Black, Asian and minority ethnic doctors achieve lower pass rates in royal college exams – a ‘stark’ difference in attainment, with environmental causes, which must be urgently addressed, say doctors. Peter Blackburn reports
‘As a doctor from an Asian background nothing is ever adapted for you – you always have to make 200 per cent effort just to survive and you are never given any leeway.’
Dr S Agrawal has chosen to raise her voice about an issue few people – understandably – feel able to discuss. Most trainees do not think they can ‘stick their heads above the parapet’, but the GP trainee is not staying silent.
Training for specialty exams has been a draining experience, Dr Agrawal says. She has found herself being castigated for mistakes and made to feel incompetent while white, male colleagues, ‘from the right side of the line’, are given extra practice and encouragement.
She spent six months in a GP surgery where she worked to the early hours of the morning just trying to keep up – with no time for revision or attention given to mentoring or training. And she has seen colleagues from Asian backgrounds trying to fit in and fearing that being themselves would bring judgement or discrimination.
Despite months of difficulties, her perception that she has had a lack of proper training or supervision, and a constant feeling of stress and worry – Dr Agrawal says she has received little to no support and is not being given any extra time or leeway for her exams. Instead, if she is unable to pass, the stigma of having to fight for an extension is the option suggested by the powers that be.
Dr Agrawal feels these experiences would be very different for a doctor from a different background. It is all weighing heavily.
Dr Agrawal, whose family comes from northern India and who went to a UK medical school, says: ‘I feel I am somebody brave enough to voice my concerns with a loud voice – what about those people who don’t have the courage to stand up and say those things? They are crushed and buried without a teardrop being shed and easily forgotten.
‘I am tired and feel very stressed about whether I can achieve it. They need to take the pressure off my head and give me a safety net to allow me to complete my training fairly.’
Dr Agrawal is far from alone in feeling discriminated against and lacking proper support during training. And the statistics suggest there is an issue, too.
Latest figures, for 2018, show that 90.2 per cent of white graduates of UK medical schools passed the Royal College of GPs membership examinations, compared with 75.5 per cent of UK medical school graduates from BAME (black, Asian and minority ethnic) backgrounds.
The figures are even lower for students whose primary medical qualifications were obtained outside the UK – as low as 41.2 per cent for BAME international medical graduate trainees.
The MRCP(UK) equality and diversity report for 2018 found that for the Part 1 examinations, the pass rate was 64.5 per cent for white UK graduates, 50.8 per cent for BAME UK graduates, and 36.9 per cent for BAME international medical graduates.
There are similar disparities in the Part 2 examinations and PACES (Practical Assessment of Clinical Examination Skills) component.
And figures from the Intercollegiate Committee for Basic Surgical Examinations, which covers the surgical medical royal colleges, show 59.1 per cent of white UK medical graduates passed MRCS, compared with 47.5 per cent of UK medical graduates from BAME backgrounds.
Dr Agrawal can understand why the figures are this way. She says: ‘After a while you get really disheartened and it becomes a cycle, you stop putting in the extra effort and ultimately you end up fulfilling the prophecy. Even the most resilient people are affected. People do make it through but it needs to be a whole culture change from the very core to support more people to succeed.’
BMA council chair Chaand Nagpaul (pictured below) says the statistics are ‘stark’ – particularly when comparing the differential attainment between doctors from BAME backgrounds educated and trained in the UK and their white counterparts.
‘That does not make sense,’ he says.
‘These are students who were educated in this country, understand the system and are hard-working, diligent and capable. We know from research that this is not related to a lack of ability.
‘There is clearly something about the environment they are experiencing which is failing to bring out the best in them. That is a detriment to patients and to the NHS. It is a moral problem – and it has a service impact.’
So, alongside Dr Agrawal’s experiences, what are the major issues driving this inherent unfairness?
A BMA report published in 2017 suggests a number of areas of concern which can put BAME students and trainees at a disadvantage. It says relationships with seniors can be more problematic for trainees who feel they don’t fit in and can struggle to access support when under pressure.
In addition, trainers may feel unease in giving feedback to students who are from different backgrounds, and there are perceptions of bias in workplace-based assessments and recruitment.
Dr Nagpaul says: ‘Throughout medical school training and thereafter, BAME students are less likely to feel included and therefore more isolated. Learning itself depends on having interaction with your peers and your tutors and educators and being isolated means you are denied that softer, more interactive, way of learning.
'That will impact on your educational development.
‘We also know BAME students and doctors are more likely to feel bullied and harassed. They feel more worried about raising concerns and that they are more likely to be blamed for medical errors.
‘They are also fearful of – and are at disproportionate risk of – being referred for disciplinary action and complaints.
‘Clearly these factors can affect wellbeing. BAME doctors are suffering from a lack of wellbeing and that impacts on performance. It is not down to any inherent lack of capability.’
The 2017 report suggests a number of potential solutions, all of which seem to be as relevant today. It suggests diversity is better recognised, cultural competence is improved, data throughout the student journey is better monitored and early intervention and support put in place.
The UK medical workforce is remarkably diverse. The GMC’s 2019 report, The state of medical education and practice in the UK, says: ‘For the first time, more non-UK medical graduates took up a licence to practise than UK medical graduates. And, UK medical graduates were more ethnically diverse than ever before.’
But it seems unclear whether the culture of medicine fully takes into account such diversity.
BMA representative body deputy chair Latifa Patel (pictured below) wants action to be taken immediately.
Dr Patel says the system needs to be overhauled because it is not only affecting doctors but also having an effect on the NHS, with doctors who do not get through training often ending up in staff grades without any continuing care or supervision rather than supported through their careers.
Among a host of possible solutions to this problem, Dr Patel suggests the removal of arbitrary time limits for passing exams, a questioning of the evidence base for the number of attempts allowed and the period of time offered, a greater degree of national oversight, and more effective tailored and early support for trainees who may be struggling.
Ultimately, what Dr Patel is suggesting is simply investment in people. And if the NHS can’t get that right, what can it be expected to get right?
She says: ‘Why are we throwing trainees out of programmes? We have a lack of consultants and a lack of doctors. What is the benefit of throwing a trainee out of a programme to have them work as a staff grade in that specialty being self-led? What is better about that?’
Dr Patel adds: ‘Maybe some people are just going to take longer to go through specialty training – that’s fine. Why not support them along the way? Some people are less likely to pass first time and they are more at risk of failing – they may also max out of time.
‘These people are more at risk. If we know they are less likely to pass an exam how can you throw them out – we should be supporting them earlier. Why not give them longer but say you will always be supervised by a national training programme – you will never be on your own.’
The BMA remains committed to tackling this issue and launched Equality Matters last year – a project which aims to promote fair treatment for all doctors working in the NHS. The association recently sent a letter asking the RCGP what it had done to address differential attainment in its exam and progress in implementing measures to make things fairer.
BAPIO (the British Association of Physicians of Indian Origin) president Ramesh Mehta says: ‘I do have a little bit of optimism for two reasons – since we challenged the RCGP, all the colleges and the whole establishment, people have realised this is a big problem and everybody is trying to see how things can improve. The second is that the Department of Health and NHS England have realised and NHS England has appointed a director for people [Prerana Issar] understanding this is a huge issue.’
The Doctor contacted three educational bodies for comment after analysing the pass rates from their specialty exams.
RCGP council chair Martin Marshall (pictured below) says: ‘[My] organisation has already taken a number of steps to address differential attainment – including developing resources and educational events to support trainers and trainees, introducing an “exceptional” fifth exam attempt, recruiting examiners from an international medical graduate or BAME background and investing in research around the topic.’
He adds: ‘The purpose of the MRCGP assessment is patient safety and to ensure GPs meet the highest standards to deliver this. We are confident it is a robust assessment of a GP trainee’s clinical knowledge and communication skills – both of which are essential to practise independently and safely as a GP in the UK.
‘The college has always been transparent about differential pass rates between candidates taking the MRCGP and is committed to identifying and addressing the underlying issues for them.’
A spokesperson for the Federation of the Royal Colleges of Physicians of the UK says: ‘Differential attainment is an extremely complex issue and touches on social, cultural, educational and other factors.
‘We have been at the forefront of research into differential attainment in examinations since the issue was first identified. We measure it as part of our exam quality assurance processes and report it as part of our governance arrangements. We undertake our own, and contribute to, research on differential attainment.’
He says the federation is ‘fully engaged with stakeholders’.
The Intercollegiate Committee for Basic Surgical Examinations says the organisation has taken a number of actions to understand and address differential attainment in exams, including ‘the identification of fair access measures in all assessment content and the production of a mandatory examinations-specific equality and diversity training module for all examiners’.
The GMC says it believes assessment pass rates are a ‘useful tool’ to measure differences but are not the ‘primary cause of difference’ and that more research into the issue is required to understand the ‘true causative factors’.
A spokesperson says: ‘Education and training should be fair for all but we know a complex range of factors can cause disadvantage. We’re working with others to understand the intricacies at the heart of this issue and share learning that could help bridge the gap faced by doctors from different backgrounds. We ask educators to keep differentials front of mind and make efforts to minimise or eliminate challenges wherever possible.’
Whatever the causes for differential attainment, while trainees are left feeling dispirited or even defeated they are being failed. And for every brave trainee like Dr Agrawal, who stands up to speak out about this problem, many others may be suffering in silence.
As Dr Agrawal says: ‘It just needs to be so much fairer and the same opportunities and judgements need to be given. It is about the enthusiasm for reaching people of all backgrounds being equal.’
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