Intended for healthcare professionals


Specialty training: ethnic minority doctors’ reduced chance of being appointed is “unacceptable”

BMJ 2020; 368 doi: (Published 12 February 2020) Cite this as: BMJ 2020;368:m479

Read all of the articles in our special issue on Racism in Medicine

  1. Gareth Iacobucci
  1. The BMJ

More than 25 years after two GPs uncovered bias in appointments to specialty training posts, new data show that the ethnicity gap persists, reports Gareth Iacobucci

Doctors from ethnic minority backgrounds are less likely than white doctors to be considered suitable for appointment to specialty training jobs in the UK, an analysis of new data obtained for The BMJ has found.

The findings indicate that little progress has been made in tackling a bias in recruitment that was highlighted in a landmark BMJ paper in1993.1 This found that doctors with English names were twice as likely to be shortlisted for senior house officer jobs as those with Asian names, despite having the same experience and training.

Aneez Esmail, professor of general practice at the University of Manchester, who carried out the 1993 research, said he was disappointed that 27 years later ethnic minority doctors were still less successful than white doctors in securing specialty training posts.

Esmail and fellow GP Sam Everington were arrested and charged with making fraudulent applications back in 1993 for using 46 made-up CVs to apply to 23 senior house officer posts, half with English and half with Asian names. They said their work showed that discrimination took place at shortlisting and suggested ways to reduce it, such as removing information from applications that identified ethnic origin.

For The BMJ’s current themed issue on Racism in Medicine (, Esmail wanted to see whether the appointments process had become fairer. He could not repeat his previous study, so instead he obtained figures from the General Medical Council showing numbers of applicants to specialty training posts who were deemed “appointable” over three years, from 2016 to 2018.

Determining “appointability”

Doctors who have completed UK foundation training have interviews at regional recruitment offices or deaneries to be approved for appointment to specialty training posts.2 They might be deemed not appointable for a range of different reasons: level of experience, competencies, examination results, or failure to attend an interview, for example.

The data show that doctors from ethnic minority backgrounds are less likely than white colleagues to be considered appointable. Across the three years, three quarters (75%) of white but only 53% of ethnic minority applicants to training posts were deemed appointable (23 589 of 31 430 versus 15 293 of 29 072).

Esmail said that the scale of the difference between white and ethnic minority doctors was “shocking,” and he called on the General Medical Council and Health Education England to investigate the causes.

“The methods used to obtain these data were different from how we carried out our study in 1993, so they are not directly comparable,” he said. “But they show a lack of progress in the intervening years. I would have expected to see ethnic minority doctors achieving the same outcomes as white doctors, but that is simply not the case. It is very disappointing and, frankly, unacceptable in this day and age,” said Esmail.

Variation across specialties

The imbalance is particularly acute in a few specialties, though some of the numbers are small. Esmail said he was “stunned” that in 2017 two thirds of white applicants to academic posts were considered appointable (14 of 23), whereas only 4% of ethnic minority applicants were (1 of 26). This gap had narrowed in 2018 but had not disappeared, with more than a third of white applicants (10 of 29) but less than a quarter of ethnic minority applicants (7 of 30) deemed appointable (fig 1). Esmail said, “I’ve never maintained that ethnic minorities don’t want to be academics. But they might be thinking, ‘I don’t have much chance, I’m not going to apply.’ I don’t know. We can’t tell that. You begin to wonder: is it to do with bias, or is it to do with the fact that ethnic minorities don’t have the right credentials to apply? I work in academia, and I don’t believe that’s the case. And yet, when they apply for these jobs there’s such a big discrepancy.”

Fig 1
Fig 1

Proportion of white and ethnic minority applicants considered “appointable,” by specialty, 2018

Even specialties with large shortages, such as general practice, have large disparities. For example, in 2016 just over half of ethnic minority applicants to general practice were deemed appointable (1660 of 3212), but in white applicants the proportion was 75% (1935 of 2575). This gap narrowed slightly to 74% (2159 of 2922) versus 93% (1880 of 2029) in 2018.

Esmail suggested that improvements in 2018 may have been due to recruitment drives across all specialties. But he said the data still indicated a big problem that needed to be investigated by the GMC, which collects the data as the regulator, and Health Education England (HEE), which oversees medical recruitment.

He said, “The data are shining a light on where there might be a problem. The reason we collect the figures is so we can deal with discrepancies, differential attainment, and differential applications, because that makes it a fairer and more transparent system.

“The onus is on HEE [to investigate], because they’re the ones that run the recruitment process. But the GMC is also in a position to tell HEE to do it. If you’ve got such big disparities, shouldn’t you as a regulator be saying, ‘Why is this going on? This can’t be right. There must be something going on here.’”

Nico Kirkpatrick, the GMC’s education operations assistant director, said that its standards made it clear that education and training should be fair for all. But she added, “We know that complex factors can disadvantage some doctors and lead to poorer outcomes and that these can persist throughout doctors’ careers. It is essential that these factors are identified and addressed early.”

The GMC was working with other agencies to build evidence for what could be done to help tackle these issues, he said.

Recent GMC research that asked ethnic minority doctors what helped them succeed highlighted the importance of inclusive workplace environments, inspirational and supportive educators, mentors, and peers, and regular and good quality feedback, Kirkpatrick added.

Wendy Reid, Health Education England’s director of education and quality, said that the organisation had done specific work on the quality of individual specialty selection processes and was working with royal colleges and others to improve understanding of the factors behind differential attainment. Health Education England had also established the Widening Access to Specialty Programme “to give international medical graduates experience of the NHS and support their applications into speciality training programmes,” she said.