning resources: past examination questions, comprehensive notes accompanying modules, and so on. It was important to be ‘in the know.’”
In its charter the BMA recommends that all medical schools have a policy aimed at improving the diversity of medical school lecturers. But there’s a paucity of evidence on what policies work.
Medical schools do, however, have the power to influence students’ experience, says Woolf. They decide how students are allocated to teaching groups, and they could be more explicit about the positivity of diversity and how it enriches relationships and students’ knowledge of their communities.
“It’s relationships between students and teachers and between students themselves that are key and need to be valued,” says Woolf.
Learning from the past
If there is one thing that staff at Cardiff’s medical school have learnt since the 2016 incident it’s that communication is key. Steve Riley, the school’s dean of medical education, says the inquiry has increased students’ and staff members’ awareness of racism and raised people’s confidence that conversations about race will happen. The school and the university are collecting anonymised data on complaints of all types and will deal with complaints in various ways, depending on how the complainant wants it to progress, but always putting the student’s wellbeing first, says Riley.
Cardiff has also placed a renewed focus on equality and diversity, professionalism, and ethics in the curriculum. Students are told about support structures for raising complaints, and a named contact is responsible for inclusion and diversity issues. And “vertical networks” of students across the five years of study encourage mentoring.
“I am very pleased personally that the project has fundamentally changed how we deal with issues raised by students,” Riley told The BMJ. “It is by no means a finished exercise, and there is a lot that we still have to do and learn, but we are on the right path.”
A mentor speaks out—“I didn’t want students to go through what I did”
“I was very naive when I applied to medical school, and looking back I realise I did not get the help I needed. I always wanted to do anaesthetics, but I didn’t see any black anaesthetists, which made me think it wasn’t the right specialty for me. I became a mentor because I didn’t want to see other young people go through that.
“I ended up doing a clinical fellowship and met a black anaesthetist and felt really empowered, so I was fine, but the feelings of isolation and inadequacy were uncomfortable. I have spoken in schools about applying for medicine, such as what subjects you need to take at A level, because many pupils choose the wrong subjects without realising that they are ruling themselves out from medicine. I have helped pupils with their personal statements and to prepare them for interviews by practising questions and telling them what to expect. I want them to be well informed. One girl has now started at medical school, and I will stay in touch with her. Knowing where to get resources or how to get a paper published is often about who you know. It is not a level playing field, and some people get a lot more help than others. I don’t want any students to be restricted in their studies and their careers by not seeing someone like them.”
Marilyn Boampomaa is in her second year of core training in anaesthetics at East of England Deanery. She is a mentor for Melanin Medics, a non-profit charitable organisation that focuses on supporting African and Caribbean medical students and doctors in the UK.
The problem with MedSoc
Every medical school has a Medical Society, the social hub that purports to unite medical students. But students from several medical schools told The BMJ it was MedSoc where segregation among the student body was rubber stamped. Students from ethnic minority backgrounds often felt excluded from the activities on offer, most of them fuelled by alcohol and low on the diversity spectrum. “I tried it once and didn’t bother again,” said one student, who requested anonymity. When the third year Nottingham student Ololade Obadare suggested to her MedSoc that its committee should have a representative from an ethnic minority group she was met with disdain. “I was told that if the society had a BME rep it would also need to have an LGBTQ+ rep,” says Obadare.
The students The BMJ spoke to are not asking for much. They would like not to feel ostracised by choosing soft drinks and to be given a wider variety of foods and music choices at events. One of the best things that happened was at a medical student BMA event, one student says. “They put up a piece of paper for suggestions of what songs we’d like to have at the evening reception. It felt inclusive.”
A spokesperson for the University of Nottingham said that there was now a dedicated BME representative on the MedSoc board and that the university was working to expand its offering of social activities and to ensure that “inclusivity and accessibility is at the heart of the entire student experience.”
Additional data analysis and reporting by Gareth Iacobucci and Sonia Ike.
The BMJ’s freedom of information request was sent to the UK’s 40 public undergraduate medical schools, of which 32 responded.