Last week, The Independent published a front page report headlined “Senior GP tells doctors to act less gay”. It related to my advice book for doctors on how to pass their Clinical Skills Assessment (CSA) examination interviews. Brief passages from the book, shown by themselves can, of course, look controversial, but when viewed in context they become sensible and necessary pieces of advice.
When I applied for a job in 1994, I was asked: “who is the Captain of the England rugby team?” and “how would you feel as a mother leaving your child at home?” I was unsuccessful. In 1996, I finally got a job at the same hospital. The white male surgeon interviewers were on that occasion thoroughly professional. Organisational culture tends to reflect a top-down attitude. Having difficulty advancing my career, I asked a renowned surgeon to look over my CV. He made one suggestion: delete my maiden name of “Choi”. I did and was called for interview each time. Concurrently, racism in medicine – ie institutional NHS racism – was being exposed. In 1999, Professor Joe Collier blew the whistle in a BMJ article. He had notified the Commission for Racial Equality about computer software that generated a lower score for medical school applicants with non-Caucasian names. As an NHS whistleblower, instead of receiving applause, he was vilified and ostracised.
For me, discrimination in medicine was stomach-churning. Gay people had the added agony of deciding whether to be discreet (or even lie) about their sexuality. In the early 1990s, I had worked in a highly diverse (ethnically and sexually) hospital in New York. The trauma surgery team I belonged to had, at one point, been all female. Our patients, too, were multicultural and open about their sexual orientation.
The greatest barrier to racial and sexual equality is institutional denial. Working in NHS hospitals, I learned the phrase “be a grey man”, which means don’t cause waves, don’t stand out, don’t speak up, turn a blind eye, and keep your head low. The consequence of “talking about the fight club” – in other words, racism, discrimination or selective social engineering was “career suicide”.
When I was first elected to the Council of the Royal College of GPs, I was given similar advice. How strange to be working in such a hostile environment coming from America where an active effort to discriminate positively on behalf of minorities was encouraged and there was zero tolerance of racism and discrimination.
A Kings Fund report, Racism in Medicine, generated powerful debate in 2001 with its finding that bullying and discrimination were a daily fact of life for black and Asian doctors. A BMA survey two years later, revealed that among ethnic minority doctors who form nearly a third of the NHS workforce, more than 80 per cent believed their ethnicity had a negative effect on their career advancement. Dr Clare Gerada, the chair of the RCGP, has herself drawn attention “to the existence of homophobia and biphobia within healthcare”.
In 2009, I published a series of articles offering CSA exam revision tips in a medical magazine, and then reprinted the same advice for GPs in a book. Shortly after its initial publication, a RCGP internal study identified the need for enhanced diversity training for examiners and patient actors. This has been implemented and the College continues to make great efforts to minimise bias. It has recently commissioned the King’s Fund to study the poorer exam outcomes of ethnic minorities.
Overt bias has been eliminated from College exams but there is still a risk of subconscious bias. The British Journal of Medical Practitioners 2009 asserted: “As blatant forms of racism become extinguished, unconscious racial biases in subtle forms are appearing. This occurs in people who possess strong egalitarian values, who believe they are not prejudiced, but have negative racial feelings of which they are unaware.”
Subjective bias cannot be eliminated in its entirety. My exam book thus advises doctors on how to adopt behaviour likely to reduce subjective bias; to not draw attention to anything that might distract from a pure appreciation of their medical skills. I am blunt, as many doctors may be in denial about cultural (mis)perceptions. I respect that some feel that to compromise one’s identity is wrong. I make no judgements. My advice has helped hundreds of doctors pass their exams by reducing bias and placing them on an equal footing.
Dr Una Coales is a south London GP and the author of more than a dozen medical exam books