Ethnic stereotypes and the underachievement of UK medical students from ethnic minorities: qualitative study

Gender, ethnicity and graduate status, and junior doctors' self-reported preparedness for clinical practice: national questionnaire surveys

OBJECTIVES

Medical schools need to ensure that graduates feel well prepared for their first medical job. Our objective was to report on differences in junior doctors' self-reported preparedness for work according to gender, ethnicity and graduate status.

DESIGN

Postal and electronic questionnaires.

SETTING

UK.

PARTICIPANTS

Medical graduates of 2008 and 2009, from all UK medical schools, one year after graduation.

MAIN OUTCOME MEASURES

The main outcome measure was the doctors' level of agreement with the statement that 'My experience at medical school prepared me well for the jobs I have undertaken so far', to which respondents were asked to reply on a scale from 'strongly agree' to 'strongly disagree'.

RESULTS

Women were slightly less likely than men to agree that they felt well prepared for work (50% of women agreed or strongly agreed vs. 54% of men), independently of medical school, ethnicity, graduate entry status and intercalated degree status, although they were no more likely than men to regard lack of preparedness as having been a problem for them. Adjusting for the other subgroup differences, non-white respondents were less likely to report feeling well prepared than white (44% vs. 54%), and were more likely to indicate that lack of preparedness was a problem (30% non-white vs. 24% white). There were also some gender and ethnic differences in preparedness for specific areas of work.

CONCLUSIONS

The identified gender and ethnic differences need to be further explored to determine whether they are due to differences in self-confidence or in actual preparedness.

Health-Related Stereotype Threat Predicts Health Services Delays Among Blacks

To our knowledge, no published research has developed an individual difference measure of health-related stereotype threat (HRST). We adapted existing measures of academic stereotype threat to the health domain on a sample of black college students (N = 280). The resulting health-related stereotype threat scale-24 (HRST-24) was assessed for internal consistency, construct and incremental validity, and whether it explains variance in self-reported delays among four preventive health behaviors-blood pressure and cholesterol assays, physical exams, and routine checkups. After adjusting for several control variables, the HRST-24's (full scale α = 0.96) perceived black health inferiority (18 items; α = 0.96) and perceived physician racial bias (6 items; α = 0.85) sub-scales explained unique variance in delays among two of the four behaviors including a blood cholesterol check (p < .01) and routine checkup-albeit at marginal levels (p = .063) in the case of the latter. Overall, these data provide preliminary evidence of construct and incremental validity for the HRST-24 among blacks. Recommendations for administering the scale are provided and future directions for HRST research are discussed.

Medical school attrition-beyond the statistics a ten year retrospective study

BACKGROUND

Medical school attrition is important--securing a place in medical school is difficult and a high attrition rate can affect the academic reputation of a medical school and staff morale. More important, however, are the personal consequences of dropout for the student. The aims of our study were to examine factors associated with attrition over a ten-year period (2001-2011) and to study the personal effects of dropout on individual students.

METHODS

The study included quantitative analysis of completed cohorts and qualitative analysis of ten-year data. Data were collected from individual student files, examination and admission records, exit interviews and staff interviews. Statistical analysis was carried out on five successive completed cohorts. Qualitative data from student files was transcribed and independently analysed by three authors. Data was coded and categorized and key themes were identified.

RESULTS

Overall attrition rate was 5.7% (45/779) in 6 completed cohorts when students who transferred to other medical courses were excluded. Students from Kuwait and United Arab Emirates had the highest dropout rate (RR = 5.70, 95% Confidence Intervals 2.65 to 12.27;p < 0.0001) compared to Irish and EU students combined. North American students had a higher dropout rate than Irish and EU students; RR = 2.68 (1.09 to 6.58;p = 0.027) but this was not significant when transfers were excluded (RR = 1.32(0.38, 4.62);p = 0.75). Male students were more likely to dropout than females (RR 1.70, .93 to 3.11) but this was not significant (p = 0.079).Absenteeism was documented in 30% of students, academic difficulty in 55.7%, social isolation in 20%, and psychological morbidity in 40% (higher than other studies). Qualitative analysis revealed recurrent themes of isolation, failure, and despair. Student Welfare services were only accessed by one-third of dropout students.

CONCLUSIONS

While dropout is often multifactorial, certain red flag signals may alert us to risk of dropout including non-EU origin, academic struggling, absenteeism, social isolation, depression and leave of absence. Psychological morbidity amongst dropout students is high and Student Welfare services should be actively promoted. Absenteeism should prompt early intervention. Behind every dropout statistic lies a personal story. All medical schools have a duty of care to support students who leave the medical programme.

The state of research on racial/ethnic discrimination in the receipt of health care

OBJECTIVES

We conducted a review to examine current literature on the effects of interpersonal and institutional racism and discrimination occurring within health care settings on the health care received by racial/ethnic minority patients.

METHODS

We searched the PsychNet, PubMed, and Scopus databases for articles on US populations published between January 1, 2008 and November 1, 2011. We used various combinations of the following search terms: discrimination, perceived discrimination, race, ethnicity, racism, institutional racism, stereotype, prejudice or bias, and health or health care. Fifty-eight articles were reviewed.

RESULTS

Patient perception of discriminatory treatment and implicit provider biases were the most frequently examined topics in health care settings. Few studies examined the overall prevalence of racial/ethnic discrimination and none examined temporal trends. In general, measures used were insufficient for examining the impact of interpersonal discrimination or institutional racism within health care settings on racial/ethnic disparities in health care.

CONCLUSIONS

Better instrumentation, innovative methodology, and strategies are needed for identifying and tracking racial/ethnic discrimination in health care settings.

Ethnic disparities in undergraduate pre-clinical and clinical performance

CONTEXT

Research from numerous medical schools has shown that students from ethnic minorities underperform compared with those from the ethnic majority. However, little is known about why this underperformance occurs and whether there are performance differences among ethnic minority groups.

OBJECTIVES

This study aimed to investigate underperformance across ethnic minority groups in undergraduate pre-clinical and clinical training.

METHODS

A longitudinal prospective cohort study of progress on a 6-year undergraduate medical course was conducted in a Dutch medical school. Participants included 1661 Dutch and 696 non-Dutch students who entered the course over a consecutive 6-year period (2002-2007). Main outcome measures were performance in Year 1 and in the pre-clinical and clinical courses. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated by logistic regression analysis for ethnic subgroups (Surinamese/Antillean, Turkish/Moroccan/African, Asian, Western) compared with Dutch students, adjusted for age, gender, pre-university grade point average (pu-GPA), additional socio-demographic variables (first-generation immigrant, urban background, first-generation university student, first language, medical doctor as parent) and previous performance at medical school.

RESULTS

Compared with Dutch students, Surinamese and Antillean students specifically underperformed in the Year 1 course (pass rate: 37% versus 64%; adjusted OR 0.40, 95% CI 0.27-0.60) and the pre-clinical course (pass rate: 19% versus 41%; adjusted OR 0.57, 95% CI 0.35-0.93). On the clinical course all non-Dutch subgroups were less likely than Dutch students to receive a grade of ≥ 8.0 (at least three of five grades: 54-77% versus 88%; adjusted ORs: 0.17-0.45).

CONCLUSIONS

Strong ethnic disparities exist in medical school performance even after adjusting for age, gender, pu-GPA and socio-demographic variables. More subjective grading cannot be ruled out as a cause of lower grades in clinical training, but other possible explanations should be studied further to mitigate the disparities.

The mediators of minority ethnic underperformance in final medical school examinations

BACKGROUND

UK-trained medical students and doctors from minority ethnic groups underperform academically. It is unclear why this problem exists, which makes it difficult to know how to address it.

AIM

To investigate whether demographic and psychological factors mediate the relationship between ethnicity and final examination scores.

SAMPLE

Two consecutive cohorts of Year 5 (final year) UCL Medical School students (n= 703; 51% minority ethnic). A total of 587 (83%) had previously completed a questionnaire in Year 3.

METHODS

Participants were administered a questionnaire in 2005 and 2006 that included a short version of the NEO-PI-R, the Study Process Questionnaire, and the General Health Questionnaire (GHQ) as well as socio-demographic measures. Participants were then followed up to final year (2007-2010). White and minority ethnic students' questionnaire responses and final examination grades were compared using univariate tests. The effect of ethnicity on final year grades after taking into account the questionnaire variables was calculated using hierarchical multiple linear regression.

RESULTS

Univariate ethnic differences were found on age, personality, learning styles, living at home, first language, parental factors, and prior education. Minority ethnic students had lower final exam scores, were more likely to fail, and less likely to achieve a merit or distinction in finals. Multivariate analyses showed ethnicity predicted final exam scores even after taking into account questionnaire factors.

CONCLUSIONS

Ethnic differences in the final year performance of two cohorts of UCL medical students were not due to differences in psychological or demographic factors, which suggests alternative explanations are responsible for the ethnic attainment gap in medicine.

Place of medical qualification and outcomes of UK General Medical Council "fitness to practise" process: cohort study

OBJECTIVES

To evaluate whether country of medical qualification is associated with "higher impact" decisions at different stages of the UK General Medical Council's (GMC's) "fitness to practise" process after allowing for other characteristics of doctors and inquiries.

DESIGN

Retrospective cohort study.

SETTING

Medical practice in the United Kingdom.

PARTICIPANTS

7526 inquiries to the GMC concerning 6954 doctors.

MAIN OUTCOME MEASURES

Proportion of inquiries referred for further investigation at initial triage by the GMC, proportion of inquiries investigated that were subsequently referred for adjudication, and proportion of inquiries resulting in doctors being erased or suspended from the medical register; relative odds of higher impact decisions, by country of qualification, adjusted for doctors' sex, years since primary medical qualification, medical specialty, source and type of inquiry, and nature of allegations.

RESULTS

Of 7526 inquiries, 4702 concerned doctors who qualified in the UK, 624 concerned doctors who qualified elsewhere in the European Union (EU), and 2190 concerned doctors who qualified outside the EU. At the initial triage, 30% (n = 1398) of inquiries concerning doctors who qualified in the UK had a high impact decision, compared with 43% (267) for doctors who qualified elsewhere in the EU and 46% (998) for those who qualified outside the EU. The adjusted relative odds of an inquiry being referred for further investigation were 1.67 (95% confidence interval 1.28 to 2.17) for doctors who qualified elsewhere in the EU and 1.61 (1.38 to 1.88) for those who qualified outside the EU, compared with doctors who qualified in the UK. At the investigation stage, 5% (228) of inquiries received concerning UK qualified doctors were referred for adjudication, compared with 10% for EU (63) or non-EU (221) qualified doctors. The adjusted relative odds of referral for adjudication were 2.14 (1.46 to 3.16) for doctors who qualified elsewhere in the EU and 1.68 (1.31 to 2.16) for those who qualified outside the EU. At the adjudication stage, 1% (69) of inquiries received concerning UK qualified doctors led to erasure or suspension, compared with 4% (24) for doctors who qualified elsewhere in the EU and 3% (71) for non-EU qualified doctors. The adjusted relative odds of erasure or suspension were 2.16 (1.22 to 3.80) for doctors who qualified elsewhere in the EU and 1.48 (1.00 to 2.19) for those who qualified outside the EU.

CONCLUSIONS

Inquiries to the GMC concerning doctors qualified outside the UK are more likely to be associated with higher impact decisions at each stage of the fitness to practice process. These associations were not explained by measured inquiry related and doctor related characteristics, but residual confounding cannot be excluded.

Risk factors at medical school for subsequent professional misconduct: multicentre retrospective case-control study

OBJECTIVE

To determine whether there are risk factors in a doctor's time at medical school that are associated with subsequent professional misconduct.

DESIGN

Matched case-control study. Setting Records from medical schools and the General Medical Council (GMC).

PARTICIPANTS

59 doctors who had graduated from any one of eight medical schools in the United Kingdom in 1958-97 and had a proved finding of serious professional misconduct in GMC proceedings in 1999-2004 (cases); 236 controls (four for each case) were selected by systematic sampling from matching graduation cohorts. Case-control status was revealed by the GMC after completion of data entry.

MAIN OUTCOME MEASURE

Odds ratios for being a "case," with multivariable conditional logistic regression of potential risk factors including pre-admission characteristics and progress during the course. These data were obtained from anonymised copies of the students' progress files held by their original medical schools.

RESULTS

Univariate conditional logistic regression analysis found that cases were more likely to be men, to be of lower estimated social class, and to have had academic difficulties during their medical course, especially in the early years. Multivariable analysis showed that male sex (odds ratio 9.80, 95% confidence interval 2.43 to 39.44, P=0.001), lower social class (4.28, 1.52 to 12.09, P=0.006), and failure of early or preclinical examinations (5.47, 2.17 to 13.79, P<0.001) were independently associated with being a case.

CONCLUSIONS

This small study suggests that male sex, a lower socioeconomic background, and early academic difficulties at medical school could be risk factors for subsequent professional misconduct. The findings are preliminary and should be interpreted with caution. Most doctors with risk factors will not come before the GMC's disciplinary panels.

Specialty choice in UK junior doctors: is psychiatry the least popular specialty for UK and international medical graduates?

BACKGROUND

In the UK and many other countries, many specialties have had longstanding problems with recruitment and have increasingly relied on international medical graduates to fill junior and senior posts. We aimed to determine what specialties were the most popular and desirable among candidates for training posts, and whether this differed by country of undergraduate training.

METHODS

We conducted a database analysis of applications to Modernising Medical Careers for all training posts in England in 2008. Total number of applications (as an index of popularity) and applications per vacancy (as an index of desirability) were analysed for ten different specialties. We tested whether mean consultant incomes correlated with specialty choice.

RESULTS

In, 2008, there were 80,949 applications for specialty training in England, of which 31,434 were UK graduates (39%). Among UK medical graduates, psychiatry was the sixth most popular specialty (999 applicants) out of 10 specialty groups, while it was fourth for international graduates (5,953 applicants). Among UK graduates, surgery (9.4 applicants per vacancy) and radiology (8.0) had the highest number of applicants per vacancy and paediatrics (1.2) and psychiatry (1.1) the lowest. Among international medical graduates, psychiatry had the fourth highest number of applicants per place (6.3). Specialty popularity for UK graduates was correlated with predicted income (p = 0.006).

CONCLUSION

Based on the number of applicants per place, there was some consistency in the most popular specialties for both UK and international medical graduates, but there were differences in the popularity of psychiatry. With anticipated decreases in the number of new international medical graduates training in the UK, university departments and professional associations may need to review strategies to attract more UK medical graduates into certain specialties, particularly psychiatry and paediatrics.

Examination performance of graduate entry medical students compared with mainstream students

OBJECTIVES

To assess whether medical students on graduate entry/fast- track programmes perform as well as students on standard courses.

DESIGN

Retrospective cohort study.

SETTING

University of Birmingham Medical School.

PARTICIPANTS

Medical students on graduate entry/fast-track course and standard (5-year) course ('mainstream').

MAIN OUTCOME MEASURES

Examination marks from all assessments taken simultaneously by graduate entry course (GEC) and mainstream course students once the cohorts have combined: i.e. for the final three years of the programme. Honours awards for 2007 and 2008 graduates.

RESULTS

In total 19,263 examination results were analysed from 1547 students. Of these 161 were GEC students and 1386 were mainstream medical students. On average mainstream students, male students, overseas students and students of South Asian ethnicity obtained lower examination marks than graduate entry students, female students, home or EU students and students of non-South Asian ethnicity, respectively. Graduate entry students were significantly more likely to achieve honours degrees than mainstream students.

CONCLUSION

On average the academic performance of Graduate Entry medical students at the University of Birmingham is better than mainstream medical students.

The effect of a brief social intervention on the examination results of UK medical students: a cluster randomised controlled trial

BACKGROUND

Ethnic minority (EM) medical students and doctors underperform academically, but little evidence exists on how to ameliorate the problem. Psychologists Cohen et al. recently demonstrated that a written self-affirmation intervention substantially improved EM adolescents' school grades several months later. Cohen et al.'s methods were replicated in the different setting of UK undergraduate medical education.

METHODS

All 348 Year 3 white (W) and EM students at one UK medical school were randomly allocated to an intervention condition (writing about one's own values) or a control condition (writing about another's values), via their tutor group. Students and assessors were blind to the existence of the study. Group comparisons on post-intervention written and OSCE (clinical) assessment scores adjusted for baseline written assessment scores were made using two-way analysis of covariance. All assessment scores were transformed to z-scores (mean = 0 standard deviation = 1) for ease of comparison. Comparisons between types of words used in essays were calculated using t-tests. The study was covered by University Ethics Committee guidelines.

RESULTS

Groups were statistically identical at baseline on demographic and psychological factors, and analysis was by intention to treat [intervention group EM n = 95, W n = 79; control group EM n = 77; W n = 84]. As predicted, there was a significant ethnicity by intervention interaction [F(4,334) = 5.74; p = 0.017] on the written assessment. Unexpectedly, this was due to decreased scores in the W intervention group [mean difference = 0.283; (95% CI = 0.093 to 0.474] not improved EM intervention group scores [mean difference = -0.060 (95% CI = -0.268 to 0.148)]. On the OSCE, both W and EM intervention groups outperformed controls [mean difference = 0.261; (95%CI = -0.047 to -0.476; p = 0.013)]. The intervention group used more optimistic words (p < 0.001) and more "I" and "self" pronouns in their essays (p < 0.001), whereas the control group used more "other" pronouns (p < 0.001) and more negations (p < 0.001).

DISCUSSION

Cohen et al.'s finding that a brief self-affirmation task narrowed the ethnic academic achievement gap was replicated on the written assessment but against expectations, this was due to reduced performance in the W group. On the OSCE, the intervention improved performance in both W and EM groups. In the intervention condition, participants tended to write about themselves and used more optimistic words than in the control group, indicating the task was completed as requested. The study shows that minimal interventions can have substantial educational outcomes several months later, which has implications for the multitude of seemingly trivial changes in teaching that are made on an everyday basis, whose consequences are never formally assessed.