Ethnic minority doctors and medical students underperform academically compared with white candidates

Ethnic minority doctors and medical students who trained in the UK continue to do worse in undergraduate and postgraduate assessments than white candidates, reports a large study published in the BMJ (BMJ 2011;342:d901; doi:10.1136/bmj.d901).

The meta-analysis of reports covering almost 24 000 students and doctors found that those of “non-white” ethnicity underperform academically compared with their white counterparts, regardless of the type of test—for example, machine marked written assessment, practical clinical assessment, or assessment with a continuous outcome. In studies with a pass/fail outcome, non-white candidates were nearly three times more likely to fail than white candidates.

A third of all UK medical students are from ethnic minority groups, 1.6 times the proportion on other undergraduate courses. In 2009, 36% of newly qualified doctors and 52% of all other hospital doctors working in the NHS were from minority ethnic groups.

“It’s unlikely that there’s a single cause of this disparity—education and ethnicity are complex,” said Katherine Woolf, lecturer in medical education at the Academic Centre for Medical Education, UCL, and lead author of the paper.

“What this study does is highlight the problem so that people can do further research to find out the reasons why it’s happening,” she adds. “In particular, there hasn’t really been a joined up approach at undergraduate level. Some medical schools have looked at the role of ethnicity in their own exam results, but it would be better if all medical schools could look at their data together so we can get an idea nationally of where this problem is happening and where it’s not happening.”

Woolf and colleagues looked at 22 quantitative reports on the performance of UK trained medical students or doctors from different ethnic groups in undergraduate or postgraduate assessments, 16 of which covered undergraduate exams at universities such as Leeds and Nottingham and six that reported on postgraduate assessments such as the MRCGP exams and the MRCP written and PACES exams.

The authors calculated that on a typical exam with a pass mark of 50, if white candidates got a mean score of 60, non-white candidates would score an average of 57.9 and would thus be 2.5 times more likely to fail.

“We’ve looked for obvious reasons, such as class, and controlled for and excluded all these things and yet studies still find a difference in performance in ethnic minorities and white individuals,” said Aneez Esmail, professor of general practice at the University of Manchester and author of an editorial on the research. “The only possible explanation remaining is that doctors and medical students are being discriminated against because of their ethnicity.”

“Direct discrimination does happen, but often it is more subtle,” he adds. “For example, bias in tests with anonymous marking could be an effect of how ethnic minority students engage with a topic, or because society expects them to do badly, so they unconsciously fulfil that stereotype.’’

The royal colleges have a duty to their membership, and universities to future doctors, to look at this ethnic disparities in performance and do something to address it, says Professor Esmail. Approaches to reducing this bias could comprise widening the curriculum to cover currently unexamined areas where ethnic minority candidates might do well, such as examining a patient with the help of an interpreter, and raising awareness of implicit bias in examiners. “For example, in a practical exam a candidate may not make eye contact for cultural reasons but the examiner may make assumptions about the candidate on the basis of this,” points out Professor Esmail.

“This study raises a number of important issues about the link between ethnicity and academic performance,” said Niall Dickson, chief executive of the General Medical Council. “We will be looking closely at its findings and the implications for our role as the regulator for all stages of medical education and training.” The GMC already asks medical schools, deaneries, and royal colleges to routinely collect and analyse data about equality and diversity issues, including ethnicity, to ensure that any trends or issues are identified and acted upon at the earliest opportunity, he added.