Medical Students / JMOsNews / Opinion

BMJ – Ethnicity and academic performance in UK trained doctors and medical students:

Published this week in the BMJ is a meta-analysis comparing educational achievement of medical students and doctors in the UK with ethnicity. Almost 24000 candidates were included with the primary measure being to compare white vs. non-white ethnic groups. Candidates of the non-white group significantly underperformed compared to white candidates but heterogeneity was present in all meta-analyses (for different testing outcomes).

Ethnicity and academic performance in UK trained doctors and medical students: systematic review and meta-analysis

Abstract

Objective To determine whether the ethnicity of UK trained doctors and medical students is related to their academic performance.
Design Systematic review and meta-analysis.
Data sources Online databases PubMed, Scopus, and ERIC; Google and Google Scholar; personal knowledge; backwards and forwards citations; specific searches of medical education journals and medical education conference abstracts.
Study selection The included quantitative reports measured the performance of medical students or UK trained doctors from different ethnic groups in undergraduate or postgraduate assessments. Exclusions were non-UK assessments, only non-UK trained candidates, only self reported assessment data, only dropouts or another non-academic variable, obvious sampling bias, or insufficient details of ethnicity or outcomes.
Results23 reports comparing the academic performance of medical students and doctors from different ethnic groups were included. Meta-analyses of effects from 22 reports (n=23 742) indicated candidates of “non-white” ethnicity underperformed compared with white candidates (Cohen’s d=−0.42, 95% confidence interval −0.50 to −0.34; P<0.001). Effects in the same direction and of similar magnitude were found in meta-analyses of undergraduate assessments only, postgraduate assessments only, machine marked written assessments only, practical clinical assessments only, assessments with pass/fail outcomes only, assessments with continuous outcomes only, and in a meta-analysis of white v Asian candidates only. Heterogeneity was present in all meta-analyses.
Conclusion Ethnic differences in academic performance are widespread across different medical schools, different types of exam, and in undergraduates and postgraduates. They have persisted for many years and cannot be dismissed as atypical or local problems. We need to recognise this as an issue that probably affects all of UK medical and higher education. More detailed information to track the problem as well as further research into its causes is required. Such actions are necessary to ensure a fair and just method of training and of assessing current and future doctors.

I find meta-analyses such as this one difficult to interpret because of the wide range of studies included and their varying methodology. This one has taken a useful measure of comparing mainly white vs. non-white medical students and doctors which makes collating a large number of studies together a little easier. Similarly this study did not take year into consideration at all and so you have reports from the 80s as well as last decade and obviously things will have changed in this area over time.<br />
<br />
A study I find more useful by way of being easier to understand and gauge effect is this one: <br />
<br />
<blockquote>BMJ 2004; 328 :</span><span style="font-style:italic;">1545</span>] <br />
<span style="font-weight:bold;"><font size="3">The standardised admission ratio for measuring widening participation in medical schools: analysis of UK medical school admissions by ethnicity, socioeconomic status, and sex</font></span><br />
<br />
Seyan K, Greenhalgh T, Dorling D.<br />
<br />
Ethnic minorities and women are no longer under-represented in UK medical schools, but lower socioeconomic groups still are. 1 Given the strong political pressure on higher education institutions to develop “widening participation” programmes, 2 3 a valid quantitative index of the impact of such programmes is needed urgently. Such an index should be derived from robust and accessible primary data, reflect the impact of multiple independent variables in different population subgroups, allow comparisons across institutions and over time, and be readily understandable by non-statisticians. <br />
Statistics on the entry profile of UK medical schools are usually expressed as the selection ratio (the proportion of admissions to applications 4). We propose that the standardised admission ratio (see box), which expresses the number of pupils admitted to medical school as a proportion of the number who would do so if places were allocated equitably across all socioeconomic and ethnic groups and equally by sex, should become the standard measure of widening participation. It would not, of course, be an index of discrimination at selection stage. … </blockquote><br />
<br />
<a href=http://www.bmj.com/content/328/7455/1545.extract>http://www.bmj.com/content/328/7455/1545.extract</a><br />
<br />
This study has very interesting findings. It ranks groups into social classes I to V with I being the highest social class. In this study, Asians from social class I were the most highly represented group with a standardised admission ratio of 41.73 compared to the least represented group, black people from social class V with a ratio of 0.07. A 600-fold difference.<br />
<br />
Interestingly sex-specific ratios did no vary by socioeconomic status but did vary by ethnicty. In Asians there was no sex-specific inequality but black and white men were significantly underrepresented compared to their female counterparts.<br />
<br />
A companion paper discusses the reasons for these differences and is available here:<br />
<br />
<blockquote>BMJ 2004; 328 : 1541</span>]<br />
<span style="font-weight:bold;">Abstract</span><br />
<br />
<span style="font-weight:bold;">Objective</span> To investigate what going to medical school means to academically able 14-16 year olds from different ethnic and socioeconomic backgrounds in order to understand the wide socioeconomic variation in applications to medical school. <br />
<span style="font-weight:bold;">Design</span> Focus group study. <br />
<span style="font-weight:bold;">Setting</span> Six London secondary schools. <br />
<span style="font-weight:bold;">Participants</span> 68 academically able and scientifically oriented pupils aged 14-16 years from a wide range of social and ethnic backgrounds. <br />
<span style="font-weight:bold;">Main outcome measures</span> Pupils' perceptions of medical school, motivation to apply, confidence in ability to stay the course, expectations of medicine as a career, and perceived sources of information and support. <br />
<span style="font-weight:bold;">Results</span> There were few differences by sex or ethnicity, but striking differences by socioeconomic status. Pupils from lower socioeconomic groups held stereotyped and superficial perceptions of doctors, saw medical school as culturally alien and geared towards “posh” students, and greatly underestimated their own chances of gaining a place and staying the course. They saw medicine as having extrinsic rewards (money) but requiring prohibitive personal sacrifices. Pupils from affluent backgrounds saw medicine as one of a menu of challenging career options with intrinsic rewards (fulfilment, achievement). All pupils had concerns about the costs of study, but only those from poor backgrounds saw costs as constraining their choices. <br />
<span style="font-weight:bold;">Conclusions</span> Underachievement by able pupils from poor backgrounds may be more to do with identity, motivation, and the cultural framing of career choices than with low levels of factual knowledge. Policies to widen participation in medical education must go beyond a knowledge deficit model and address the complex social and cultural environment within which individual life choices are embedded. <br />
<br />
</blockquote><br />
<br />
<a href=http://www.bmj.com/content/328/7455/1541.abstract>http://www.bmj.com/content/328/7455/1541.abstract</a>
<blockquote></blockquote><br />
The topic of discrimination in medical practice and education can be an awkward one for a variety of reasons; but to at least <span style="font-style:italic;">consider</span> if such a disparity exists is nevertheless laudable.
It should be noted that, interestingly, in England, Asians are taken to mean people from South Asia. Like Indians andPakistanis. (thanks to my asia pacific studies class)
M