Taking the difference out of attainmentBMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m438 (Published 12 February 2020) Cite this as: BMJ 2020;368:m438
“The person who came first in your class, does he have two heads?”
Frank Chinegwundoh, consultant urological surgeon at Barts Health NHS Trust in London, laughs, recalling a saying many Nigerians know well. Achievement was not for the exceptional few, he was taught, but for everyone with hard work and opportunity.
For many UK medical students and graduates from ethnic minority backgrounds the phrase might ring hollow. Data show that they have consistently poorer academic and job recruitment outcomes than their white peers (box 1).1
Mapping differential attainment
Doctors and medical students from ethnic minority backgrounds are up to three times as likely as their white counterparts to fail an examination.1 These include undergraduate and postgraduate assessments, machine marked written assessments, practical clinical assessments, assessments with pass or fail outcomes, and assessments with continuous outcomes.
In 2017 the pass rate in postgraduate examinations was 75% among white students and 63% among UK ethnic minority students. Among international medical graduates, the pass rate was 46% for white students and 42% for students from other ethnic groups.2
In 2016 94% of white GP trainees who were educated in the UK passed the clinical assessment skills (CSA) examination set by the RCGP at their first attempt, whereas 80% of ethnic minority GP trainees educated in the UK did so.3
Among UK medical graduates, 72% of ethnic minority foundation doctors applying for a specialty training programme succeeded on their first attempt, while 81% of white doctors did so.4
In 2016 UK doctors from an ethnic minority background applying for consultant posts were:
more likely to apply for more posts than white doctors (1.66 versus 1.29 posts)
less likely to be shortlisted than white doctors (66% versus 80%)
less likely to be offered a post than white doctors (57% versus 77%).5
Basic pay for consultants from ethnic minority backgrounds was 4.9% less than for white consultants in 2017, equivalent to £4644 a year. Median basic pay for white consultants was higher than for all other ethnic groups, varying from around 3.5% higher than black or black British consultants to more than 6% higher than mixed or dual heritage consultants.6
“These are very bright people,” Chinegwundoh tells The BMJ. “They got into medical school, so they have what it takes to excel.” Then why do we see this gap?
It’s a question that is being asked in the US, Canada, Australia, the Netherlands, and across UK higher education, where similar gaps in attainment have also been seen.7
Peter Coventry, director of undergraduate programmes in the school of medicine at Keele University, says that the data on differential attainment are unequivocal. “Our mission as a medical school is to produce good doctors, and addressing differential attainment is crucial to achieving that mission,” he tells The BMJ. “Racism is widespread, and medical schools are now recognising that it is a moral expedient to move forwards and address this.”
Coventry describes differential attainment as a “thorny issue” that requires some bravery, given the risks of negative unintended consequences.
He chooses his words carefully, being mindful of the stereotype threat: the fear that talking about differential attainment may negatively stereotype a particular group of students and that their performance will be affected as a result.
It was this fear that partly stopped him for some time in terms of taking action on differential attainment, acknowledges Coventry. And it may be why there has been so little progress on differential attainment despite evidence of its existence for more than 20 years. For Coventry, understanding and then being open with students and colleagues about the pitfalls of the stereotype threat led to a breakthrough and allowed his medical school to take the first steps to start doing something to tackle differential attainment.
Relationships are key
For Chinegwundoh, relationships with peers and staff are the key. Good relationships with seniors and being part of a network have been shown to significantly affect clinical placements, practical assessments, and progression in annual reviews of competence.7
“When you are struggling, you need people to support you and reassure you,” he says. However, ethnic minority trainees are less likely to report support and reassurance from their seniors when in challenging situations.7 One solution is mentors who can provide pastoral support and help trainees to build confidence in interacting with senior colleagues.
“I wasn’t comfortable talking to my seniors until my late 20s, nor having a drink with consultants, even at registrar level,” says Chinegwundoh. “I didn’t feel we had anything in common . . . I see a similar discomfort among many young black doctors.”
Ethnic minority doctors may also feel alienated from the medical curriculum, and some research has focused on how this might change. In 2017 Faye Gishen and Amali Lokugamage, clinical and professional practice leads at University College London medical school, received funding to diversify the undergraduate medical curriculum.8
“It allowed us to reflect on areas of the hidden curriculum that may have contributed to unconscious bias,” says Lokugamage.
After feedback, curriculum changes included more diversity in case studies, information on laboratory reference ranges for different ethnic groups, and teaching on detecting dermatological conditions and clinical signs, such as anaemia and cyanosis, on dark skin.9
Gishen explains, “It’s about creating an inclusive curriculum that represents the patients and students we serve.”
A contentious explanation for differential attainment is examination bias. In 2014 the Royal College of General Practitioners and the General Medical Council faced court action for unlawful racial discrimination in the clinical skills examination (CSA) (box 2). An analysis of 2010-12 data for the examination for membership of the RCGP showed that even after controlling for performance on the machine marked applied knowledge test, ethnic minority UK graduates were nearly four times and international medical graduates 14 times as likely to fail their first CSA attempt as white candidates.10 The authors could not exclude “subjective bias due to racial discrimination” as a cause.
2013—British Association of Physicians of Indian Origin brings High Court action against the Royal College of General Practitioners and the GMC for unlawful racial discrimination and breach of public sector equality duty.11
2014—Judge rules the clinical skills examination (CSA) lawful, and the British Association of Physicians of Indian Origin loses its case. But the judge warned that if the RCGP and GMC did not take action they could be subject to further challenge.12
2017—CSA pass rates show the gap between white and ethnic minority doctors to be widest ever recorded.3
2018—A 10 year independent review of the membership examination commissioned by the RCGP concludes that the examination is “fit for purpose and fair.”13
2019— British Association of Physicians of Indian Origin considers repeat legal challenge against the RCGP.14
However, in the courts the examination was judged lawful, though since then the GMC and the royal college have had regular discussions with the British Association of Physicians of Indian Origin and have produced examination preparation resources and guidance for trainers and assessors, and have introduced an exceptional fifth CSA attempt.15 A Health Education North West programme that has been shown to improve outcomes of CSA resits by GP trainees is also being extended.16
However, Aneez Esmail, lead author of the GMC’s 2014 review of the RCGP membership examination, criticises the focus on “remedial rather than preventive” action, calling the overall response “cosmetic.”
“The RCGP is hiding behind the notion that differential attainment is present everywhere and that their examination is no different. That is unacceptable,” he says. “If you control for differential attainment on the applied knowledge test, BME [black and minority ethnic] candidates still do worse on the CSA.
“Trainers who have observed these doctors for 18 months have signed them off as competent . . . These doctors pass comprehensive workplace based assessments but then attempt the CSA and fail. Clearly, the CSA is not a test of competence. Why not use a fairer assessment?”
A fairer assessment, he says, would involve developing the workplace based assessment, which could include some elements of summative assessment. This could be, for example, a “live clinic” where the trainer and an external examiner could assess the candidate with real patients rather than the simulated surgery using actors that is part of the current CSA.
“Waste of talent”
Esmail argues that the high failure rate among international and UK ethnic minority graduates is a “waste of talent,” especially given that the UK is facing a widespread shortage of GPs.
“Where do we go from here, except for another legal challenge? . . . The data tells a story. You cannot ignore it.” He argues that “the GMC recognises the problem and has a responsibility to mandate colleges to take action.”
Jane Cannon, the GMC’s head of approvals and project sponsor for differential attainment, says that more needs to be done to build an evidence base for effective interventions. “The layering of [disadvantage that ethnic minority doctors face] means there are different levels at which we can effect change . . . from individual trainers thinking about bias to policy decisions about the allocation of posts,” Cannon tells The BMJ. “The onus is on all of us to pool resources and share the lessons learnt.”
Alongside sharing case studies of initiatives on differential attainment, the GMC has produced guidance on evaluating interventions and has embedded work on differential attainment into its quality assurance framework.
“We asked every dean to develop a local action plan for their region,” Cannon says. “We provided data on the scale of the gap within their region so that they own the issue.” Deans must provide routine updates on their action plans and show how they will evaluate their interventions. The GMC is developing a similar system for medical schools and medical royal colleges, she adds.
For others it is the learning environment that needs closer examination. “We have to look at the culture that students and staff are embedded in, the experiential issues that affect learning,” says Keele University’s Coventry.
The focus of his school’s working group on differential attainment will be students’ day to day experiences, rather than just examinations.
This approach recognises that racist behaviour is prevalent in the learning environment, says Coventry. “We’re looking at a far more complicated challenge than simply addressing issues around assessments, and there aren’t going to be any easy wins. It is therefore crucial that this is a high level school priority so momentum may be maintained,” he says.
The group has a champion who is leading work on developing training packages for students to help them handle microaggressions, harassment, and discrimination. “We are also putting together proposals for reporting systems for students to come forward and record their experiences of racial harassment,” he tells The BMJ.
The RCGP’s chair, Martin Marshall, agrees. “If we are to truly address differential attainment, we need to focus on much wider factors than the exam, such as the training environment, the early identification of the support and training needs of individual trainees, and other issues highlighted by the GMC in its What supported your success in training? report published last year,”17 he says.
This report raises the issue of discrimination and asks organisations to reflect on the support they provide to doctors from ethnic minority backgrounds who experience prejudice in the workplace.
More inclusive NHS
Chaand Nagpaul, the BMA’s chair of council, sees tackling differential attainment as part of the larger work to create a more inclusive NHS.
“If you want the most productive health service, you want everyone working within it to be their best,” he explains. “The current system is inhibiting the ability of each doctor to be their best and flourish.”
He says the BMA has produced “bespoke training on diversity and equality” to meet training needs.18
Looking forward, Nagpaul hopes to see “equality and inclusivity as values embedded in the core specification” of medical leaders’ job descriptions. “If they were, I think we would start to see more change.”
Competing interests: I have read and understood BMJ’s policy on declaration of interests and have no relevant interests to declare.
Samara Linton is a junior doctor, writer, and coeditor of The Colour of Madness: Exploring BAME Mental Health in the UK.
Provenance and peer review: Commissioned; not externally peer reviewed.
For more articles in The BMJ’s Racism in Medicine special issue see bmj.com/racism-in-medicine.