Desk review part 2

Literature review

A review of the academic literature and relevant policy documentation was conducted to explore equality and diversity issues in relation to selection. Academic journal databases and other sources i.e. government and organisational reports and policies were searched and results sifted for relevant articles. Specifically, the review focused on the following questions:

• What are the key equality and diversity issues in selection?
• What can we learn about equality and diversity in selection medical education?
• What is the nature of group differences, particularly in relation to ethnicity, nationality or place of qualification, in selection performance
• What causes group differences, particularly in relation to ethnicity, nationality or place of qualification, in selection performance?
• What guidance currently exists, in relation to equality and diversity in medical selection?
• Are there interventions which effectively reduce the group differences in selection?
• How are strategies aimed at reducing group differences implemented?

The outcome of the literature review presented in this report is based on the key themes identified. The key findings summarised and presented in the report have been weighted based on where a body of evidence exists across the literature.

References from the literature review are listed at the end of this report.

Group differences in Medical selection and Education

The literature identified similar patterns as those noted in GP selection with differences in performance identified for ethnicity, gender, age and place of training. A recent meta-analysis indicated that findings of an ethnic difference in assessment outcomes were both consistent and persistent (Woolf et al, 2011).

• Differential performance has been indicated for gender in terms of females performing better than male candidates in selection or medical education (e.g. McDonough et al, 2000).
• Females have also been found to perform better in communication skills-based assessments in general practice (e.g. Dewhurst et al, 2007). Explanations for this difference have included women’s greater effectiveness in the ability to listen (Clack and Head, 1999) and potentially a greater sense of patient care values (Zaharias, Piterman and Liddell, 2004).
• Across medical education and training, at both undergraduate and postgraduate levels, differential performance between ethnic groups is a consistent finding. Notably ethnic minority groups do not perform as well as White candidates across various assessments.
• Overseas training, significantly predicted lower success rates for doctors on qualification assessments such as the MRCGP (Wakeford, Farooqi, Rashid and Southgate, 1992). The literature has also indicated that a significant proportion of the Asian doctors in the UK are from India (Young et al, 2003) and that Asian doctors born and trained in the Indian subcontinent perform particularly badly (Wakeford et al 1992).
• Medical students and doctors from ethnic minority group significantly underperform academically at machine-marked tests and practical clinical assessments (Woolf et al., 2009; Woolf et al., 2011; Dewhurst et al., 2007).
• Doctors who had qualified and undertaken training overseas tended to have lower success rates during training than UK-trained doctors (White, 2009).
• There are examples within the literature of no significant differences existing between ethnic groups trained in the UK e.g. no differences in GP placement success amongst ethnic minority doctors trained in the UK in 2004 and 2008 (Plint et al, 2009). This suggests that place of qualification and experiences during training may be a significant influential factor.

Causes of group differences in performance

The causes of group differences in selection and educational performance in medicine are multi-factorial. There is no conclusive evidence within the literature to provide an explanation for group differences although a number of significant factors may be contributing to the phenomenon to varying degrees.

• A difference in the cultural values of certain ethnic groups was identified within the literature as a possible explanation for differences in performance within other medical speciality areas (e.g. MRCP examinations). For example cultural differences in the perceived status of a medical career may result in non-white candidates making exceptional efforts to gain entrance into medical school (Dewhurst et al, 2007). These efforts may not however be sustainable in the long term resulting in regression to the mean when it comes to more senior selection.
• Hofstede’s (1984; 2001) ‘cultural dimensions theory’ offers a systematic framework for differentiating national cultures and provides an approximate understanding of other cultures in terms of values. The model assists with cross-cultural understanding and may be useful in informing some of the cultural differences between the UK and non-UK candidates entering the GP selection process (as well as other medical selection processes).
  • All levels of communication are affected by cultural dimensions: verbal communication (words and language itself), non-verbal communication (body language, gestures) and etiquette (e.g. do’s and don’ts in terms of clothing, customs and protocol). Cross-cultural understanding and intercultural competence7 is therefore critical.
  • Hofstede’s six dimensions of values are as follows: power (equality versus inequality), collectivism (versus individualism), uncertainty avoidance (versus tolerance), masculinity (versus femininity), temporal orientation, and indulgence (versus restraint).
  • In Europe, power distance8 tends to be lower in northern countries (e.g. Sweden, UK) and higher in southern and eastern parts (Italy, Spain). Individuals in low power distance countries therefore expect and accept relationships between superiors and subordinates are more consultative or democratic. In high power distance countries, individuals may accept power relations between superiors and subordinates that are more autocratic and paternalistic.
  • Generally, western countries can be considered as individualistic (i.e. importance is placed on personal achievements and individual rights) whereas countries such as Asia, Africa and Latin America have strong collectivistic values (i.e. individuals act predominantly as members and in the interests of their cohesive group or organisation).
• Schwartz (1992; 1994) also identifies 7-10 cultural values which exist in varying degrees across different countries. In a comparison of different countries in terms of their values Schwartz (1999) identified where countries were similar or differed in terms of national cultures. For example Sweden and Denmark appeared to have similar national value cultures whereas China and Italy had largely opposite profiles.
• Development of intercultural competence appears crucial for successful communication between individuals of different cultural backgrounds. One of the most difficult aspects of the intercultural communicative competence is the ability to distinguish between idiosyncratic and culturally conditioned behaviours. Difficulty in explaining the nature of group differences in relation to ethnicity, country of origin or training could be linked to the complexity associated with areas such as this.
• Diverse university populations provide unique social forums to foster intercultural development (Volet, 1999) and the development of multicultural individuals (Adler, 1974). Differences in the diversity of universities and medical education facilities in different countries could therefore explain differences in individuals’ levels of intercultural development and their effectiveness interacting in different cultural environments.
• Related to cultural differences, is the finding that eastern and western cultures also demonstrate different thinking styles based on the difference in their individualistic versus collectivistic contexts (e.g. Nisbett, 2003). For example Eastern Asians have been found to think contextually whereas Westerners focus on the point in hand. In addition Eastern Asians tend to think holistically whereas Westerners think more analytically.
• In terms of communication differences, research suggests that vernacular language and accents can cause difficulties. In addition, language related to prescribing can present some problems – with generic names being common in the NHS, but with some use of brand names when communicating with patients. However overseas-qualified doctors are often accustomed to using scientific names (Illing et al, 2009).
• Many overseas doctors come to the UK to post-Foundation roles. These doctors’ clinical practice is established, and so they may find greater difficulty in adapting to a different workplace culture, and may not have as much support as the Foundation Programme (FP) doctors (Illing et al, 2009). The FP may therefore be an influential factor in enhancing performance.
• Furthermore non-UK qualified doctors entering specialty rather than foundation training are likely to be older therefore also impacting on age-related group differences.
• The negative impact of unconscious bias is currently being explored and is growing in popularity as a possible explanation for emerging differences in ethnic minority doctors’ learning and performance ratings.
• Differences in the culture of the UK NHS compared to overseas healthcare systems was highlighted as a possible explanation for the difficulties experienced by overseas doctors training in the UK; in particular the patient-centred culture of the NHS and working within a holistic model of care where social issues are important, was considered a cultural change for overseas doctors (e.g. Illing et al, 2009). International doctors may be less familiar with holistic models and have a more paternalistic view of the doctor-patient relationship.
• The literature highlights areas in which overseas medical graduates differ, or attribute their perceptions to differences from their country of origin e.g. elements of teamwork, such as working in a less hierarchical environment with greater equality between clinical professions, and greater communication between trainees and senior doctors (see Illing et al, 2009). Doctors who have trained overseas may therefore experience difficulties understanding the roles and responsibilities of other team members within the NHS.
• Overseas doctors may also encounter different clinical presentations and pathologies and social problems within the UK which may not have been encountered within their own cultural environments.
  • Research within the Canadian health service found that international medical graduates rated knowledge of healthcare systems and processes as well as knowledge of pharmaceuticals as two key areas of difficulty when moving to practice abroad (Zulla et al, 2008). This could indicate a mismatch in perceptions and could suggest some form of integration programme for overseas doctors may be beneficial.
  • Some research suggests the possibility of ‘stereotype threat’ as a psychological explanation for individuals from ethnic minority groups underachieving academically. This research has predominantly focused on Black student populations and may not be widely generalised to all ethnic group differences in the medical context, however the impact of stereotypes is a widely recognised psychological phenomena (see Woolf et al, 2009).
  • According to stereotype threat theory, in test situations members of negatively- stereotyped groups can feel sufficient anxiety at the prospect of fulfilling a negative stereotype about their group that they subsequently underperform.

Interventions and strategies for reducing group differences

There was limited evidence of the effectiveness of targeted interventions aimed at reducing group differences in performance during medical selection or wider medical education. Strategies to support international doctors or reduce adverse impact were identified and may inform possible future interventions, although it is recommended that further evidence of effectiveness is explored before actions are implemented.

• In relation to the concept of stereotype threat, the effect may be reduced by changing individuals' perceptions of themselves, their ability and their potential. Following a self- affirmation intervention the ethnic attainment gap was narrowed by almost 40% in one study. The self-affirmation task (asking doctors to write about their values) enhanced individuals’ self-esteem and self-worth thus removing the stereotype threat.
• The quality and availability of pre-registration training is variable and international medical graduates may benefit from more consistent approaches to induction. In addition mentoring schemes supporting refugee doctors have been found to positively impact on performance and such support could have benefits for qualified doctors from overseas.
• Research suggests pre-arrival information, induction on arrival, and ongoing support can benefit overseas-qualified doctors coming to the UK, making the transition experience easier (Illing et al, 2009). This support may positively impact on performance in selection and training but needs a more programmatic approach to measure the effect of each of these elements in more detail.
• Research suggests performance differences are greatest in relation to communication skills and it has been demonstrated that training in this area is valued by non-UK trained doctors (Slowther et al.2008).
• The academic literature still recommends that performance differences, especially in relation to ethnicity, are tracked over time and studied further to understand the underlying causes. Royal Colleges, medical specialities and medical schools should share and explore patterns in the performance differences they experience in selection and during training.
• A growing number of studies show a link between hidden biases and actual behaviour; discrimination can therefore still occur without an individual being conscious their actions. Implicit Association Tests (IATs) (see Greenwald, McGhee, and Schwartz, 1998) measure unconscious, or automatic, biases and are designed to tap into our stereotypes in order to determine how biased they are and how we are governed by them. Raising individuals’ awareness of their personal biases could assist with reducing unconscious discrimination.

Existing guidance and interventions

Existing guidance and information on interventions or guidelines currently used in GP / medicine and evidence of their effectiveness was investigated. Website resources, policy and guidance documentation was reviewed.

Equality and diversity guidance within healthcare

General guidance and information in relation to equality and diversity as well as advice for international medical graduates or doctors can be sourced from the General Medical Council (GMC), Department of Health (DH), British Medical Association
(BMA), regional postgraduate medical deaneries and relevant NHS organisations (e.g. NHS Employers, NHS Careers etc).

• The UK’s Race Relations Amendment Act (2000) places a duty on all public authorities, including universities and the NHS, to monitor admission and progress of students and the recruitment and career progression of staff by ethnic group to be able to address inequalities or disadvantage.
• Information and support available to doctors who qualified overseas focuses on practical issues such as immigration and examinations; research suggests guidance does not necessarily provide adequate information about ethical/professional standards.
• Guidance has been produced for International Medical Graduates (e.g. by NHS Employers) which provides an overview of the healthcare system in terms of structure and including information about the employment of general practitioners in primary care; it does not specifically relate to medical selection processes.
• Approaches across medical deaneries differ somewhat in terms of the general guidance and support offered to overseas doctors and IMGs although guidance specifically related to selection is relatively standardised.

Guidance and information in GP/Medical selection 

• DH best practice guidelines suggest that GPs recruited from abroad should be given a mentor, an individual induction assessment and group induction upon entry into the NHS. Employers should also make available information about English language support through local education providers.
• The GP National Recruitment Office website outlines their equality and diversity policy and provides information for overseas doctors on the requirements regarding immigration status, application processes and the GP role within the NHS.
• There is more detailed information about what it is like to work in the NHS, including short videos of current employees, on specialist NHS careers websites (e.g. NHS Careers and NHS Medical Careers) and there are links to these websites from the GP recruitment website. These alternative websites also include specific advice and information regarding the GP speciality.
• The GMC provides detailed information about their requirements for medical selection processes including the use of criteria and processes which treat eligible candidates fairly, selection of candidates through open competition and the need for information about places on training programmes, eligibility and selection criteria and the application process to be published and made widely available in sufficient time for doctors who may be eligible to apply.
• The BMA has produced a report which recommends equal opportunities awareness training for selectors, further guidance for applicants on filling in application forms and on interview procedures and best practice in equality and diversity to be shared in order to improve medical recruitment processes and reduce potential barriers for ethnic minority applicants.