Background

National awareness of differential attainment among key stakeholders in postgraduate medical education was increased when the Royal College of General Practitioners (RCGP) was taken to judicial review over perceived discrimination within its Clinical Skills Assessment.7 IMGs had a pass rate of 36.8%, compared with a 90.6% pass rate for UK graduates (UKGs).8 A review suggested that ‘subjective bias due to racial discrimination’ could be the cause of this difference.8 While ultimately the courts found in favour of the RCGP, the judgement in 2014 highlighted the need for the medical establishment to work to reduce differential attainment. ‘If it (RCGP) does not act and its failure to act is the subject of a further challenge, it may well be held to be in breach of its (public sector equality) duty’.9

The public sector equality duty places an extra duty on public sector organisations to advance equality of opportunity between those who share a protected characteristic and those who do not and to foster good relations between such groups.10 This judgement clarified that if such organisations were not working to reduce differential attainment, they could be reasonably subjected to a challenge for a perceived breach of their public sector equality duty. Differential attainment is not exclusive to general practice having been seen across other specialities.11 The General Medical Council (GMC), the UK Medical Royal Colleges and the Statutory Education Bodies (SEBs) are working together on the issue of differential attainment. There is a small, but growing body of evidence to underpin this work.

Causes of differential attainment

No one factor can entirely explain why differential attainment exists. Doctors’ prior attainment or socioeconomic background12 ,13 are not the sole cause of these differences. Even when such differences are accounted for, the gap only narrows, not closes. This suggests ethnicity and country of qualification could act as independent risk factors for poorer outcomes in medical education. Assessing the impact of ethnicity and country of qualification is hampered by medicine in the UK being dominated by individuals from the most affluent groups.14 Similarly, it is unlikely that examiner bias alone is at fault, as gaps in attainment persist in machine marked exams as well as live examiner marked exams.5 There is minimal evidence as to the result of intersectionality on differential attainment for BAME IMGs. However, when UK citizens trained overseas and returned to the UK they were deemed more appointable to training than other IMG groups, despite subsequently having poorer ARCP outcomes than other IMGs.15

Systemic inequalities appear to be present in medical education, reflecting wider societal workforce and employment inequalities.16 ‘Fair Training Pathways for All’,17 sought to understand the reasons for differential attainment in postgraduate medical training. They collected qualitative data from trainees across four deaneries, different levels and different specialties (Medicine, Surgery, Psychiatry, General Practice, Clinical Radiology, Obstetrics and Gynaecology, and Foundation). This research identified 12 risk factors, summarised in table 2, that made individuals from BAME and/or IMG groups more vulnerable to differential attainment. While medical training was found to be psychologically risky for all groups, there were additional risk factors experienced by BAME UKGs and IMGs when compared with white UKGs, placing extra barriers in the way of their progression.

How can we tackle differential attainment?

‘Fair Training Pathways for All’17 identified a number of protective processes that lessen the attainment gap, listed in table 3.

The GMC funded a subsequent study: ‘What supported your success in training?’.18 This identified 10 success factors which, when present in a training programme, led to reduced levels of differential attainment. These success factors fell across three areas; the working environment, the people who support learning and strategies used to support learning. This strongly echoes the protective processes illustrated in table 3, suggesting that change which enables effective supervisee-supervisor relationships, supportive work environments and the availability of support structures is what impacts on reducing differential attainment.

The onus of making change must not be solely placed on affected groups, rather it should be everyone’s responsibility, but any interventions made should include views and inputs from members of affected groups to ensure inclusivity. The risk factors and protective processes identified suggest what we can do, but putting these into practice will require change at varying levels. We make a number of our own suggestions based on these and case studies from other specialties19 as to what that change might look like. At an individual level, we can make the effort to learn and pronounce names correctly. We can facilitate opportunities to get to know our colleagues or share advice and learning widely, not just within silos. Supervisors can focus on developing relationships with those they supervise, to better understand and support them. It is important to remember that while reference is made to groups such as IMGs or BAME UKGs, these terms and groupings are in themselves inadequate. While used to reflect the terminology used in this area, it should be noted that the vast heterogeneity within these groups means a universal experience cannot be assumed. The emphasis should be on supervisors getting to know supervisees as unique individuals, each with their own challenges and strengths, while recognising that for some there may be additional hurdles along the way, that may require tailored support.

At an institutional level, organisations can adopt and enforce antidiscrimination policies. At an individual level, being seen to actively uphold these values is just as important. When a new doctor joins an organisation, ensuring that their induction is thorough and more than just a password exchange will safeguard those new to the National Health Service so they are not left unsure of expectations and processes. Institutions can also prioritise supervision within job plans and provide opportunities to access mentoring.

At a policy level, it is important that organisations such as the Royal College of Paediatrics and Child Health (RCPCH), GMC and SEBs are making culturally competent decisions about matters such as recruitment or high stakes assessment. This is best achieved by ensuring diversity in appointments to these organisations, something the RCPCH has openly committed to following publication of its ‘Putting Ladders Down’20 report, with clear recommendations to improve the diversity of those appointed to college roles. Specific research into the drivers of differential attainment within paediatrics is needed. This could start with quantitative research using national data sets from the GMC, UK Medical Education Database or the RCPCH.

The case for reducing differential attainment is clear. While the courts may have brought this to the fore, it is not just a matter of serving justice, it is about doing what is right. With change, we can make medical education and paediatric training fairer for all, ensuring that we really do harness the full potential of our current and future paediatricians.