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Rapid Responses: Rapid Responses published:
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Similar study on ethnic minority doctors would be helpful
- Suparna Das (19 August 2008)
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Haiku Me And You
- Hugh Mann (20 August 2008)
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Ethnic Stereotypes
- Sandra R Teare (20 August 2008)
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Ethnic stereotyping is inevitable in the medical profession
- Dr Rahul Potluri (20 August 2008)
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Stereotyping or another cultural clash!
- R Sawant (21 August 2008)
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No Smoke Without Fire
- Dr N.S Bassi (21 August 2008)
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What is stereotyping?
- Hugh Mann (22 August 2008)
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What is the big deal?
- Juhi Sharma (12 September 2008)
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'Non-whites' are not one homogeneous mass of people
- Piyush Durani (14 September 2008)
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Globalisation has profoundly affected all health care
- Ming Chen Hsieh (15 September 2008)
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Why the paranoia?
- Rowan H Harwood (15 September 2008)
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Healthcare Stereotypes
- Andrew L Tambyraja, Caroline A McCrea, GP Registrar, Simpson Medical Practice, West Lothian, EH48 2SS (15 September 2008)
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Time to start the debate
- kiran sinha (15 September 2008)
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Compounding Stereotyping of Medical Students
- George A Khoury (16 September 2008)
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Re: 'Non-whites' are not one homogeneous mass of people
- John M Davis (29 September 2008)
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Ethnic differences in medical school attainment require further investigation
- Katherine V M Woolf, Judith Cave, Trisha Greenhalgh, Jane Dacre (2 October 2008)
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Pervasive negative stereotypes of ethnic minority medical students: What do they suggest?
- A Garg (10 October 2008)
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It does not add up!
- George Khoury (15 December 2008)
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Suparna Das, Ex-consultant anaesthetist & fulltime MBA student Leeds University Business School, UK
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As a senior female doctor of south Asian origin, I faced similar negative stereotyping from white, especially male, consultants in the NHS. I experienced this both as a junior doctor as well as a consultant. The comment "sweet little Asian girlies" from one of your white,male consultant respondents sums up the stereotype. We are expected to be docile and submissive and not speak up. As a consultant anaesthetist, when I challenged the dubious and potentially unsafe, unethical clinical practice of a white, male consultant surgeon, I got branded as aggressive. But I have observed my white, female colleagues get away with much worse and be labelled as assertive. This appears to correlate well with the stereotype of the white, female medical student in your study as "confident, outspoken and good communicators". As a junior doctor, two of my white, male, consultant supervisors repeatedly compared me to two white, female registrars and advised me to become 'a little bolshie like them'. Currently, studying full time on an international MBA programme, my experience has been quite the opposite. I can't help thinking that the problem lies with the medical profession itself. It needs to wake up and catch up with the rest of the world in the 21st century. Suparna Das MD FRCA MSc (Medical Education) Competing interests: None declared |
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Hugh Mann, Physician Eagle Rock, MO 65641 USA
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Stereotyping: Competing interests: None declared |
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Sandra R Teare, GP on career break London NW10 8AL
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This study deeply saddens but does not surprise me. I am a female doctor with one Asian, one white parent, neither of whom pushed me to do medicine or anything else. I qualified at Manchester in the 80s, and am a Londoner, born and bred. However, I am quiet. I have discovered over the years that many people don't like small, quiet, brown women, and you definitely get treated differently from your white peers. I have met many fantastic and encouraging doctors, but I have to say that as a student and as a doctor, at various times I've been passively unnoticed, actively ignored, treated with aggression or outright rudeness for no apparent reason, or politely tolerated. This has been from white males, but also from females, and non-whites. My sister (now a consultant), recalls as a student a tutorial with a senior white male doctor. The tutor looked around at the circular group of 10 throughout this hour long tutorial, but not once did he make eye contact or speak to the 3 non-white students in the group. Maybe he did not even realise this. Maybe he would be shocked to be called racist, but I think people's prejudices run very deep, and not just in the medical profession. Being treated unfairly is disheartening and undoubtedly affects our learning, making already quiet and unconfident students even more so. We all become more enthusiatic, confident and motivated if we feel we are doing well or if we feel we are being taken seriously, and we all look to others (whether consciously or not) to provide this validation. We all have our prejudices, but I would urge teachers to look closely at how their prejudices affect their teaching - maybe then they'll see their quiet Asian students blossom. Competing interests: None declared |
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Dr Rahul Potluri, Academic Foundation Trainee Faculty of Medicine, Imperial College London, London, SW7 2AZ
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Dear Editor – Woolfe et al address a common topic of discussion during my time at medical school [1]. From my experience as a medical student, I do agree that stereotypes of the typical "white" medical student and the typical "asian" medical student exist and unfortunately sometimes such stereotypes result in particular students under-achieving when they really deserve better and vice-versa. Whilst, I acknowledge personal experiences may introduce an element of bias, I should share one of my experiences as an asian medical student during my final year where I was asked to redo my final primary care viva examination which was mainly a test of communication skills. My medical school career until then was successful, during the previous 6 years, my communication skills had never been questioned and in addition, I was well attuned in communicating to a wide variety of people including large audiences at numerous national and international conferences. Whether on the day of the examination I presented myself as a “typical asian student” (as described by Woolf et al) with communication difficulties, I am not sure - but certainly until that point and since my communication skills had not been questioned [1]. The rest of the year was an up-hill task as it was a massive blow to confidence at such a pivotal point in medical training but in reflection I am grateful for this as it improved my focus and concentration and enabled me to sail through my final year and but I know of numerous asian friends and colleagues who did not make it through and deserved better after 5-6 years dedicated to medicine. Whether or not ethnic stereotyping played a part in my experience is not important but looking at the wider picture, it is not difficult to understand why stereotyping exists in the medical profession. In clinical medicine we are taught to learn from our experience and as we progress in our careers, we learn to pattern recognise and make clinical decisions based on our past experience, applying it to the current situation. No matter we try to respect the situation in hand, sometimes pattern recognition leads to mistakes as each case is different. The same analogy applies when we discuss stereotyping medical students of different ethnic backgrounds and consequently some students are wrongly stereotyped. Whilst, such stereotyping sets a dangerous precedent as it has the potential to ruin successful careers, I fear that little can be done to change this in a profession where stereotyping is inherent and often necessary. [1] Woolf K, Cave J, Greenhalgh T, Dacre J. Ethnic stereotypes and the underachievement of UK medical students from ethnic minorities: qualitative study. BMJ 2008;337:a1220 Competing interests: None declared |
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R Sawant, Registrar,cardiology.Barts and the London NHS Trust London Chest Hospital.E29JX
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I read this article with great interest. Firstly, this is a small study of limited number of graduates and teachers performed at a single centre. So conclusions should not be generalised. Secondly, answers are recorded and interpreted by subjects and it will be wrong to draw objective conclusions. Thirdly, this is more than stereotyping. There are cultural differences in various communities round the world,immaterial of racial origin. So people from one community perceive others differently. Same is true with patients. Asian or Afro carribean patients find it easy and comfortable to speak to a doctor of the same ethnicity. Besides,favourism is well recognised human character which plays significant role in human behaviour. There are multiple reasons why one individual could favour another,ethnicity is one of them. To me,it just appears another face of lack of integration of communities in this multicultural population. Competing interests: None declared |
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Dr N.S Bassi, GP Nottingham
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How can it be a stereotype when many asian students will themselves admit that they're in medicine only out of respect for their parents' wishes? 'A'grades at A-Levels don't mean anything.To be a "good" doctor in the modern world means to be a well rounded,well adjusted person.No one should be allowed to study medicine out of duress.That is a sacrilege in itself.Urgent tools need to be designed to recognise and weed out such candidates at the earliest opportunity. Competing interests: None declared |
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Hugh Mann, Physician Eagle Rock, MO 65641 USA
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Stereotyping is ethnocentrism, racism, sexism, paternalism, chauvinism, elitism, egotism, narcissism, and solipsism. Competing interests: None declared |
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Juhi Sharma, Specialty Doctor, Psychiatrist WD7 9HQ
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What’s so odd about stereotypy? For some, it’s just another word for generalising an aptitude. It’s just that traditionally Asians are more accustomed to onerous learning and do tend to excel in academics. That is why; Asians do well as doctors, scientists and now IT professionals. There is a stereotype, not only in medicine but also in other fields. Blacks are better at Sports and Music. That is why, we see so many black people playing for Caucasian countries. And I do think that Asians are not as good as communicators and do not have leadership qualities as much as the British and other Europeans. Hence, the colonisers of the 19th and 20th centuries were from Europe. But there is a trend that people are becoming more similar and less diverse. That is bringing about a change in the attitude of both the assessors and the assessed, albeit gradually. And in response to one of the other responders, what is wrong with a little push? Most of us chose our careers at a very young age, when we really do not know what exactly we want or what our capabilities are. Our parents on the hand know us better, having raised us and having gone through more in their lives. Obviously, I am aware that certain people from Asian families have been forced into making certain choices, be it in choosing a career or be it in choosing a life partner. However, these situations are becoming a thing of the past, and certainly not part and parcel of an adequately broad-minded and reasonably well-educated Asian family. My reasons for choosing a career in Medicine have been similar. Coming from a family with my Dad a Surgeon and my Mum an Anaesthetist, I wasn't keen to pursue a career in Medicine having witnessed the long and unsocial hours that doctors worked. Coming from an Asian background, where we 'respect our parent’s wishes' and where being a doctor is an achievable status symbol, I continued into a medical career. At the time it felt that I was being coerced into it. They, especially my mum, felt the guilt almost immediately and constantly reminded me that I could leave medicine anytime and that she would support me to pursue another career. By the time, I had started to enjoy and excel in almost all the subjects, and especially the 6-week psychiatry placements in my 4th and 5th year were extremely rewarding. I am proud to be a doctor and a psychiatrist, and I hold my late mother largely responsible for it. Competing interests: None declared |
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Piyush Durani, Specialist Registrar, Plastic Surgery Sheffield, S5 7AU
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Ethnic stereotypes are one of many stereotypes that pervade not only the medical profession, but society at large. Although this article suggests there clearly is some ethnic stereoptyping, I am surprised that such a small study can result in such a prominent feature in the BMJ and then also imply that stereotyping may be a reason why 'ethnic minorities underperform'. Qualitative studies are simply a collection of views generated from a certain number of individuals. We should be careful not to generalise this to the medical profession as a whole. The small sample of students and tutors, specifically from one London medical school, means that the study is likely to be riddled with confounding factors and bias. It is effectively unhelpful in delineating the subtle issues in this area, despite its 'exploratory' nature, because it simply reinforces/highlights stereotypes that may actually only be a minority view. Many studies on ethnicity, including those suggesting ethnic minority students underperform in medical school, are hampered because they fail to recognise the significant heterogeneity amongst 'ethnic minorities' with regards to success in society generally. The government's Office of National Statistics highlights this, based on Census work, by dividing ethnic groups and conducting appropriate analysis on subgroups (Pakistani, Bangladeshi, Indian, Chinese, White, Black African, Black Carribean, Mixed). The work has shown that Chinese and Indian groups outperform White Brits in many areas, including education, employment and overall household income. (http://www.statistics.gov.uk/focuson/ethnicity/). If success amongst ethnic groups in medicine even needs any further evaluation, studies should avoid analysis on 'Asians' or 'Non-whites' as a homogeneous mass of people and look more rigorously at other confounding factors such as different ethnic subgroups, religion, socioeconomic class and level of social integration, amongst White British AND 'Non-White' British groups. Such studies must be conducted on a much larger and more quantitative scale to produce any meaningful analysis. Competing interests: None declared |
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Ming Chen Hsieh, Attending Physician, Director of General Internal Medicine, Buddhist Tzu Chi General Hospital, Huali No. 707, Sec. 3, Chung Yang Rd., Hualien 970, Taiwan, R. O. C.
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Globalisation has profoundly affected all health care by increasing the diversity of clinicians and their patients. Worldwide, medical schools highlight the need for students to understand and show respect for their patients, classmates, teachers and peers of different ethnicities. Student migration will remain one key domain for the emergence of global labor market, enhanced cooperation for Europe and Chinese on information sharing, data exchange and orderly management of return migrants, and this in turn will boost the potential benefits for both parties in a long run [1]. In the past, traditional Chinese medical students studied passively, learned without comprehension and received mechanical training. The personality types of Chinese medical students may be somewhat different from the personality profiles exhibited by medical students from other nation. These characteristics may be of value to individuals who desire to investigate personality type differences among medical students with different cultural backgrounds. The associations of cognitive processes, family condition, societal values, mental status and learning behaviors are intertwined dynamically with time and environment. However, longitudinal and multi-dimensional research in this area is very limited [2]. It is important for contemporary medical education to develop a framework for the theory and practice of the development of all medical students that leads to their attainment of professional, sociological, and psychological competencies. The particular social economic status factors may increase the risk that medical students will experience stress, mental disturbances, and status attainment. Chinese parents much care about their children¡¦s occupation and focus related factors of the evaluation of occupational reputation were professional skills, respect, social contribution, knowledge, and income. For Chinese peoples, the occupational reputation of doctors was still relatively high in the occupational reputation hierarchy [3]. Therefore the pressure of the Chinese medical school students is always being existed rather than decreased, even they already grow up. Depressive mood, family environment, self concept and sleep and even food were important factors of affecting well-being of ethnic minorities medical college students. Quality of life in these medical college students needs to be improved in its weakness. The university should make the relationship and depression symptoms of medical students importantly and take some measure to help medical students keep study. 1. Phillips SP. Models of medical education in Australia, Europe and North America. Med Teach 2008;30(7):705-9. 2. Fischer MA, Harrell HE, Haley HL, Cifu AS, Alper E, Johnson KM, et al. Between two worlds: a multi-institutional qualitative analysis of students' reflections on joining the medical profession. J Gen Intern Med 2008;23(7):958-63. 3. Robins LS, Alexander GL, Wolf FM, Fantone JC, Davis WK. Development and evaluation of an instrument to assess medical students' cultural attitudes. J Am Med Womens Assoc 1998;53(3 Suppl):124-7. Competing interests: None declared |
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Rowan H Harwood, consultant physician Nottingham University Hospitals NHS Trust NG5 1PB
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It is a shame that this article appears to have had the preconception that 'Asian' students are discriminated against, as it made interesting data less useful than they might otherwise be. The paper may have stereotyped clinical teachers as badly as it claims we do students. 1. The first is the assumption that all 'Asians' are the same. As a group, British-born or educated ethnic Asians are socially and culturally idential to their white peers. In many cases these are the sons and daughters of our professional colleagues, and the classmates of our children! And as such they vary one from another as much as white students do. However, there are real issues with international students (not just Asia, eastern Europe as well, for example) where the tradition of 'teacher knows best and is not to be questionned' sometimes persists. We often teach by dialectic, challenge and argument. It is a problem if the student is not comfortable with that (but one which a good teacher will recognise and try to adapt to). 2. The data presented show that both teachers and students are aware of, and appraise the educational impact of, different competencies and traits amongst differnet individuals. This is a good thing. Some behaviours in an educational and clincial setting indicate a problem. You cannot teach unless you identify these. We have a very dominant culture that values extroversion, confidence, and communication. You cannot learn at medical school by being spoon fed. You have to be self directed and participatory. Book work is absolutely essential, but so is the aquisition of skills allowing this knowledge to be applied in clinical practice. Both lack of book work and over-reliance on books are problems, regardless of race. For me it is also a problem to identify what we can do for the quiet, reflective type. 3. Identifying 'typical' traits in a group is not the same as applying assumptions to individual students where they do not exist. There are occasional female students who do not communicate well, although most do. A charismatic Asian student is charismatic even if that is not what you expected. It usually takes all of two minutes to spot. 4. The person who suggested getting to know students individually (presumably meaning socially) clearly does not understand the current plight of NHS clinical teachers. 5. The most negatively sterotyped group of all now is the white male. It is very surprising that the research did not pick this up, which questions its external validity. Competing interests: I am a member of the Indian Community Centre Association of Nottingham |
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Andrew L Tambyraja, Specialist Registrar & Honorary Clinical Tutor Clinical & Surgical Sciences (Surgery), University of Edinburgh, EH16 4SA, Caroline A McCrea, GP Registrar, Simpson Medical Practice, West Lothian, EH48 2SS
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Woolf and colleagues have acknowledged some of the limitations of their single centred, highly selected, qualitative study [1]. However, the authors have revealed their own unsupported stereotype of Surgery as a bastion of white, male sociopaths who are especially guilty of negative perceptions about medical students. It is unclear why surgeons were so deliberately sampled in the study protocol, and the selected comments illustrating antagonistic behaviour towards students do little to challenge this stereotype. In contrast, our own study of 194 final year medical students, of whom 45 (23%) were from an ethnic minority, showed that ethnicity had no impact on students’ perceptions of Surgical Tutors’ approachability, availability to teach, nor their regard of surgery as a future career choice [2]. Furthermore, students’ ethnicity had no impact on the citation of positive surgical role models as an attraction, nor negative role models as a disincentive, from a career in surgery. In their exploration of healthcare stereotypes, perhaps the authors should reconsider, rather than perpetuate, their own anecdotal and outdated prejudices. Andrew L Tambyraja
Caroline A McCrea
References: 1. Woolf K, Cave J, Greenhalgh T, Dacre J. Ethnic stereotypes and the underachievement of UK medical students from ethnic minorities: qualitative study. BMJ. 2008; 337: a1220 2. Tambyraja AL, McCrea CA, Parks RW, Garden OJ. Attitudes of medical students toward careers in general surgery. World J Surg. 2008; 32: 960-3. Competing interests: None declared |
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kiran sinha, General Practitioner E7 8AB
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My first,quick reading of this rather painful subject brought back all the 'traumatic' memories of my hospital jobs where I was aware that there was a very fine line between my consultants seeing me as a good,efficient and caring doctor and falling into the typical Asian stereotype.The factors that may have been responsible was often to do with the senior doctor,often a registrar, the circumstances etc.(One of these is of the 1980s when a Registrar at a Central London teaching hospital told me that Indian had a very 'bad' habit of shaking their head when being told what to do and that I should stop doing it.)It maybe that my background made it less easy for me to predict or work my way out of these difficult situations. My second reading made me appreciate the choice of the subject.It is quite 'telling' that people were reluctant to discuss this subject especially the non- attendance by the 'poor achieving'asian group.However once this kind of debate has been started, I hope that the 'low achievers' will also start getting involved.However the kind of commentary by Hugh Ip does not help- hopefully the days when people subjected to discrimination were told that it is their own fault is in the past. There will still be areas of difficulty.After working for some years in the NHS I realized that to the majority of my 'white' colleagues I was only that- my personal experiences were neither of relevance nor of interest to them.So I too stopped making an effort to 'socialize' with them.The trouble is that hospital doctors,I feel, put a great deal of emphasis on this so they will enjoy talking and socializing with students/junior doctors with whom they feel comfortable.This probably has an effect on how they teach- in my days it affected one's entire career!!I don't think this is my bias and would be interested in people's views on this. Finally, there are just a couple of points for further discussion.It is not clear why medical schools take in students from ethnic minority groups on lower grades across the board as it did not seem to be just a feature of this study.In addition,the interview process plays a large part in which of the students with equally 'good' grades get into medical school.Maybe we will need to examine this process as well. Competing interests: None declared |
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George A Khoury, Consultant Surgeon Conquest Hospital TN37 7RD
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The abstract states 27 students and 25 teachers participated. The results show only 21 students and 26 teachers agreeing to be interviewed. Only 12 students were selected for interview, and not 27. It is reported the sampling frame for clinical teachers was designed to reflect the demographics of the Royal Free Hospital (1). The reference cited does not concur with the figures in the article. The percentage of male consultants is 66% not 69%, with no mention of 88% of consultants being white. The only mention of 88% of whites relates to grade H nurses. Interviews took place in 2005 and 2006 and yet the sampling frame was based on 2003 figures. It is claimed that information on self-reported sex and ethnicity was obtained from student records. However, a previous study (2) at ICSM & RUMS in 2003, also by members of this group, relied on photographs and hearsay to assign ethnicity codes in 50% of students. It remains unclear whether express consent was available from all 360 students initially invited to contribute since there was no mention that the study was specifically about ethnicity and stereotypes. The 49 students selected were sent ambiguous emails informing them that the purpose was a PhD project about the factors that affect performance at medical school, when in reality only one factor was considered. It is therefore not surprising that after 12 interviews it became clear that students did not feel comfortable discussing ethnicity. Selection bias is obvious, preventing meaningful analysis since the 12 students are not representative of the student population opinion. Having previously worked at the Royal Free for 10 years, I find the published remarks of the teachers disturbing. Perhaps those contributing have done so because of strong views introducing further bias. One consolation from this subjective analysis is that it aims to improve teaching methods, whereas the previous study (2) suggested that the differences in attainment were genetically determined or alternatively that performance reflected varying study style and personality, ignoring socioeconomic factors. The differences in written examination and OSCE results (2) were very minor and disagree with the 2004 national statistics (3) which show a significant higher level of achievement in Chinese and Indian groups as compared with White British, in GCSE attainment. The problem, if any, reflects on the institution and not the students’ abilities. Institutions must exercise caution in not inadvertently compounding stereotyping of students without very clear evidence, prejudicing the selection process, where already there are inherent biases when candidate names are known. 1. Royal Free Hampstead NHS Trust Report on Equal Opportunities 24th June 2004 www.royalfree.nhs.uk/doc/240604/AppendixF.doc 2. Haq I, Higham J, Morris R, Dacre J. Effect of ethnicity and gender on performance in undergraduate medical examinations. Med Educ 2005;39:1126-8.[CrossRef][ISI][Medline] 3. National Statistics online, education: ‘Chinese pupils have best GCSE results’ http://www.statistics.gov.uk/cci/nugget.asp?id=461 Competing interests: None declared |
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John M Davis, Retrieval Registrar Townsville, Qld. 4814
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I contend that a quick look at Europe would show that 'whites" are far from homogeneous, too. As part of my medical training, I attended a 2 day, mandatory cultural awareness workshop, delivered mainly from the perspective of Australian aborigines. From the lambasting we (mostly white) students received, it's clear that racism is a two-way street. Human nature is to suspect "outsiders", and I understand that some native Americans had the same word for "stranger" as "enemy". Rest assured, either genuine problems will exist regarding race, or someone will stir one up for personal gain. Competing interests: None declared |
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Katherine V M Woolf, Research Associate Academic Centre for Medical Education, UCL Division of Medical Education, London N19 5LW, Judith Cave, Trisha Greenhalgh, Jane Dacre
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Evidence from UK medical schools shows ethnic minority medical students on average achieve lower marks in examinations than White students (1)(2)(3)(4)(5)(6). These differences may be small, but we argue that this does not make them insignificant. In the interests of equality, it is vital to find out why the ethnic gap in attainment exists, and to explore evidence-based ways of narrowing it. Khoury has misunderstood our research group’s previous study conclusions. Despite a number of studies investigating the ethnic gap in UK medical student attainment we have yet to be convinced of the reasons for it. We suspect they are multifactorial, possibly idiosyncratic, and probably interact in complex ways. Our qualitative study appears to shed some light by showing that negative stereotypes about Asian clinical medical students exist, which we hypothesise may negatively affect ethnic minority students’ learning and attainment. We recommend clinical teachers be given opportunities and training to counter stereotyping by getting to know their students as individuals. Khoury also makes a number of unsubstantiated claims about our methods. The use of 2003 staff figures (reproduced below) to inform the sampling in our study conducted in 2005/6 is valid given the overall stability of the consultant grade. In terms of the number of interviewees, we interviewed 12 students one-to-one and a further 15 in groups: total 27. As for student ethnicity, recorded student ethnic data were considerably more complete in 2005/6, when we conducted this study, than in 2002 when previous research took place. Finally, the UCL ethics committee approved our study procedure whereby, at invitation to interview, students were reminded in writing about the voluntary nature of their participation, and before the interview participants gave verbal consent to being asked specifically why they thought ethnicity affected medical student performance.
Katherine Woolf, Judith Cave, Trisha Greenhalgh, Jane Dacre References: 1. Dillner L. Manchester tackles failure rate of Asian students. BMJ 1995;310:209. 2. Ferguson E, James D, Madeley L. Factors associated with success in medical school: systematic review of the literature. BMJ 2002;324:952-7. 3. Wass V, Roberts C, Hoogenboom R, Jones R, Van der Vleuten C. Effect of ethnicity on performance in a final objective structured clinical examination: qualitative and quantitative study. BMJ 2003;326:800 -3. 4. Lumb AB, Vail A. Comparison of academic, application form and social factors in predicting early performance on the medical course. Med Educ 2004;38:1002-5. 5. Haq I, Higham J, Morris R, Dacre J. Effect of ethnicity and gender on performance in undergraduate medical examinations. Med Educ 2005;39:1126-8. 6. Woolf K, Haq I, Higham I, McManus IC, Dacre J. Exploring the underperformance of male and minority ethnic medical students in first year clinical examinations. Adv Health Sci Educ 2007 May 9 [ePub ahead of print]. Competing interests: None declared |
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A Garg, Research Fellow Lancaster University
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I read Woolf, Cave and Greenhalgh’s (1) paper with great interest. The study highlights that both white medical students and clinical teachers hold negative stereotypes of ethnic minority medical students. The negative stereotypes of ethnic minority medical students are: shy, too quiet, under-confident, doing medicine to please their parents, poor communicators, too respectful and even casting doubt about their ability to be good doctors. In contrast, the positive stereotypes of white medical students are: autonomous learners, caring communicators, self-motivated, tough and sociable team players. It is clear that these stereotypes are not only well-known but also readily acknowledged by the ethnic minority and white students and their mostly white clinical teachers. Based on this, one can argue that a power differential exists in the psyche of both groups, where white means superior and ethnic minority means inferior, which is central to maintaining racism in any setting (2)(3). Macpherson (4) has argued that negative stereotypes help to justify negative outcomes by ‘races’ or ethnicities (see the cultural conception of race (5)), which is a feature of institutional racism. Furthermore, where negative stereotypes are internalised by ethnic minority students, poor results are not only likely to be more acceptable to them but also expected by them, which would then feed into the academic under-achievement highlighted by the researchers. The researchers also highlight that “there was no evidence from the
data to suggest that students perceived themselves as victims of racism;
indeed some specifically said they were not” (web version of the article,
p. 4). I would like to highlight that in a research setting, where focus
groups of ethnic minority medical students were moderated by a
white faculty member and a black Caribbean female undergraduate student’s
role was only to take notes, ethnic minority students are unlikely to
voice their perceptions of racism. This is because of four main reasons.
To conclude, the researchers have shown that negative stereotypes about ethnic minority medical students, a fundamental mechanism of operationalising racism, are pervasive within the medical school environment. As far as the question of racism not being reported is concerned, if the study was conducted by an ethnic minority lead researcher or there was ethnic matching of researcher and participants, whilst accepting its shortcomings (11), the results are likely to have been different. 1. Woolf K, Cave J, Greenhalgh T. Ethnic stereotypes and the underachievement of UK medical students from ethnic minorities: qualitative study. BMJ 2008;337:a1220. 2. Coker N. Understanding race and racism. In: Coker N, editor. Racism in Medicine. London: King's Fund, 2001:1-22. 3. Jones JM. Prejudice and Racism. New York: McGraw-Hill, 1997. 4. Macpherson W. The Stephen Lawrence Inquiry - Report. London: The Stationery Office, 1999. 5. Goldberg DT. The semantics of race. In: Bulmer M, Solomos J, editors. Racism. Oxford: Oxford University Press, 1999:362-377. 6. BMA. Career barriers in medicine: doctors' experiences. London: BMA, 2004. 7. Cooke L, Halford S, Leonard P. Racism in the medical profession: the experience of UK graduates. London: BMA, 2003. 8. Essed P. Understanding Everyday Racism. An Interdisciplinary Theory. London: Sage, 1991. 9. Twine FW. Racial ideologies and racial methodologies. In: Twine FW, Warren JW, editors. Researching Race. Methodological Dilemmas in Critical Race Studies. New York: New York University Press, 2000:1-34. 10. Ruggiero KM, Taylor DM. Why minority group members perceive or do not perceive the discrimination that confronts them: The role of self- esteem and perceived control. Journal of Personality and Social Psychology 1997;72(2):373-389. 11. Gunaratnam Y. Researching 'Race' and Ethnicity. Methods, Knowledge and Power. London: Sage, 2003. Competing interests: None declared |
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George Khoury, Consultant surgeon Conquest Hospital TN37 7RD
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Your research group's previous study (1) conclusion states: "The differences, although small, do appear real. These effects may not be due to ethnicity alone as many factors affect performance, such as study style and personality." There was then no indication that any fault lies within the institution. Rather, it was factors inherent in ethnicity that were blamed. There was no misunderstanding - the conclusions of that original study were clear. As to your methods, the abstract states, "Participants: 27 year 3 medical students and 25 clinical teachers, purposively sampled for ethnicity and sex". Your results section states, "Of the 49 students invited to participate, 21 agreed to be interviewed (43%)." It would therefore appear, from your response, that of the 27 interviews ("12 students one-to-one and a further 15 in groups"), 6 students were interviewed without agreement or consent. Alternatively, your published figures do not add up. In your Methods section it states, "Data from one London hospital's website showed that in 2003 69% of consultants were men, 88% were white, 1% were black, and 9% were Asian. (www.royalfree.nhs.uk/doc/240604/AppendixF.doc)" The tables in your response of 2nd October 2008 do not appear either in the BMJ publication or on the website referred to. For clarity, the Equal Opportunities Monitoring section in Appendix F is copied here in its entirety (2). It states, "34% of the Trust's consultant staff are women." You can easily extrapolate from this that 66% of the consultant staff are men. Yet, your table shows only 31% of consultants to be female, and 69% male. It would appear, therefore, that either you cited the wrong reference, or alternatively, the tables are not representative. I note also that these tables are not referenced or adequately labelled in your response. Further, there was no mention in Appendix F of 88% of consultants being white. The only mention of 88% referred to percentage of white grade H nurses. The article is in the main anecdotal, and the number of unfavorable responses is testimony to the flaws in the article. It is surprising that this paper ever passed peer review. Equal Opportunities Monitoring (Workforce Profile) "1.1 Table 1 gives details of Trust staff at 31 March 2004. The Trust currently has information on the ethnic origin of all but seven of its staff, who have declined to complete a monitoring form. 70% of staff are female, 4% down on recent years. As last year staff from minority ethnic groups make up 44% of the non-medical workforce. 39% of the medical workforce are from minority ethnic groups. Up-to-date information from the 2001 census on the populations from which the Trust draws its workforce is shown for comparative purposes. It may be seen that minority groups are well represented in most sections of the Trust’s workforce other than managers, the professions allied to medicine and, for some minority groups, scientists. 1.2 Table 2 gives the gender and ethnic distribution of medical staff. 34% of the Trust’s consultant staff are women, an increase of 3% over the last three years. The distribution in other grades remains broadly in balance. As last year, minority ethnic groups are most strongly represented amongst doctors in training and in the “other” category, which includes non-consultant career grades and clinical assistants. Compared with the population as a whole, black people are under-represented in the Trust’s medical workforce. 1.3 Table 3 gives the ethnic origin of nurses by grade. Nearly a third of grade D nurses are black, a 2% increase on last year. Conversely, 3.9% of grade H nurses are black, while 88% are white. 1.4 Table 4 is a breakdown of the nursing workforce by gender and grade. The highest proportion of male nurses (21%) is at grade E. Nearly 20% of grade G nurses are male, a 7% increase from 2003.” 1. Haq I, Higham J, Morris R, Dacre J. Effect of ethnicity and gender on performance in undergraduate medical examinations. Med Educ 2005;39:1126-8.[CrossRef][ISI][Medline] 2. www.royalfree.nhs.uk/doc/240604/AppendixF.doc Competing interests: None declared |
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