Racism in Medicine: Education and employment

Introduction There is an ethnicity attainment gap that appears in early education and persists into the senior levels of the NHS. Disadvantage and discrimination is certainly pervasive for Chinese, Pakistani, Bangladeshi and Indian students, but this editorial will focus on how Black students appear to be systematically disadvantaged compared to their white peers, as factors of social and cultural biases and class work to create layers of disadvantage that work against them from their education to their medical careers. Racism exists in both the UK education system and in healthcare, not only through biases and prejudices, conscious or unconscious, but also through the systemic lack of racial and cultural literacy that exists in those institutions and their practices. Here we consider the ways in which racism presents itself in the journey of a Black doctor, from childhood to employment, and how it may produce this attainment gap. Because research often groups subjects into a collective BAME category, that term is used here, but care has been taken to disaggregate those groups where possible.


Introduction
There is an ethnicity attainment gap that appears in early education and persists into the senior levels of the NHS. Disadvantage and discrimination is certainly pervasive for Chinese, Pakistani, Bangladeshi and Indian students, but this editorial will focus on how Black students appear to be systematically disadvantaged compared to their white peers, as factors of social and cultural biases and class work to create layers of disadvantage that work against them from their education to their medical careers.
Racism exists in both the UK education system and in healthcare, not only through biases and prejudices, conscious or unconscious, but also through the systemic lack of racial and cultural literacy that exists in those institutions and their practices. Here we consider the ways in which racism presents itself in the journey of a Black doctor, from childhood to employment, and how it may produce this attainment gap.
Because research often groups subjects into a collective BAME category, that term is used here, but care has been taken to disaggregate those groups where possible.

A Shaky Foundation
There is an attainment gap between Black students and white students 1 . To suggest that this gap exists because of a fundamental difference in cognitive ability would be reductive and inappropriate. In reality, there are a multitude of contributing factors that create invisible barriers for Black students that become apparent in school.
A 2017 report revealed that only 13% of statefunded school teachers are from black and minority ethnic backgrounds, compared to 27% of pupils 2 , with the Department for Education reporting in 2020 that white teachers account for over 91% of the teaching workforce 3 . Increasing diversity in the teaching workforce not only has the potential to provide black and Asian students with role models, but can benefit white students as well. Runnymede has asserted that seeing BME people represented in professional positions as leaders can combat negative stereotypes and create a more racially sensitive student body 4 . Of course, it should not be assumed that a teacher will automatically hold anti-racist ideals if they are black. It is therefore also important to increase racial literacy in teachers. Further, the curriculum has played a role in alienating black and Asian students through narrowing the contextual scope of their education and through enforcing an agenda of "traditional British values," which the government outlines those British values as "democracy, the rule of law, individual liberty, and mutual respect and tolerance for those of different faiths and beliefs" 5 . However, this move has been characterised as a "response to fears of extremist religious ideologies, terrorism and Muslim sharia law" 6,7 . This restructuring of the curriculum coincided with the education secretary's desire to "celebrate the distinguished role of these islands in the history of the world" as he removed the curriculum's explicit focus on racial and ethnic diversity 8 . This move effectively shut black history and racial and ethnic diversity out of the conversation, giving teachers less room to raise a racially literate student cohort. These failures to provide BME students with accurate representation in the teacher workforce and in their curriculum alienates them, and the resulting lack of racial literacy in schools leaves them more vulnerable to racism and their teachers less equipped to deal with those incidents 9 . It is also important to note that there is a clearly demonstrated causative relationship between lower income and lower educational attainment, with children from less privileged socio-economic backgrounds being less likely to receive a university degree 10 . Moreover, children who are eligible for free school meals are also likely to make less progress and achieve lower grades in school than children of the same gender and ethnicity who don't receive free school meals 11,1,12 (Figure 1). This is especially alarming in light of research demonstrating that this underperformance in children of a "lower socio-economic position" happens regardless of cognitive ability 13 . This link between income and educational attainment is particularly salient when you consider the relationship between ethnicity and income; Black children are more than twice as likely to live in low income and material deprivation compared to white children 11 , meaning the educational disadvantage experienced by children from low-income households is disproportionately affecting Black children.
Then there is the question of how prevalent unconscious bias and discrimination is in the education system and how this is impacting children. For example, Black Caribbean students are almost three times as likely to receive a permanent exclusion from school compared to the general population 14 . One contributing factor behind this imbalance is the bias that exists in disciplinary policies. In a survey of Black students, 46% of their schools were reported to have policies that penalised their natural hair 15 . Such policies represent a failure by schools to approach their policies with cultural sensitivity as they position Black students and their hair outside of the cultural acceptable norm. Then there are policies such as those instituted by Royal Docks Academy in Newham that penalise "teeth kissing", a gesture of Caribbean origin that involves sucking air through pursed lips, with the same degree of punishment as bullying and theft 16 . It would be reasonable to question who is deciding how rude teeth kissing is versus tutting, because it is statistically likely that they will be white, as 93% of head teachers and 85% of classroom teachers are white 3 . Accounts of Black Caribbean writers and students tend to describe it in such a way that is comparable to tutting 17,18 , yet tutting received a much lighter punishment in the Royal Docks Academy (a phenomenon that has been echoed by Black students in other schools) 16 . Even if you assume the position that Black students should fall in line with more traditionally British cultural norms, this difference in the way discipline is meted out to students from different cultures is alarming, especially when we can see Black students are having their access to education restricted at a higher rate than white students.
Another factor researchers believe contributes to the attainment gap is the effect of unconscious bias in marking examinations. For years there have been concerns that teachers' unconscious biases have set their expectations for Black students lower than for white and Asian students 19 . This issue has been brought into sharper focus in recent months due to the way A Level and GCSE grades have been awarded in the wake of the global pandemic. With exams scrapped, the task of assigning GCSE grades was handed to teachers, who would use students' prior performances to inform their decision. This approach, however, leaves ethnic minority students particularly vulnerable to unconscious biases. These biases are present even from Key Stage 2 assessments, where a study revealed that Black students were more likely than white students to receive a higher grade when assessed externally than when assessed by their teacher-38.7% and 47.6% for Black Caribbean and Black African students respectively. The same undermarking was happening to Pakistani, Bangladeshi, Indian and Chinese students 20 . In an effort to address concerns that teachers may give their students inflated grades, the government also employed the use of statistical modelling (with reports that up to 60% of A Level grades and the "vast majority" of GCSE grades were being awarded in this way) 21 . When results were published, 39% of teacher assessments had been downgraded 22 . Because the algorithm took school performance into account, bright students from under-achieving schools were penalised, while students in private education were given an advantage over state school students. In Scotland, the Scottish Higher pass rate for students from the most deprived backgrounds dropped by 15.2%, compared to 6.9% for students from more socioeconomically privileged backgrounds 23 . This algorithm compounded the disadvantage that Black pupils faced and allowed them to be graded lower than they deserved not once, but twice.

Higher Education
The discrimination that Black students face continues into higher education, with an ethnicity attainment gap that exists even after controlling for gender, age, discipline and, perhaps most importantly, prior attainment 24 . Ethnic minority medical graduates in the UK are 2.5 times more likely to fail their exams compared to their white peers 25 . This issue isn't confined to specific specialities, either. Differences in attainment across ethnicities persists across medical schools, exam types and undergraduate and postgraduate assessments. The uncomfortable fact is that this is a widespread, systemic issue in UK medical training 26 .
The reasons for the ethnic attainment gap are complex. It cannot be fully explained by socioeconomic status, age, motivations for becoming a doctor or conscientiousness despite these factors significantly predicting final exam scores 27 . Racial bias cannot be ruled out as a reason for ethnic disparities in exam performance, but it is also worth noting that these differences remain even in machine marked tests 28 . Further, the clinical skills assessment has been criticised for not being a "culturally neutral examination," potentially disadvantaging students who have received their education abroad as well as black and minority ethnic students 28 ; this cultural disadvantage means that the pass rate in postgraduate examinations drops from 63% to 42% for ethnic minority students 29 . So even with racial bias and discriminatory marking practices disadvantaging Black medical students, it would seem that there are further reasons compounding the attainment gap.
Beyond bias and discrimination in exams, performance is heavily influenced by: the relationships between students and their peers and staff; the relationship between students and their institution; and psychological, societal and cultural factors and experiences 30 . What the Atlantic has dubbed as "the stress of racism" erodes BAME students' sense of belonging and constrains their potential and progress 31,32 . It is therefore necessary to consider the culture that exists in UK medical schools when looking to understand the attainment gap.
An aspect of Black medical students' experiences that has garnered a great deal of attention recently has been around racial harassment, which is another contributing factor to the attainment gap 29 . Racial harassment persists throughout UK universities; The Equality Rights Commission conducted a study that revealed that 24% of ethnic minority students had experienced racial harassment since starting their course, but over two thirds of those who experienced racial harassment didn't report it 32 . The same report confirmed that when a student did raise a formal complaint, fewer than 40% of those complaints were upheld and offered some kind of redress. The situation in UK medical schools is no better, with nearly a third of BAME medical students reporting that bullying or harassment was a problem in their medical school; they were also four times as likely as their white peers to say it is "often" a problem, compared to "sometimes" a problem 33 .
It seems clear that there is an issue with underreporting of racial harassment incidents and an issue with universities' ability to effectively handle complaints when they are raised. Major barriers to reporting harassment include a lack of knowledge about the reporting process, lack of understanding of what constitutes racial harassment, fear of repercussions and a lack of confidence in the complaints process 34 . There is an urgent need to address the lack of confidence in the process, as most complaints are handled through these procedures ( Figure 2) and so few complaints handled in this manner are upheld.
Racial harassment is symptomatic of a culture where Black and minority ethnic students are excluded and denied a sense of belonging. This exclusion is further fuelled by a lack of Black mentors and role models, with only 13% teaching staff being from ethnic minority backgrounds, compared to 40% of medical students 35 . This is a significant shortfall when considering the impact that mentors and sponsors can have on an individual's career: as ethnic minority individuals lack mentors and sponsors from similar backgrounds, they tend to receive less of this type of support than their white peers, restricting their access to certain resources and networks 36 . This restriction is compounded by social exclusion from their peers, as Black medical students report often being excluded from social activities 35 . This lack of representation and persistent social exclusion not only erodes BAME students' sense of belonging, but also denies them access to important networks and resources, further constraining their progress 35 .

In Employment
With the attainment gap that exists for BAME students, it is perhaps unsurprising to learn that they are less likely to be considered "appointable" for posts-across three years, 75% of white candidates compared to 53% of ethnic minority applicants were considered appointable 37 . This disparity exists across specialties (Figure 3) and the trend continues into recruitment to consultant posts. In 2016, UK ethnic minority doctors applying for consultancy posts were more likely to apply for more posts, less likely to be shortlisted and less likely to be offered the post than white doctors 29 . There are also ethnic disparities in the allocation of NHS distinction awards (which are supposed to be awarded based on merit alone), and ethnic minority doctors are twice as likely to be referred by their employer to the General Medical Council compared to white doctors 38,39 . These apparent issues with performance and recruitment frame a situation where 46% of white doctors are consultants, compared to 30.6% of black doctors 40 , and an ethnic pay gap of 4.9% exists within consultancy grades 41 . Again, ideas of belonging shed some light on these discrepancies. In a survey conducted by the BMA, only 55% of BAME doctors said there was a respect for diversity and a culture of inclusion in their workplace 42 . This compounds the lack of diversity in senior positions in the NHS to diminish black and minority ethnic doctors' confidence and feelings of inclusion in the workplace 43 . An increase in diversity in the NHS, particularly in more senior positions, and greater racial literacy within the workforce could actually provide ethnic minority doctors with greater ongoing support and more feedback, increasing access to resources and opportunities to develop for ethnic minority staff and addressing disparities in perceived performance 44 .

Solutions
There is clearly a layering effect of multiple disadvantages being faced by Black students and doctors that require intervention at multiple levels. Firstly, greater diversity in our teaching workforce, at both University and in earlier education, is needed to increase a sense of belonging and to widen the pool of potential role models and mentors with a similar background experience to Black students. Schools should also reconsider their policies around uniform and acceptable hairstyles to ensure they are not disadvantaging Black students, but they should also examine the ways in which their disciplinary policies are being enacted and rectify any discrimination that may be occurring. On a societal level, there needs to be greater educational support for low-income families to address the significant attainment gap between children based on household income. Schools, universities and workplaces must work to improve their processes of dealing with racial harassment. The Equality Human Rights Commission recommends: • Ensuring all staff (and students, where applicable) understand their options to report harassment and receive support and information on what constitutes racial harassment.
• Building trust in the process by ensuring staff who deal with complaints are impartial and adequately trained.
• Implementing a centralised reporting system. • Regularly monitoring the prevalent of racial harassment.
•Taking into account how experiencing harassment affects physical and mental wellbeing 32 .
Research has demonstrated that racism has direct effects on mental and physical health 45 . Psychological theories have explored what protects people from worse outcomes in the face of such risks as those discussed here, one of which being resilience. Resilience is something that can be developed and strengthened through: exposure to challenges with support and feedback; fostering a sense of belonging and self-worth; perceived control over one's life; strong personal relationships etc. 46 . There is a clear opportunity to increase resilience by ensuring Black medical students have access to appropriate role models and by eradicating the racial harassment many of them have experienced.
Of course, we should be wary of placing the responsibility of creating and enacting solutions on the shoulders of individuals, especially Black individuals who have been experiencing and dealing with the disadvantages of racism in the system for years. The issue of racism in education, medical training and medical employment is so widespread and pervasive that it requires a radical overhaul of that system; there is a need to address the racial illiteracy that is still prevalent in society, to create a stronger system of reporting and resolving cases of harassment where they exist (potentially by offering an anonymous reporting tool) and in creating an inclusive, informed culture that allows people to thrive regardless of race.

Conclusions
As is evident, the same issues that appear in early education persist throughout higher education and into employment. Unconscious bias, discriminatory marking practices and performance assessment, racial harassment and ineffective mechanisms for dealing with it and lack of representation are all contributing factors to feelings of alienation in Black students and staff, eroding confidence and trust between Black students and staff and institutions. It is important when looking at the attainment gap, the pay gap and any other disparities in performance between Black and white medics, to look further into cultural factors and experiences that shape people's perceptions and, ultimately, their performance. To make progress in this area will require moving past outdated and biased preconceptions that cognitive ability is the only thing that affects achievement and that education and medicine are purely meritocratic systems. Figure 2: Percentage of candidates considered "appointable" by ethnicity and speciality (37)