Why do black and minority ethnic (BME) medics and international medical graduates underperform academically on average compared to their white counterparts? Dr Katherine Woolf, Senior Lecturer in Medical Education at UCL Medical School reports on her team’s recent research commissioned by the GMC.
A psychologist and medical educationalist by training, I’ve spent the last 12 years studying medical students’ and doctors’ performance. During that time I’ve focussed on exploring why medics from black and minority ethnic (BME) backgrounds – even those who are born and brought up in the UK – underperform academically compared to white medics on average. This phenomenon is known as ‘differential attainment’, and understanding why it happens is a crucial first step towards making medical education fairer and ultimately to improving healthcare.
Understanding why differential attainment happens is a crucial first step towards making medical education fairer and ultimately to improving healthcare.
Individual-level factors and direct examiner bias are not main causes of differential attainment
To date, research has shown that the main causes of ethnic differences in attainment in medical school exam results are not individual-level factors such as students’ previous performance in exams (e.g. at A level and GCSE), type of school attended, parents’ socioeconomic group, first language, personality, learning habits, or motivation for becoming a doctor. We also know the difference can’t just be caused by examiner prejudice in face-to-face clinical examinations because the effect is present in machine-marked multiple choice examinations too.
The importance of social learning experiences
It seems that medical students’ and doctors’ experiences of learning medicine – what actually happens during medical school and on the wards – play an important part in explaining differential attainment.
Instead it seems that medical students’ and doctors’ experiences of learning medicine – what actually happens during medical school and on the wards – play an important part in explaining differential attainment. For example, previous research has shown that BME medical students can face negative stereotyping from teachers and colleagues, and that BME and white medical students’ social environments differ in terms of their friendships and their relationships with teachers.
Exploring junior doctors’ experiences of learning medicine
To find out more about how BME and white medics’ experiences might differ in ways that affect their learning and performance, the General Medical Council commissioned our team at UCL Medical School to interview 137 doctors (96 trainees and 41 trainers), from different ethnic and national backgrounds working in England and Wales, about their experiences of postgraduate medical training. As well as looking at ethnic differences within UK medical graduates we explored differences between international medical graduates and UK graduates, since evidence suggests that doctors who trained abroad tend to underperform academically.
Evidence suggests that doctors who trained abroad tend to underperform academically.
Three key causes of differential attainment
We found that while most doctors from all backgrounds had experienced challenges during their medical training, international graduates and BME doctors who graduated in the UK faced more challenges that negatively affected their learning and performance.
Three key findings were:
- Cultural differences and subtle unconscious bias against trainees who didn’t ‘fit the mould’ could affect doctors’ ability to get the support and encouragement they needed to learn and develop, particularly in stressful and chaotic NHS work environments
- While reports of overt racism were rare, unconscious bias was felt to hinder success in recruitment and assessments
- In a system where success in recruitment and exams determines where in the country you can get a job, and where work-life balance is often poor, UK BME and international graduates were more likely to face separation from family and support outside of work, and reported more mental health problems as a result of work.
In addition to these three key findings, we found that international graduates could face hurdles due to working in a different culture and assessment system.
Differential attainment is a global problem with significant healthcare implications
We know differential attainment in medicine is also a problem in the USA, Canada, Australia and the Netherlands, and that it is also found in non-medical higher and professional education. Indeed, a recent comprehensive study of differential attainment in British BME university students showed that – just as in medicine – the main causes were not differences in students’ socioeconomic class or prior educational achievement, but instead were a mix of social and structural problems similar to those found in our study.
We may not be getting the best out of our diverse workforce, and that is particularly problematic when the state of the workforce directly affects the health of the nation.
Differential attainment suggests we may not be getting the best out of our diverse workforce, and that is particularly problematic when the state of the workforce directly affects the health of the nation.
Dismantling barriers so we can all benefit from the diversity of the medical profession
We need to act now to dismantle the additional unfair barriers that black and minority ethnic medical students and doctors can face throughout their careers.
Medicine is one of the most ethnically diverse professions. To ensure that we can all benefit from this diversity, we need to act now to reduce prejudice and unconscious bias, increase equality of opportunity during medical training, and dismantle the additional unfair barriers that black and minority ethnic medical students and doctors can face throughout their careers.
Read more about this latest research by the UCL team here.
The GMC has also published new data on the progression of doctors, which you can read more about in the new report, ‘How doctors progress through key milestones in training‘. You can also read about the work the GMC and others are doing to better understand and tackle variation in performance is here.
Dr Katherine Woolf is a Senior Lecturer in Medical Education at UCL Medical School.
Andrea Callender, the GMC’s Head of Diversity, blogs about her work to tackle bias in the decision-making process
Niall Dickson talks about how we can better support non-UK trained doctors to make sure they thrive