The term “differential attainment” refers to the phenomenon in which specific groups of people, in this case, the medical community, experience variations in achievement due to factors outside their control. When there are gaps in the level of success experienced by various doctors, this is an example of unequal attainment. Considerations include age, gender, race/ethnicity, socioeconomic status, and physical ability. There is evidence that Black and minority ethnic medical professionals, women, people with disabilities, medical graduates from other countries, people of low socioeconomic status, and people from geographical areas with low participation (in higher education) are more likely to face barriers both during their careers and after they leave the field. The General Medical Council, the Medical Schools Council, and the Academy of Royal Colleges have all been working hard over the past five years to provide transparency and annual reports that allow for reflection and self-evaluation (post-2014). Alliance for Equality in Healthcare Professions and the British Association of Physicians of Indian Origin have been working together on a project to close a range of achievement gaps, with BAPIO at the helm. Focus group data is analysed, and SMART interventions that are both feasible and effective in reducing these inequalities are developed through this partnership between a wide range of stakeholder organisations and grassroots bodies and international experts. Six of these issues, including this evaluation of DA in recruitment, will be covered in the “Bridging the Gap” report, which is scheduled for completion in time for BAPIO’s silver jubilee celebrations in September 2021. In addition to making evidence-based recommendations for national, regional, and local action, the report will also highlight areas for future collaborative research.
Differential attainment in UK Nursing System
The path to becoming a primary care physician (PCP) or hospital consultant is long and arduous, but nursing remains one of the most popular jobs for high school graduates. After completing medical school, the next step is to take several postgraduate exams before devoting much more time to training. Despite this, many bright, caring, and committed people are drawn to careers in the medical field. These people are not only willing to put in a lot of time and money to get into medical school, but they are also willing to put in a lot of time and money to get through their postgraduate studies and back into the cycle of lifelong learning, evaluations, and recertification or renewal of the license to practice medicine. It’s no secret that many jobs are stressful and time-consuming, and that many workers put in unusually long hours. Many other fields don’t have this kind of work environment. Progression in one’s medical career presents a number of challenges and opportunities, given the length and difficulty of the various training programs. The authors settled on a common definition of DA in terms of career development. The “observed gap in the achievements of various cohorts of people due to circumstances beyond their individual aptitude” is what is meant by the term “difference in achievement” (DA) (Lachish et al, 2016, pg. 109). A person’s ability to consistently improve in their chosen field is a key factor in being promoted. Therefore, we did not include any reports or studies whose primary audience was premed undergraduates. Despite the importance of good results on exams and a strong showing during the recruiting process, some “Bridging the Gap” teams focused more on other areas of the process. As a result, periodicals whose primary focus is on the selection and evaluation of personnel were also disqualified (Lachish et al, 2016, pg. 109). The authors determined the category (size and impact, causes and solutions, etc.) into which each paper or report fell during the preliminary material analysis. It’s possible that some of them can be placed in more than one group. After that, groups were created to analyse the three subfields, with at least one instructor or consultant and one student.
Power distance norms
Like in the UK, the medical field attracts people who are conscientious, self-driven, academically curious, fiercely ambitious, rich, and have access to significantly more socioeconomic resources. Therefore, those from higher socioeconomic origins are more likely to choose nursing as a profession (with the exception of cases involving reservations, positive discrimination, or expanded participation). Thus, in many nations, nurses and the bulk of their patients have vastly different levels of material resources. The National Health Service (NHS) in the United Kingdom ensures that all citizens have access to medical care, and as a public service, the power-distance disparities between doctors and their patients are less pronounced. As the power-distance gap between a country’s political elite and its citizens widens, the roles of the nurse and the patient become more clearly delineated, according to (Meeuwesen et al, 2015, pg. 101). They also found that the “nurse knows best” approach can sometimes win out (38). Hofstede argues that countries with a large power gap see few instances of challenge to the status quo Jones et al, (2003), found that the power differential between nurses and patients posed the greatest difficulty for international medical graduates (IMGs) making the transition to working in the United Kingdom. Foreign-trained doctors from high-power-distance countries often mislead patients by acting as though they are experts in their field. These kinds of encounters may come out as condescending to certain patients. Understanding the patient’s goals, obtaining informed consent, and fully explaining any therapeutic recommendations can all create a new and unfamiliar setting for IMGs. The ability of members of interdisciplinary teams to effectively interact with one another could be negatively impacted by power imbalances.
Much of the DA in the workplace, especially in terms of promotions and hiring, may be traced back to pervasive bias in the system. Two of the three structural drivers of health inequality are systemic racism and the aftereffects of colonialism, as explained in an article by Sir Michael Marmot titled “The Three Structural Drivers of Health Inequality.” Environmental and economic factors are the other two structural drivers. Qualitative studies undertaken in the UK show that racism negatively affects people’s physical and mental health. The harmful impacts of racism on health, especially mental health, have been the focus of 121 research studies, as was recently reviewed. One research of London’s youth found that “reported racism was consistently associated with lower psychological health across gender, race, and age,” which is in contrast to other indications of hardship. Disparities in racial health, according to David Williams’ idea, can be attributed to bias among other causes. Williams’ theory was confirmed by both statistical evidence and hard data. This means the NHS is currently in a state not unlike to the rest of the world. There is evidence of systemic prejudice in the competitive allocation of seats in foundation schools (Daga et al, 2021, pg. 112). A person’s likelihood of being assigned to their top-choice Foundation school in the United Kingdom is significantly influenced by factors such as their racial or ethnic background, their secondary schooling setting (private vs. public), their proximity to an area with a high educational participation rate, and the country of their medical degree. People of Black, Asian, and Minority Ethnic (BAME) ethnicity had a reduced chance of acceptance to their top Foundation school choice after controlling for application score and competition ratios. Staff grade and SAS nurses, who account for one in five registered nurses and a disproportionate share of the nursing workforce (they make up 29% of nurses with licenses, and 69% of nurses with credentials gained outside the EEA), are acknowledged to be the victims of inadequate assistance (Daga et al, 2021, pg. 117). These nurses are subjected to unreasonable conditions, including heavy workloads, lack of supervision, and lengthy hours.
Unconscious bias can assist create “in-groups” and “out-groups,” which can exclude IMGs, BAME nurses, part-time nurses, and those with impairments from opportunities and access to suitable advancement even when there is no overt racism present (Daga et al, 2021, pg. 122). Discrimination on multiple fronts can result from unconscious bias, including a lack of sponsorship or mentoring, which can have a negative effect on professional development.
Many international migrants suffer from psychological and social issues after arriving in a new country. These issues can range from a lack of confidence in one’s abilities to a lack of clarity about one’s role and obligations to an inability to support oneself financially. Individuals abilities to connect with others and feel like they belong in a group grow stronger as a result of increased opportunities for inclusion. Having a higher opinion of oneself is a possible result. One’s belief in his or her own abilities has a significant impact on both the ambitions and methods with which they seek to achieve those ambitions (Daga et al, 2021, pg. 123). Afraid of being labeled as a member of a stereotypical group? You might be facing stereotype threat. This event has gained a lot of attention in recent years. Gender and racial gaps in educational attainment may be exacerbated by this.
Social Capital: Relationships with seniors and peers
Woolf et al, (2018, pg. 167) explains that a lack of support from superiors and an inability to make friends at work can have negative effects on one’s mental health, including a decrease in learning opportunities, a loss of confidence, burnout, social isolation, and a lack of assistance from one’s employer in dealing with personal issues. It’s difficult to learn from and connect with people who have already achieved success in your field if you’re constantly switching employment (Woolf et al, 2016, pg. 91). Relationship building can be slowed down by cultural differences, which is especially bad for IMGs. Minority ethnic (BME) graduates in the UK may be at a disadvantage since they are less likely to be seen as “fitting the mold” than other graduates. Nurses often look to their culturally similar peers for guidance and comfort in the workplace. As a result, many IMGs avoided groups where they could have met people with similar backgrounds and gained social support (Woolf et al, 2016, pg. 91).
Help in a Real Way Nurses, according to Woolf’s findings, appreciate the help they get from their loved ones, both at home and at work, especially when it comes to tackling problems at the office. An unhealthy work-life balance can be a hindrance to success because of long work hours, stringent training regimens, a lack of understanding from superiors, and so on. Traveling women, persons with impairments, and people who provide care for others may find these factors particularly relevant. They are social outcasts because they are typically isolated from their friends, families, and other social support networks (Woolf et al, 2016, pg. 91). Woolf noted that nurses rarely have options in terms of where they work or live. International students and scholars are more prone to be distressed by this because they have fewer social networks to turn to. Additional fees, including those for clinical attachments, or issues acquiring work authorisation or visas might put a strain on an IMG’s finances and limit their career prospects.
The National Health Service (NHS) in Britain has been very successful at recruiting qualified medical professionals from all over the world, especially from Commonwealth countries. Perhaps the United Kingdom’s status as a colonial power explains why its medical system and education are so well-liked. The prestige and worth of a British medical degree or certification has expanded throughout the Commonwealth thanks to the legacy institutions that make up the medical royal colleges and the internationally focused departments within them. Many other countries look up to and envy the United Kingdom because its National Health Service (NHS; created in 1948) provides healthcare to all citizens regardless of their capacity to pay. It’s not surprising that doctors would want to get their hands dirty with this system because they’re naturally ambitious, driven, and social. British healthcare provider NHS also uses international recruitment and training programs to staff its facilities. The National Health Service (NHS) would not be able to provide the high-quality treatment that it strives for and that its patients expect without the dedication of skilled employees from all over the world. The economic impact of medical immigration to the United States is substantial, but it comes at the price of the nations of origin. However, the protocols for recruiting, onboarding, and educating “foreign” experts are not only inadequate, but also deeply faulty. Since then, the NHS has been unjust and unexplainable in the way it treats foreign nurses working for the organisation (Kehoe et al, 2016, pg. 121). Migrant nurses (and other healthcare workers) bring a richness of cultural knowledge and clinical diversity, but they often aren’t given credit for it (Rimmer, 2020, pg. 88). The nursing profession, in particular, recognises this. Our research makes it crystal evident that racial bias is a major contributor to the DA in professional development, and that members of disproportionately affected minority groups who have relocated to the UK suffer extra obstacles to their success. This is a problem for women in the workforce, people with disabilities, people of color, and people of ethnic minorities in the United Kingdom. Although it has been recognised as a phenomenon by law since a legal challenge in 2014 (BAPIO vs. Royal College of General Practitioners) and the GMC declaration in 2015, there is scant evidence to suggest that the causes, consequences, and mitigation strategies have been fully understood over the course of generations (Rimmer, 2020, pg. 88). This research also showed that thousands of nurses from underrepresented minorities face an absence of publicly available information, career development monitoring, and legislative or regulatory responsibility.
Health Education England has made it a goal from the start to create better classroom settings for educators. It has collaborated with medical royal colleges to create and implement educational programs, but until recently it has paid little attention to or offered support for “non-training grade” doctors. Just recently has, the governing authority, the GMC, began looking into the experiences of non-training doctors, trying to understand the challenges SAS doctors confront, and acknowledging that DA in the medical sectors is an intolerable type of institutional prejudice (Rimmer, 2020, pg. 108). Medical personnel who answered recruiting appeals “to preserve the NHS from disintegrating” have had it made worse by frequent fighting between government agencies (regulations from the Home Office versus those from the Department of Health and Social Services) (Kehoe et al, 2016, pg. 78). Unions and support groups for doctors, such as the British Medical Association, are unable to make a major impact on issues such as raising educational and employment standards and reducing bias against marginalised groups. The establishment of the WRES standards, the GMC National Training Surveys, and the HEE National Education and Training Surveys, however, has ushered in a new era of awareness that things are not as they should be. Education, welfare, and support for all areas of medicine have recently gained more focus. Growing concern has been voiced in recent years about the problems of discrimination and underrepresentation that large minority groups face. The gender pay gap, the drawbacks of flexible training, and bias in career development may now be remembered. This is a chance to enhance data gathering, define career routes, provide support, evaluate and hold organisations responsible, and, most importantly, cultivate a setting conducive to having meaningful conversations with a group of employees who are underrepresented in the labor market. Our research led us to the following interesting projects. Conditioning conditions: A paper commissioned by the GMC called “What Supported Your Success in Training” highlights the significance of prospective DA solutions that look at the big picture, go beyond examination bias, and enable the identification of each person’s support and training needs Rai et al, 2020, pg. 101). Boost work and working environments have been advocated for by businesses and governments as a means to better the experience, involvement, and possibilities for BAME employees and employees from disadvantaged backgrounds.
The report “What Supported Your Success in Training,” commissioned by the GMC, highlights the importance of proposed DA solutions having a holistic focus that goes beyond the bias on the training environment itself and addresses people’s support and training needs. Boost work and working environments have been advocated for by businesses and legislators as a means to better the experience, involvement, and possibilities of people of color and those from underprivileged backgrounds (Atewologun et al,2018, pg. 23).
Implicit and unconscious bias training has been used to combat discrimination in a wide range of settings. Changing attitudes and behaviors, increasing understanding, decreasing implicit prejudice, and eliminating overt bias are all viable options. There is insufficient evidence for the efficacy of commonly used bias training methodologies in enacting behavior change, according to an assessment of the impacts of bias training conducted by the Equality and Human Rights Commission. This lack of proof was blamed for the unavailability of effective behavior modification methods in the scientific literature (Atewologun et al,2018, pg. 23). The training could backfire and legitimise bias in ways that undermine its intended purpose if it is seen as normalising the occurrence of unconscious bias Duguid et al, 2015, pg. 56). Devine et al. argue that the efficacy of anti-bias training may be diminished if the trainees are not in a mental state that allows them to be open to having their biases challenged. These results stress the significance of colleagues undertaking future research in this field, providing training on unconscious bias while taking into account the environment, topic matter, and evaluation approach.
If our existing medical school system gave every doctor the resources and opportunity they required to flourish, we wouldn’t have the current uneven distribution of levels of professional performance. Consequences for those who do not benefit from “the status quo” are far-reaching as a result of this multifaceted and multifaceted problem. This causes a loss of expertise, perspective, and input from the surviving medical staff, which has a negative impact on the entire system. Rectifying wrongs is essential for moral and legal reasons. There are no simple or apparent answers. The success of this endeavor depends on the inter- and intra-organizational cooperation of several groups. Affected communities should be consulted and included in the creation of solutions. Transitioning from “action planning” to “action,” interventions must be created in a way that allows for evaluation of their effectiveness. The best way to address differential accomplishment is with proof, just like any other illness. Limitations Using Google Scholar, PubMed, and the reports of numerous organisations, this scoping study gives a high-level summary of the relevant literature. A lot of workplaces may have taken some action in the past without following up or reporting it.
Royal College of Psychiatrists, British Geriatric Society. Depression among older people living in care homes — collaborative approaches to treatment. 2018. https://bjgp.org/content/69/685/e578/tab-eletters (accessed 7 Oct 2019).
Hegeman JM, Kok RM, van der Mast RC, Giltay EJ. Phenomenology of depression in older compared with younger adults: meta-analysis. Br J Psychiatry 2012; DOI: 10.1192/bjp.bp.111.095950.
Park M, Unützer J. Geriatric depression in primary care. Psychiatr Clin North Am 2011; DOI: 10.1016/j. psc.2011.02.009.
King’s Fund. Primary care networks and mental health. 2019. https://www.kingsfund.org.uk/ blog/2019/07/primary-care-networks-mental-health (accessed 7 Oct 2019).
NHS England. Guidance on co-locating mental health therapists in primary care. 2018. HTTPS:// www.England.nhs.UK/wp-content/uploads/2018/08/ guidance-co-locating-mental-health-therapistsprimary-care.pdf (accessed 7 Oct 2019).
Royal College of Psychiatrists. Suffering in silence: age inequality in older people’s mental health care. 2018. https://www.rcpsych.ac.uk/docs/defaultsource/improving-care/better-mh-policy/collegereports/college-report-cr221.pdf?sfvrsn=bef8f65d_2 (accessed 7 Oct 2019).
Atewologun, D., Cornish, T. and Tresh, F., 2018. Unconscious bias training: An assessment of the evidence for effectiveness. Equality and human rights commission research report series.
Chakravorty, I., Daga, S., Chakravorty, S., Bamrah, J.S. and Mehta, R., 2020. Protocol for Thematic Synthesis of Differential Attainment in the Medical Profession-‘Bridging the Gap’Series. Sushruta Journal of Health Policy & Opinion, 13(3).
Daga, V., Blizzard, R., Dhelaria, A., Hosdurga, S., Hussein, S., Madabhushi, S., Sawney, G., Shah, A., Theocharidou, L. and Shah, R., 2021. Differential Attainment in Career Progression for Doctors in the UK. Sushruta Journal of Health Policy & Opinion, 14(1), pp.1-10.
Devine, P.G., Forscher, P.S., Austin, A.J. and Cox, W.T., 2012. Long-term reduction in implicit race bias: A prejudice habit-breaking intervention. Journal of experimental social psychology, 48(6), pp.1267-1278.
Duguid, M.M. and Thomas-Hunt, M.C., 2015. Condoning stereotyping? How awareness of stereotyping prevalence impacts expression of stereotypes. Journal of Applied Psychology, 100(2), p.343.
Frost R, Beattie A, Bhanu C, et al. Management of depression and referral of older people to psychological therapies: a systemic review of qualitative studies. Br J Gen Pract 2019; DOI: HTTPS:// doi.org/10.3399/bjgp19X701297.
Jones, L., Halford, S. and Leonard, P., 2003. Racism in the medical profession: the experience of UK graduates.
Kehoe, A., McLachlan, J., Metcalf, J., Forrest, S., Carter, M. and Illing, J., 2016. Supporting international medical graduates’ transition to their host‐country: realist synthesis. Medical education, 50(10), pp.1015-1032.
Lachish, S., Svirko, E., Goldacre, M.J. and Lambert, T., 2016. Factors associated with less-than-full-time working in medical practice: results of surveys of five cohorts of UK doctors, 10 years after graduation. Human resources for health, 14(1), pp.1-11.
Rai, Y. and Al-Uzri, M., 2020. Medical training initiative (Mti) psychiatry scheme: Online survey of trainees’ experience.
Rimmer, A., 2020. Covid-19: Health Education England shares advice for trainees. BMJ, 369.
Woolf, K., Rich, A., Viney, R., Needleman, S. and Griffin, A., 2016. Perceived causes of differential attainment in UK postgraduate medical training: a national qualitative study. BMJ Open, 6(11), p.e013429.
Woolf, K., Viney, R., Rich, A., Jayaweera, H. and Griffin, A., 2018. Organisational perspectives on addressing differential attainment in postgraduate medical education: a qualitative study in the UK. BMJ Open, 8(3), p.e021314.