Also Human

by Caroline Elton

  We only met once. But six months later I received a card in which he informed me he had managed to get a surgical job back in London. Perhaps in that one session I managed to reduce the risk of Khalid’s surgical career spiralling rapidly out of control.

  *

  The racial legacy is not the same on both sides of the Atlantic. As an editorial in the Journal of the National Medical Association noted, the history of medicine in the United States has been haunted by a deeply painful past. This includes ‘segregated hospitals, limited opportunities for medical training of African-Americans, US government supported clinical trials utilizing African-Americans for human experimentation and reduced access for minority patients to medical care’. In an unprecedented step, the American Medical Association officially apologised to African-American physicians for enabling decades of discriminatory practices against them32.

  This apology took place in 2008.

  In spite of the lack of openness of key organisations what is clear, beyond any doubt, is that African-American, Asian and white medical students in the US don’t compete on an even playing field. This was clearly demonstrated in a recent paper in the Journal of the American Medical Association. The study looked at racial differences in those accepted into the Alpha Omega Alpha Honor Society33. To be asked to join this exclusive club, medical students need to be more than academic high-flyers – they also have to demonstrate ‘leadership among their peers, professionalism and a firm sense of ethics’. Why this matters is that being a member of Alpha Omega Alpha is associated with future success in academic medicine. Eleven of the fifteen US Surgeons General have been members, as have more than fifty Nobel laureates. Alpha Omega Alpha are three mighty letters to have on your medical CV.

  The design of the study was pleasingly simple – a retrospective analysis of 4,655 residency applications to Yale Medical Center, from students currently attending 123 different medical schools across the US. All of these applications were completed online, and data on the applicants’ self-reported race, sex and age were collected. In addition to this basic demographic information, data on the applicants’ STEP1 scores, research productivity, community service and leadership activity were also extracted. What the researchers were interested in was whether, after taking all the relevant variables into account, there were any racial differences in Alpha Omega Alpha membership. And their results?

  After controlling for numerous demographic and educational covariates, we found that the odds of Alpha Omega Alpha membership for white students was 6 times greater than those for black students and nearly 2 times greater than for Asian students.

  In an invited commentary to the article the need for tracking the data on allegedly race-neutral systems of advancement was stressed34.

  It’s a pity that neither the USMLE nor the NRMP have taken this message on board.

  *

  ‘The first thing that I became aware of in the UK was that I was a different colour,’ Tanisha told me. ‘The second thing was that I spoke differently. Neither of these two observations had occurred to me before.’

  Tanisha was an Indian doctor who attended an Indian medical school, and then came to the UK as a postgraduate. Although her secondary school and medical school education had been in India, the language used in both of these institutions was English. Tanisha’s English-language skills were impeccable, so she was completely unprepared for the ways in which she was made to feel different. ‘I became so conscious of my accent that I wouldn’t speak in public,’ she said. People didn’t ask her about the novels she had read (she was a voracious reader) or the films she loved; they heard a slight accent, and assumed that she knew nothing about English culture.

  Before Tanisha could work as a doctor in the UK there were also examinations to pass, followed by arranging an unpaid clinical attachment in order to gain exposure to NHS clinical practice. During this period Tanisha had to pay rent, but didn’t receive a salary; the money her father had given her ran out and she didn’t have enough money to pay for adequate food. By the end of two months, her weight had dropped to 47 kilos.

  Each week she spoke to her father in India, reassuring him that she was fine. ‘Whether he really knew all along, I will never know,’ Tanisha told me.

  Four hundred and fifty applications later, she got a six-month job in Wales, in a town where she knew nobody. Without adequate induction into the role, initially she felt completely overwhelmed. To ensure that she didn’t make a mistake, Tanisha had no option but to continually ask questions. In turn, her colleagues assumed that she was stupid or ignorant, rather than seeing her as somebody who had trained in a different medical system, and needed a bit of time to find her feet.

  And still Tanisha battled on. She stayed late every evening, studied hard, asked for guidance from a fellow international medical graduate, and gradually built up her confidence. Just when she was starting to feel comfortable with the work, she had to move on, as her visa only let her take on short-term contracts. And so it went on for four years, until her visa status changed and she was eligible to apply for specialty training.

  Once she started earning a salary she paid back her friends (other international medical graduates) who had lent her money when she had nothing. But she still felt obliged to contribute money to her parents, who were far from wealthy. With all the moving around, she also found herself desperately lonely and isolated. Resisting parental pressure to agree to an arranged marriage, she wanted to fit in with her peers in the UK. Yet in the process, she lost all sense of belonging anywhere: ‘I was neither here, nor there,’ was how she put it. Exactly the same sentiment as Damon Tweedy made, about his experience as a black medical student in an elite white university.

  I have encountered hundreds of doctors from the Indian subcontinent, the Middle East and Africa over the past twenty years. Each one is an individual with their own particular personality, family background, medical training, specialty interests and English-language skills. Some have an easier ride than others once they start working as doctors in the UK. But what unites this disparate group is the fact that the medical profession as a whole systematically underestimates the challenges that these doctors face: inadequate induction; separation from family and friends; being made to feel unwelcome within the medical team; being on the receiving end of barbed comments from colleagues or patients; visa and money worries; concerns about family members that they have left behind – to name but a few of the hurdles they have to overcome.

  What makes this collective underestimation all the more shocking is the sheer number involved. Although the number of international medical graduates from Asian backgrounds is decreasing (at least in part, due to visa changes), the contribution that this group makes to the medical workforce is immense. In 2016 the GMC reported that over a quarter of all doctors on the UK medical register gained their primary medical qualification outside UK or Europe35. (This is a similar figure to the US, where a quarter of practising physicians are graduates of international medical schools.) When it comes to doctors who are in service roles in hospitals (i.e. those who are working as a doctor without being part of a training scheme), the figures are considerably higher. Imagine for a moment that all these international medical graduates packed their bags and left. Who would care for us?

  *

  ‘What happens in medical school is a reflection of wider society,’ wrote Professor Aneez Esmail in the British Medical Journal36. And how could it be otherwise? A medical school isn’t a monastery cut off from the outside world. The consultant at the back of my seminar room, Professor only-interested-in-marriage and the revue participants at Cardiff University are all giving voice to sentiments that are widely held in society. Probably not sentiments which everybody would espouse – but when we include unconscious bias, from which nobody is exempt, we get a glimpse of the unevenness of the playing field.

  As medical school is a reflection of wider society, differential attainment according to race doesn’t just apply to doctors; it h
appens across the whole higher education sector, as well as in primary and secondary school. And it doesn’t just happen in the UK or the US; similar gradients have been found in Canada, and Australia and in Western Europe. Across the world, BME students in predominantly white countries face obstacles to their progress.

  It’s one thing to give a presentation or prepare a report when riddled with self-doubt. That can certainly feel horrid. But it’s not the same as having to take responsibility for somebody’s life when your confidence has been shattered. This was the situation that Rahma, Khalid and Tanisha, and many other doctors who have come to see me, have found themselves in, day after day. And what’s the best buffer against the inevitable stresses of clinical responsibility? Getting support from understanding colleagues. So yet again, BME doctors are disadvantaged, as they are more likely to be isolated and feel that they don’t belong in the team.

  It’s tempting to despair, given the ubiquity of unconscious bias, the depth of structural inequalities and the pervasiveness of differential attainment across the Western world. But there are places where things are done differently. It is possible37.

  What differentiates these institutions is the scope of their ambitions. As an example (and there are others), over a ten-year period, the University of Texas Medical Branch introduced a raft of significant reforms to change the learning environment, including programmes for students prior to starting medical school38; identifying those at risk of struggling with their exams and providing support before problems emerged; spending more hours each week in small group teaching and expanding peer support. And the result? The failure rate of African-American students decreased by 93.6%.

  More recently, in 2012 a new state-funded medical school in Camden, New Jersey – the Cooper Medical School of Rowan University – matriculated its first class39. The mission of the school is to attract students who will serve the local community, 96% of whom are African-American or Hispanic. Like the University of Texas Medical Branch – this new medical school also includes pipeline programmes prior to starting medical school as well as pre-matriculation support. Then there are curricular initiatives such as only having pass-fail grades in the first couple of years, and an emphasis on small-group teaching and peer-tutoring rather than large formal lectures. There’s also a mandatory service-learning component from the beginning of the first year so that all students make significant contributions to the Camden community – one of the poorest in the US.

  The first cohort at Cooper Medical School graduated in 2012; only one student failed to gain a residency and the school as a whole gained national recognition from the AAMC for its service-learning programme. I strongly suspect that faculty at these institutions don’t see an African-American face in the lecture theatre and enquire whether they are there to mend the lights. And I don’t imagine that students would put on a theatrical performance that lampooned staff members who were black, or gay, or disabled. I’m not so naïve as to imagine that students don’t find themselves on the receiving end of, or overhear, all sorts of examples of unconscious bias. But if there’s enough good stuff in the learning environment – supportive faculty and colleagues coupled with plenty of opportunities to develop a strong sense of professional confidence – the risks of failure can be substantially mitigated.

  Perhaps, just perhaps, a small imperceptible change is afoot. A 2017 article in the journal Academic Medicine has the title ‘Breaking the Silence: Time to Talk About Race and Racism40.’ The article begins with a quote from the African-American novelist James Baldwin:

  ‘Not everything that is faced can be changed, but nothing can be changed until it is faced.’

  How true.

  8

  No Exit

  THE FIRST THING Bijal told me was that he didn’t want to put patients at risk. He ended up double-checking everything he did on the ward because he was so anxious about getting something wrong. The second thing he said was that he was terrified of having another breakdown. These two statements were not unrelated. Bijal was a junior doctor who had a breakdown in his third year of medical school at the point when he started having contact with patients. Although, with extra time, he had managed to finish his undergraduate studies and start his foundation training, the pressure of clinical practice had precipitated recurrent breakdowns. Bijal came to see me four years after he had graduated from medical school; he was working part-time, and still trying to complete his first foundation year. His peers at medical school were way ahead of him on the clinical career ladder, and he had lost contact with most of them.

  Bijal questioned whether it was feasible for him to complete his first foundation year. The foundation programme regulations state that doctors have to work in more than one placement in order to pass the year, and there was no way round this formal requirement. Yet each time he attempted to move to a different placement he became unwell. However, if you can’t get through the first foundation year, your medical career is over.

  In our first session Bijal came armed with a shopping list of possible alternative careers, none of which he felt were quite right. Colleagues had suggested medical journalism, or working in the pharmaceutical sector. Or perhaps he could become a dietitian or a speech and language therapist? But he also worried that working alongside doctors in a different healthcare profession might constantly remind him of what he saw as his failure to complete his medical training.

  Bijal was stuck.

  In our second session, I asked Bijal to draw his ‘lifeline’ – a visual depiction of the ups and downs of his life to date.

  ‘Every time I change work I get sick,’ Bijal told me, looking down at what he had drawn.

  But the problem, as he knew, is that you can’t progress your medical career by staying put. It was pretty obvious that Bijal had no future in medicine. And towards the end of the session he acknowledged this reality, when he told me that he was ‘80–90% sure’ that he would have to leave clinical practice.

  Yet although Bijal was on the cusp of accepting that a medical career wasn’t going to work, there was an additional problem. Helping him to move on also involved helping him to change the mind of his training programme director, who was hell-bent on ensuring that Bijal at least completed the first foundation year. She told me she would feel that she had failed in her duty as programme director if Bijal couldn’t take his career this far. But by pushing Bijal to continue, when each change of job ended up with him having another breakdown, the consultant was actually prioritising her own fear of failure over what was best for her trainee.

  What Bijal taught me is that leaving medicine is rarely straightforward. Despite the persistent stereotype of the Asian family who put pressure on their children to become doctors, Bijal’s family were resigned to him leaving the profession. His parents had seen how unwell he had been at different stages of his training, and they didn’t want him to endure a lifetime of mental illness. But even with parental acceptance that a career switch was necessary, Bijal was still unable to decide what to do.

  My starting point for helping Bijal was to explore whether there were any aspects of working as a junior doctor that he had enjoyed. For Bijal, all the clinical tasks that he was supposed to be getting on with – taking blood, listening to a patient’s heart or chest, interpreting blood test results or prescribing drugs – typically felt overwhelming. But Bijal became quite animated when he described how he liked searching the Internet to find clear information leaflets on relevant clinical topics to give to patients when they were being discharged from hospital. Bijal enjoyed researching good information sources, and helping patients. He just didn’t want the pressure of being responsible for their clinical care.

  In the next session Bijal told me that he wanted to have predictability in his work as he found uncertainty too daunting. He also wanted the option of working part-time and hoped to find a career with reasonable job security. ‘If I do become ill again, I want a job where the work will still be there for me, once I recover,’ was ho
w he put it.

  I started to wonder whether Bijal would be better suited to working as an academic librarian. Initially the idea came to mind after he told me how much he enjoyed researching information for patients. But I also thought the profession would provide a working environment capable of withstanding periods when he was not well enough to work. Bijal was interested in the suggestion and over the course of the next couple of months went to talk to some librarians, researched different training courses that would enable him to switch profession, and did an internship in an academic medical library.

  At a session a couple of months later Bijal reported that he had loved his internship. But still he had doubts. What about the length of training? And had we considered all the different career options that might suit him? Bijal’s intense dislike of uncertainty made the practice of clinical medicine extremely stressful for him. And this dislike also impacted on how he approached a major career decision. He needed to feel absolutely certain that librarianship was the right way forward. Feelings of absolute certainty eluded him.

  A few months later, Bijal made a decision. After four years of trying to complete the first foundation year and seeing me quite regularly over a six-month period, Bijal was ready to move on. He emailed me from time to time to tell me about his progress. Shortly after starting his new training I saw an advert for a part-time assistant librarian in an academic institution near to where he was studying. I forwarded it to him, and in turn he let me know that he had applied for the post and had been appointed. At the end of the course he contacted me to tell me that he had been awarded a distinction.

  Then there was silence for a couple of years, so I was surprised to receive an email from him asking if we could meet up. On the ‘no news is good news’ principle, I feared that he wanted to see me because this new career had started to unravel. I was wrong. He wanted to talk to me because he was wondering whether or not to embark on a PhD. He also wanted to tell me that while working as the part-time librarian on the evening shift, he regularly found himself going home on the same bus as a graduate student who was using the library. Over the weeks they had started chatting on the bus, then he asked her out, and a few months ago they had got married. As I had sent the job details to him in the first place, he wanted to thank me for helping him meet his wife!