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Causes of differential attainment in UK postgraduate medical training: a national qualitative study

Journal: BMJ Open

Manuscript ID bmjopen-2016-013429

Article Type: Research

Date Submitted by the Author: 11-Jul-2016

Complete List of Authors: Woolf, Katherine; University College London Medical School, Research Department of Medical Education Rich, Antonia; University College London Medical School, Research Department of Medical Education Viney, Rowena; University College London Medical School, Research Department of Medical Education Needleman, Sarah; University College London Medical School, Research Department of Medical Education

Griffin, Ann; University College London Medical School, Research Department of Medical Education

<b>Primary Subject Heading</b>:

Medical education and training

Secondary Subject Heading: Qualitative research

Keywords: EDUCATION & TRAINING (see Medical Education & Training), QUALITATIVE RESEARCH, postgraduate education, ethnicity, diversity, international medical graduate

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Causes of differential attainment in UK postgraduate medical

training: a national qualitative study

Dr Katherine Woolf, Senior Lecturer in Medical Education1

[email protected]

Dr Antonia Rich, Research Associate1

Dr Rowena Viney, Research Associate1

Dr Sarah Needleman, Clinical Teaching Fellow1

Dr Ann Griffin, Senior Lecturer in Medical Education2

1 Research Department of Medical Education

UCL Medical School

Room GF/664, Royal Free Hospital

London NW3 2PF

2Research Department of Medical Education

UCL Medical School

74 Huntley Street

London WC1E 6AU

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Structured abstract

Objectives

Explore trainee doctors’ experiences of postgraduate training and perceptions of fairness in

relation to ethnicity and country of primary medical qualification.

Design

Qualitative semi-structured focus group and interview study.

Setting

Postgraduate training in England (London, Yorkshire & Humber, Kent Surrey and Sussex) and

Wales.

Participants

137 participants (96 trainees, 41 trainers) were purposively sampled from a framework

comprising: doctors from all stages of training in General Practice, Medicine, Obstetrics &

Gynaecology, Psychiatry, Radiology, Surgery or Foundation, in four geographical areas, from

white and black and minority ethnic (BME) backgrounds, who qualified in the UK and

abroad.

Results

Most trainees described difficult experiences, but BME UK graduates and international

medical graduates could face additional difficulties that affected their learning and

performance. Relationships with senior doctors were crucial to learning but unconscious

bias was perceived to make these relationships more problematic for BME UKGs and IMGs.

IMGs also had to deal with cultural differences and lack of trust from seniors, often looking

to IMG peers for support instead. Workplace-based assessment and recruitment were

considered vulnerable to unconscious bias whereas examinations were typically considered

more rigorous. In a system where success in recruitment and assessments determines

where in the country you can get a job, and where work-life balance is often poor, UK BME

and international graduates in our sample were more likely to face separation from family

and support outside of work, and reported more stress, anxiety, or burnout that hindered

their learning and performance. A culture in which difficulties are a sign of weakness made

seeking support and additional training stigmatising.

Conclusions

BME UKGs and IMGs can face additional difficulties in training which may impede learning

and performance. Non-stigmatising interventions should focus on trainee-trainer

relationships at work and organisational changes to improve trainees’ ability to seek social

support outside work.

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Strengths and Limitations of this study

• This is the first study to explore how ethnicity affects UK-qualified doctors’ experiences

of postgraduate medical training. It therefore provides valuable insights into the causes

of Black and Minority Ethnic UK graduates’ underperformance in postgraduate

assessments and recruitment, and provides a basis upon which interventions to reduce

differential attainment can be developed and evaluated.

• The study has a large and diverse sample, comprising trainees from white and Black and

Minority Ethnic backgrounds, UK and international graduates, across six medical

specialities, four geographical areas in England and Wales, and all training grades. It also

includes trainers, programme directors and postgraduate deans. This allows in-depth

analysis of the issues from a range of perspectives.

• Selection bias is a possibility, although the data showed a wide variety of views. Related

to that, data were collected in November and December 2015 during the junior doctor

contract dispute which may have led to trainees vocalising greater discontent with their

training than usual, although the findings did not suggest doctors from dissimilar

backgrounds perceived the new contract differently.

• Low recruitment from some specialties, for example Radiology, did not permit

comparison of potential differences between specialties.

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Introduction

International medical graduates (IMGs) are more likely to fail postgraduate assessments and

have poorer outcomes in recruitment in the United Kingdom (UK), United States (US),

Canada, and Australia (1-6). Doctors from Black and Minority Ethnic (BME) groups also have

poorer academic and recruitment outcomes compared to white doctors in the UK, US,

Netherlands, and Australia (1, 7-9) and in higher education more generally (10, 11) (12).

These group differences are known as differential attainment and pose a significant problem

for the medical profession. Healthcare provision relies on IMGs (1, 13); and medicine is a

very popular choice for BME students (14). In the UK public authorities such as universities,

Royal Colleges, and the National Health Service (NHS) have a legal duty to address

differences between groups with and without the protected characteristic of ‘race’ (which

covers “race, colour, and nationality (including citizenship) ethnic or national origins”) (15).

In 2014 the Membership of the Royal College of General Practitioners (MRCGP) examination

and the General Medical Council were brought to judicial review over differential

attainment (16) (15) raising the profile of the problem.

IMGs are known to face challenges including adapting to a new culture and style of teaching

and learning, new language, change in hierarchy, discrimination, and the psychological

impacts of migration (17) (18) (19) (20). Much less is known about the causes of the ethnic

attainment gap among UKGs, and it is unclear whether IMGs and BME UKGs have

experiences in common. A 2015 GMC-commissioned rapid review of the literature (21)

highlighted a lack of consensus and research about the causes of the ethnic attainment gap

in UKGs. There is however general agreement that examiner unconscious bias or overt

discrimination is unlikely to be the sole cause in examinations in medicine because

differential attainment is seen in written machine marked multiple choice examinations (22)

and research into two postgraduate clinical examinations found no evidence of bias (23, 24).

This has shifted the focus of differential attainment research onto understanding

experiences and opportunities.

This shift is reflected in a recent Higher Education Funding Council England (HEFCE)-

commissioned report into causes of ethnic differences in UK higher education (HE) (25).

Four categories of explanatory factors were identified: 1) students’ experiences of HE

learning, teaching, and assessment; 2) relationships that underpin students’ experiences of

HE; 3) psycho-social and identity factors and 4) cultural and social capital factors. This report

was important because it moves understanding on from the “deficit model” whereby

differences are attributed to student deficits such as poorer previous attainment, lower

motivation, poorer preparation for university, none of which can fully explain ethnic

differences (26, 27). The current study was part of a General Medical Council-funded

workstream on differential attainment, and aimed to explore trainee doctors’ experiences

of postgraduate medical training and their perceptions of its fairness, using the HEFCE

framework as a guide to identify causes of differential attainment by ethnicity and country

of qualification (UK vs non-UK).

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Methods

Design

We took a qualitative approach to gain understanding of trainees’ lived experiences of

training and progression.(28) Data were gathered in focus groups and one-to-one interviews

in person and over the phone, using a semi-structured interview guide (see Appendix).

Trainee experiences were contextualised by views of trainers, programme directors and

postgraduate deans. All participants received a certificate of participation and focus group

members received refreshments.

Participant sampling framework and recruitment

In UK medical training, an undergraduate medical course is followed by postgraduate

training comprising two Foundation years and then specialty training. In England

postgraduate training is organised into geographical areas administered by Health Education

England (HEE) Local Education and Training Boards (LETB’s); in Wales it is organised by the

Welsh Deanery.

We sampled across five LETBs in England (Kent Sussex and Surrey; North Central and East

London, North West London, South London, Yorkshire and Humber), the Welsh Deanery,

and the corresponding Foundation Schools, all chosen because they have varying

proportions of IMGs/UKGs, and varying average postgraduate examination performance.

Our sampling frame included trainees from four ethnic/country groups (BME UKG, white

UKG, BME IMG, and white IMG), from six specialities with differing competition ratios and

proportions of IMGs/UKGs and white/BME doctors (Medicine, Surgery, Psychiatry, General

Practice, Clinical Radiology, Obstetrics & Gynaecology) plus Foundation Training, and across

training (Foundation, Specialty Training (ST) Years 1-3, and 4+) as well as doctors who had

failed to progress in their training, or who had completed their training within the last year.

Participants were eligible if they were currently in training, had recently completed training,

or had failed to progress, or were trainers in one of the specialties or Foundation in one of

the geographic regions. We recruited purposively from within our sampling frame. All

participating organisations emailed invitations to all trainees and trainers. We recruited at

courses in London and advertised. Eligible participants were invited to attend focus groups

locally or to be interviewed. Due to high interest we chose participants deliberately to

populate our sampling frame.

Analysis

We adapted Mountford-Zimdars et al’s (25) analytic framework to fit medical workplace

training. We also allowed themes and sub-themes to arise from the data during analysis.

Data were analysed in QSR NVivo 10©. Three researchers (RV, AR, KW) read all the

transcripts and developed an initial coding framework, seeking negative examples to refine

codes. Each researcher coded three transcripts independently and then came together to

refine the framework. One researcher (RV) then coded all the transcripts and four others

double-coded a selection. Discrepancies were discussed and agreed.

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Ethical approval

Ethical approval was granted by the University College London Ethics Committee reference:

0511/11. Participants gave informed consent before taking part.

Results

Participants

392 trainees and trainers expressed interest and 137 (96 trainees including 1 post-CCT & 1

who failed to progress; 41 trainers) participated. Data were gathered in November and

December 2015 in 13 focus groups and 35 one-to-one interviews with trainees, and 3 focus

groups (all GPs at HEKSS) and 14 one-to-one interviews with trainers. Participant

demographics are shown in Figure 1.

Figure 1. Participant demographics

Perceived causes of differential attainment

Most trainees had experienced difficulties but several themes were identified that described

how additional difficulties faced by BME UKGs and/or IMGs could cause differential

attainment. These themes are described below and relationships between themes are

depicted in Figure 2.

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Figure 2. Relationships between the main themes describing the difficulties faced by BME UKGs and/or IMGs that could cause differential attainment. They are coloured according to four categories of causal factors: relationships at work (green), curriculum and learning (blue), psycho-social and identity (orange), and cultural and social capital (yellow). Arrows show the direction of the relationship e.g. cultural differences can affect relationships with seniors and peers.

Relationships with senior doctors

Relationships with senior doctors were perceived as crucial to learning. The best seniors

gave trainees confidence by providing them with opportunities to take responsibility for

patients, giving constructive feedback, and reassuring about problems including exam

failure. Building confidence was especially important in extremely busy understaffed or

disorganised environments in which trainees had little choice but to take responsibility.

When seniors did not believe in trainees’ abilities, were bullying, blamed trainees, or were

perceived not to care, trainees’ confidence could be damaged for months, following them

into subsequent jobs. The same trainee could be treated positively by one senior and

negatively by another, hugely affecting confidence and success.

I had a six month experience with a boss where I learned how to be resilient, and I

learned how to take the knocks, but I didn’t learn a great deal […]. Whatever I could

do beforehand was questioned. […] I sort of just kept my head above the water. […]

After that [I] spent about a year basically getting my confidence back.

Asian Other UKG Male ST4+ Surgery

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From day 1 it was criticism. I had a college tutor walk up to me once and told me

“Anaesthetics is not for everybody, you can get a job as a resident medical officer”.

So that stayed at the back of my mind for quite another 5, 6 months while I was there.

It was getting unhealthy for me, I was getting a lot of psychological emotional stress,

so I decided before I leave anaesthetics let me see if other hospitals are like that. […]

And within the first month of me working [at another hospital] […] the college tutor

there, called me and said “you seem to be not confident about anything, and we’ve

had someone assess you, she thinks your skills are good […] just relax and pay

attention to the work”. [laughs] […] I decided to stay on with that encouragement,

with a little bit of effort, and I went on to finish my final anaesthesia fellowship.

Black IMG Male ST1-3 GP

BME UKGs and IMGs in our sample were less likely to report support from seniors in

pressurised situations and more likely to say seniors did not believe in them. There were

several potential reasons for this.

Cultural differences

Cultural differences could impede good educational relationships for IMGs. It was generally

agreed that IMGs who found it difficult to adapt to UK patient-centred care and who - even

if they spoke English a first language - struggled with colloquialisms, would struggle with

colleagues. UKGs felt IMGs would struggle with patients too and trainers including an IMG

reported difficulties teaching trainees who behaved culturally inappropriately. IMG trainees

felt cultural difficulties affected their relationships with colleagues more than with patients.

They described how difficult it could be to learn new cultural norms especially if they had to

‘unlearn’ previously acquired knowledge or if UK norms were very different.

I’ve been in this country for more than a decade now. It’s still a learning journey […]

I personally think that maybe there must be some time given us to relearn what we

have learnt already and then learn what we are supposed to learn.

Asian Indian IMG Female ST4+ Psychiatry

Lack of trust

Many IMGs felt UKG trainers did not appreciate the challenges they faced and trainers

reported finding it challenging to help some IMGs - one white UKG trainer wondered

whether differences were sometimes too large to be overcome. Only one trainer, a BME

UKG, said more effort should be made to help IMGs adjust. Many UKGs were concerned

that IMGs’ prior training - especially in communication skills – did not prepare them for UK

medicine, and thought IMGs may have attended medical schools with lower standards.

Some UKGs felt IMGs in or coming from locum jobs were poor at communicating and/or

disinterested in education; however many IMGs found it very frustrating that locum jobs did

not provide training opportunities, and several non-EEA IMGs and one foreign national UKG

said difficulties getting a visa or ineligibility prevented them getting jobs with good learning

opportunities. A few White UKGs said BME UKGs and IMGs were more likely to be pushed

into medicine.

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My experience probably comes from a lot of locum doctors who are trying to get

more established in the UK. I think perhaps there may be less trust from a senior

perspective to somebody coming into that environment and therefore you don't also

give them the time to help support as much as you would somebody who is in a more

permanent post here. […] I just feel a little bit unnerved when somebody hasn't

trained here.

Trainer White UKG Female Medicine

With time and effort trainers could bridge cultural gaps and get a better understanding of

trainees’ abilities. White UKGs trainers described how getting to know their IMG trainees

over several months built trust and understanding and led to positive outcomes; however

trainers did not always have that time. More junior trainees moved jobs frequently,

meaning relationships had to be formed quickly and trainees were under pressure to prove

themselves. This was perceived to disadvantage IMGs but also BME UKGs who were less

likely to “fit the mould” (Asian Pakistani UKG Female ST4+ Surgery).

Unconscious bias, belonging and fitting in

While reports of overt racism were rare, unconscious bias “a subtle ‘I feel more comfortable

with this person’” (Black IMG Male ST1-3 Medicine) was widely considered to be a cause of

differential attainment, especially the ethnic differences within UKGs.

I was with a GP a couple of weeks ago having a coffee with him. He's like, “Oh,

yeah, normally when we recruit people we look at whether they're going to mingle

with us, they're going to gel with the kind of background we are, whether they can

come to barbecues with my family”. I thought to myself, “That is what my dad had to

experience when he first came to this country and was rejected by society”.

Asian Pakistani UKG Female ST1-3 GP

F1: There’s still quite a lot of sponsorship that goes on. So rather than there being a

meritocracy in terms of mentoring, certain trainees will sponsored as the chosen ones.

And those factors that define chosen ones can be varied depending on speciality, so

they could include gender, ethnicity, where you went to school.

M1: Choice of sport.

F1: Who you’re married to.

F2: What your accent is.

F1: All sorts of things, I’ve seen it all, it still goes on.

F1: White UKG Female ST4+ Medicine

F2: White UKG Female ST1-3 Medicine

M1: White UKG Male ST4+ Medicine

Some BME UKGs remarked that it was only because they spoke with middle class accents

and went to a medical school with a good reputation that they didn’t suffer discrimination;

many IMGs felt their accent made people immediately question their ability, made them

less likely to be recruited, and more likely to fail exams. Several BME UKGs felt they had not

personally suffered discrimination, although in our sample BME UKGs were more likely than

white UKGs to believe that there was an ethnic attainment gap. One BME UKG described

why she didn’t want to think she had been discriminated against:

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I'm not going to start assuming [discrimination], because if you start assuming that,

that's a very slippery slope. You just then think, you become very paranoid. You start

thinking that everyone is out to get you. […] If you try and - this sounds really awful

saying this - but if you try and blend in and just get on with everyone and, you know,

you come across less problems. No one likes the one who's going to kick up a fuss or

start saying “Oh, it's because I'm an ethnic minority this, that and the other”. No, you

start getting yourself into problems if you start thinking like that.

Asian Other UKG Female ST1-3 Medicine

Many trainers acknowledged that unconscious bias could exist but white trainers were more

likely to say medicine was unbiased. A GP trainer said that he felt as a white UK male he

had the fewest opportunities. By contrast, a BME trainer remarked “you are probably less

likely to be successful the more different you are from the people assessing you” (Trainer

Black UKG Medicine).

Relationships with peers

Peers provided practical support and advice, solidarity, understanding, and emotional

support. Trainees tended to seek support from others within the same cultural group, even

within the UKG group:

Ever since medical school I’ve pretty much hung around with the ethnic minority

people, I don’t know why actually. And then you see other groups that are all white.

Mixed UKG Female ST1-3 GP

UKGs describe organising opportunities to get together in person or online to share

knowledge and provide emotional support – something they felt IMGs missed; however

many IMGs said they particularly valued the opportunity to meet other IMGs who could be

trusted to understand and not to judge, and described supporting junior IMG colleagues. A

few IMGs felt integration and immersion in UK culture was important.

Hidden curriculum: the culture of medicine

Medicine was perceived as a vocation that demanded hard work, long hours and personal

sacrifice, and where success or failure is largely determined by individual factors such as

motivation. Experiencing difficulties was a sign of weakness, meaning trainees felt they were

not always given the support needed to learn or were blamed for problems that weren’t

their fault. IMGs could feel stigmatised or disadvantaged by attending extra courses.

Reputations were thought to follow trainees between jobs, which made it hard to report

bullying including race-related problems. This was perhaps amplified for IMGs and BME

UKGs who were more likely to report seniors not believing in or trusting them.

I've gotten used to sometimes if I tell people I'm an ST7 in Medicine they almost

seem surprised.

Black UKG Female ST4+ Medicine

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Just imagine someone starting on F2 being told to stay in an Acute Care bay, which is

the really deep end. […] The next morning I called the consultant, it was a professor,

and I told him that I struggled overnight, and unfortunately […] the registrar was not

very supportive that night, and I told him that I struggled overnight, I think I should

be in a place where I could grow. […]. But unfortunately that experience was

misinterpreted […] for being a weakness. […] [My educational supervisor] told me

that “Oh you need to go back to become an F1”. […] I was in tears.

Black IMG Male ST1-3 Medicine

Fairness of assessments and recruitment

Royal College examinations were generally perceived as more rigorous and fair than Annual

Review of Competence Progression assessments and recruitment. UKGs were more critical

of ARCPs than IMGs, who were more critical of Royal College examinations. UKGs felt ARCPs

could depend on good relationships with colleagues who would sign them off at the last

minute and complete their multi-source feedback positively, and this could be harder for

IMGs and BME UKGs; however IMGs were more likely to feel ARCPs were fair because all

trainees have to tick the same boxes. Participants from all groups believed recruitment was

vulnerable to unconscious bias and some UKG trainers had concerns about employing IMGs.

IMGs described being ineligible for some training jobs.

The employers are going to look for someone who can be well integrated in their team

and they might not see that in you as an ethnic minority even though it's not

something that they would outright say. That's why I always say it's very subtle. They

might look for something else and blame it on that: “Oh, it's because you don't have

enough experience at this or that”. Even though your CV actually might match your

colleague or even be better than your colleague's.

Black UKG Female Foundation

If somebody had trained in another country and you didn't have confidence in the

registration of that qualification in that country, the people are going to be to the same

standard, you might be less happy to recruit people from that environment.

Trainer White UKG Male GP

IMG and BME UKG trainees thought communication in examinations was different from real

life and described learning to “play the game” (Black IMG Male ST1-3 GP) to pass.

Confidence was perceived as important to pass clinical exams but IMGs were less confident

because they worried their accent would disadvantage them, they knew they were

statistically more likely to fail, and they knew colleagues who were good clinically who had

failed. Reassurance and practical support from seniors was important to build confidence.

Trainers were more positive about ARCPs, the main criticism being that panels passed

trainees they shouldn’t. Trainers felt examinations were robust and fair (many were

involved in examining), even if they were harder for candidates who were unfamiliar with

UK culture and language.

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Work-life balance

Trainees valued emotional and practical support from partners and families especially when

they were having difficulties at work; but long hours, inflexible training, and lack of family-

friendly attitudes made it hard to get this support. Trainees lacked autonomy about where

they worked and lived, especially those who did not score as highly at medical school or in

recruitment tests, which is perhaps why BME UKGs and IMGs talked more frequently about

ending up separated from family and the pressure this entailed.

M1: The year apart. We've tried a year so I deferred for a year but still couldn't start

and all my wife and kids couldn't move up. We spent a year commuting from

Sheffield to Bristol. […]

M2: You can't give up a [training] number, that's just a golden ticket. It's really career

or family sometimes. It's tough.

M1: Arab UKG Male ST4+ Surgery

M2: White IMG Male ST4+ Surgery

Impact of work on wellbeing

BME UKGs and IMGs in our sample were more likely to mention mental health problems

caused by work stresses including problematic relationships with colleagues that lowered

confidence, burnout, social isolation, and lack of pastoral support. These problems impeded

learning and performance at work.

F1: I feel, like, on constant level of burnout […] So unless I either declare myself- if I

say I’ve actually got depression and I’m unfit to practice, then there is no way. I’ve

been quiet before about…

F2: […] I was at the point, like everyone is, when they’re working where just an

entire 3 months of just not sleeping at night because you’re just so worried about the

next day and how you’re going to manage.

F1: Asian Indian UKG Female ST1-3 Psychiatry

F2: Asian Indian UKG Female ST1-3 Medicine

I did not have any work experience, neither back home nor here. And also my

Foundation training was up North and then I left my daughter and my husband here in

London. […] I was really anxious during that time.[…] I could not pay attention to

what was going on. […] [My educational supervisor] said “Okay, if you cannot work

like this then probably you need to, you may need to think about changing your

career”’ […] Medicine has always been my passion. I cannot think doing anything

else apart from that. I got really upset.’

Asian Pakistani IMG Female ST1-3 Psychiatry

Many IMGs and two BME UKGs talked about the psychological pressure of knowing that

they may be subject to negative stereotyping or failure, with one IMG wondering whether

“we just aren’t as clever as the local trainees” (Asian Other IMG Male ST4+ Surgery).

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During my training I have seen lots of local trainees or white doctors, they are not

doing that much work, and then in fact the other doctors - we are immigrant doctors -

they have been given more work to do, and then they still do it, but they are still

considered inefficient. […] We need to work twice as much as, twice as hard as the

local trainees does to be half as good as they are.


I'm expecting to get a lower mark because I'm- I know it's a stupid way of thinking

but actually it got to the point where I was thinking “What is it? Am I…?” I wasn't

sure if it was my knowledge anymore, I wasn't sure if it was my confidence, I wasn't

sure if it was my skin colour. So you start-I think it creates almost like a nasty way of

thinking and how you perceive yourself to be. And if that someone's expectation of

you is low subconsciously, your performance will be low.

Black UKG Female ST4+ Psychiatry

Discussion

Statement of principal findings

In this national study of trainees’ experiences of postgraduate medical training, most

trainees reported difficulties, but BME UKGs and IMGs faced additional difficulties that

impeded learning and performance. Relationships with senior doctors were considered

crucial to learning but were more problematic for BME UKGs and IMGs, which was

perceived to result partly from unconscious bias. IMGs faced cultural differences and lack of

trust from seniors, and many looked to IMG peers for support instead. A culture in which

success is determined by drive and ability, and difficulties are a sign of weakness could make

it hard to access support, and additional training for IMGs could be stigmatising. Workplace

based assessment and recruitment were widely considered vulnerable to unconscious bias

whereas examinations were considered more rigorous. Relationships outside work were an

important source of emotional support but lack of work-life balance and lack of autonomy

about geographical location of work could mean separation from family, especially for BME

UKGs and IMGs, several of who reported mental health problems that impacted on work.

Strengths and weaknesses of the study

This large-scale qualitative study provides new insights into the causes of ethnic differences

in attainment among UK graduates, which to date have been little understood, making it

difficult to develop interventions. This study points to several areas for interventions to

focus on. The study is novel in exploring similarities in the causes of differential attainment

within UKGs and between UKGs and IMGs, facilitating the development of interventions to

address both.

Our analysis was based upon factors identified in an international study of higher education

(25) reflecting that differential attainment is a widespread problem. Our study aimed to

understand the issues in depth rather than to provide statistical generalisations; however its

theoretical foundations allow theoretical generalisability (29). Trainee interviews were

contextualised by trainer interviews; interviewees were purposively sampled to provide a

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spread across different specialties, geographic areas, and stages of training; and the data

were analysed by a linguist, psychologists, and two clinicians - all of which improved

reliability and validity.

Poor recruitment from some specialties, for example Radiology, didn’t allow us to look at

differences between specialties. The large number of GP trainers could have skewed the

trainer findings, although we also interviewed 14 trainers from hospital medicine. With all

research it is possible that participants had particular reasons for taking part. Data were

collected in November and December 2015 just after junior doctors in England voted to

strike over the Government’s imposition of a new contract (30). This may have encouraged

participants to speak negatively about their training, but there is little to suggest that white

and BME doctors or IMGs and UKGs view the concerns surrounding junior doctor contracts

differently.

Strengths and weaknesses in relation to other studies, discussing important

differences in results

The central role of the teacher-learner relationship in medical and other adult education is

well known (31, 32), and teacher-learner relationships in medical students but not doctors

can be impeded by ethnic differences (33) (34). The perception that bias can affect learning

is reflected by national surveys reporting that newly-qualified BME UKGs were less likely to

agree “The NHS is a good equal opportunities employer for doctors from ethnic minorities”

(35) and were less satisfied with their training (36) although IMGs were more satisfied than

UKGs (36). It may be that IMGs have different expectations – one IMG in our study expected

to be discriminated against feeling it was natural to prefer one’s own (Black IMG ST1-3

Medicine). IMGs in our study reported worrying they were going to fail or be disadvantaged

in examinations – a form of stereotype threat that impedes minority students’ performance

in education generally (37) but has been relatively under-studied in medical education. The

culture of long hours, hard work, lack of work-life balance, and difficulties being a sign of

weakness is well-known (38) but previous research has not to our knowledge considered

whether it may adversely affect BME or IMG doctors particularly, although lack of social

support in IMG psychiatrists in the US is associated with increased mental health problems

(39). The finding that trainees tended to seek support among their own cultural group fits

with previous medical school research (34, 40).

Meaning of the study: possible explanations and implications for clinicians and

policymakers

Trainers need time to develop good relationships with trainees, which can be difficult due to

clinical pressures. While unconscious bias training exists, more could be done to raise

awareness of the potential of even quite subtle bias to affect minority trainees during

training as well as during assessments; but care should be taken to avoid stigmatising

trainees with interventions. A lack of work-life balance and autonomy over job locations

could prevent trainees from benefitting from social support outside work and affected their

wellbeing. This may be especially problematic for BME UKGs and IMGs who - because of

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poorer academic performance - may have even less choice, and thus be more likely to be

socially isolated and suffer mental ill-health, which could impact patient care. Changes to

systems to increase work-life balance and autonomy have the potential to reduce

differential attainment.

Unanswered questions and future research

Further research is needed to determine the prevalence of the problems identified within

the entire population and to examine how organisational systems affect the relationships

and wellbeing of trainees from different ethnic and cultural groups, especially as doctor

wellbeing impacts patient care (41). There is increasing evidence about the fairness of Royal

College examinations, but more work is needed to examine the fairness of all assessments

especially workplace based assessments and recruitment. The research provides the basis

for interventions but these need to be developed, trialled, and rigorously evaluated.

Funding

The research was funded by the General Medical Council who were involved in designing

the study, were kept informed of progress with the collection, interpretation and analysis of

the data, and approved this report before submission. The researchers remained

independent from the funders.

Competing interests

All authors have completed the ICMJE uniform disclosure form at

www.icmje.org/coi_disclosure.pdf and declare: all authors except Sarah Needleman had

financial support from the General Medical Council who commissioned this research;

Katherine Woolf receives a fee as educational consultant to the Membership of the Royal

College of Physicians (UK) Examination. No authors have any other relationships or activities

that could appear to have influenced the submitted work.

Details of contributors

KW and AG designed the study in response to a tender from the General Medical Council.

RV, AR, KW and SN carried out the field work. RV, AR, and KW analysed and interpreted the

data with input from AG and SN. KW drafted the manuscript and is the guarantor. All

authors revised it critically for important intellectual content and approved the final version

for publication. All authors agree to be accountable for all aspects of the work.

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Transparency Declaration

Katherine Woolf affirms that the manuscript is an honest, accurate, and transparent

account of the study being reported; that no important aspects of the study have been

omitted. This research was funded by the General Medical Council, and the report on the

full findings can be found here http://www.gmc-uk.org/about/research/23658.asp . The

current paper describes the main causes of differential attainment and a separate paper will

describe the protective processes that allowed BME UKGs and IMGs to achieve positive

outcomes despite this. There were no discrepancies from the study as planned.

Exclusive License

The Corresponding Author has the right to grant on behalf of all authors and does grant on

behalf of all authors, a worldwide licence

(http://www.bmj.com/sites/default/files/BMJ%20Author%20Licence%20March%202013.doc) to the

Publishers and its licensees in perpetuity, in all forms, formats and media (whether known

now or created in the future), to i) publish, reproduce, distribute, display and store the

Contribution, ii) translate the Contribution into other languages, create adaptations,

reprints, include within collections and create summaries, extracts and/or, abstracts of the

Contribution and convert or allow conversion into any format including without limitation

audio, iii) create any other derivative work(s) based in whole or part on the on the

Contribution, iv) to exploit all subsidiary rights to exploit all subsidiary rights that currently

exist or as may exist in the future in the Contribution, v) the inclusion of electronic links

from the Contribution to third party material where-ever it may be located; and, vi) licence

any third party to do any or all of the above. All research articles will be made available on

an Open Access basis (with authors being asked to pay an open access fee—

seehttp://www.bmj.com/about-bmj/resources-authors/forms-policies-and-checklists/copyright-open-

access-and-permission-reuse). The terms of such Open Access shall be governed by a Creative

Commons licence—details as to which Creative Commons licence will apply to the research

article are set out in our worldwide licence referred to above.

Data sharing

No additional data available.

Acknowledgements

Huge thanks to all the participants who gave their time, to Catherine O’Keeffe and Lynne

Rustecki at London’ Professional Support Unit Health Education England for their support

and advice, the administrators at the LETB’s, the Welsh Deanery and UCL Medical School

who helped gather data, Marcia Rigby who managed the research process, and the project

steering group who guided the research.

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References

1. The State of Medical Education and Practice in the UK. London: General Medical Council, 2015.

2. Examination USML. USMLE Performance Data 1996-2014 2016 [Available from: http://www.usmle.org/performance-data/default.aspx#2014_step-1

3. Leaving our mark: 2014-2015 Annual Report. Ottawa: Medical Council of Canada, 2015.

4. Falcone JL, Middleton DB. Performance on the American Board of Family Medicine Certification Examination by Country of Medical Training. The Journal of the American Board of Family Medicine. 2013;26(1):78-81.

5. Amod KB, V; Daniel,A. Analysis of performance and predictors of success in the final fellowship examination of the College of Intensive Care Medicine. Critical Care and Resuscitation. 2015;17(1):3.

6. Results and Data 2015 Main Residency Match®. Washington DC: National Resident Matching Program, 2015.

7. Kleshinski J, Khuder SA, Shapiro JI, Gold JP. Impact of preadmission variables on USMLE step 1 and step 2 performance. Advances in Health Sciences Education. 2007;14(1):69-78.

8. Stegers-Jager KM, Steyerberg EW, Cohen-Schotanus J, Themmen APN. Ethnic disparities in undergraduate pre-clinical and clinical performance. Medical Education. 2012;46(6):575-85.

9. Pilotto LDGA-WJ. Issues for clinicians training international medical graduates: a systematic review. Medical Journal of Australia. 2007;187:3.

10. Differences in degree outcomes: Key findings. Higher Education Funding Council England, 2014.

11. Zwysen WL, S. Labour market disadvantage of ethnic minority British graduates: university choice, parental background or neighbourhood? Essex: University of Essex, 2016 Contract No.: 2016-02.

12. Fletcher J, Tienda M. Race and Ethnic Differences in College Achievement: Does High School Attended Matter? The Annals of the American Academy of Political and Social Science. 2010;627(1):144-66.

13. Pettigrew LM. The NHS and international medical graduates. Education for Primary Care. 2014;25(2):71-5.

14. Higher Education Statistics Agency. Table 6a - Full-time HE student enrolments by level of study, subject area**, sex, age group, disability status and ethnicity 2014/15 2014 [Available from: https://www.hesa.ac.uk/free-statistics.

15. Equality Act, 2010. London: Stationery Office.

16. Richens D, Graham TR, James J, Till H, Turner PG, Featherstone C. Racial and Gender Influences on Pass Rates for the UK and Ireland Specialty Board Examinations. Journal of Surgical Education. 2016;73(1):143-50.

17. Pilotto LS, Duncan GF, Anderson-Wurf J. Issues for clinicians training international medical graduates: a systematic review. Medical Journal of Australia. 2007;187(4):225-8.

18. Chen PG-C, Nunez-Smith M, Bernheim SM, Berg D, Gozu A, Curry LA. Professional Experiences of International Medical Graduates Practicing Primary Care in the United States. Journal of General Internal Medicine. 2010;25(9):947-53.

19. Rothwell C, Morrow G, Burford B, Illing J. Ways in which healthcare organisations can support overseas-qualified doctors in the UK. International Journal of Medical Education. 2013;4:75-82.

20. Khan FA, Chikkatagaiah S, Shafiullah M, Nasiri M, Saraf A, Sehgal T, et al. International Medical Graduates (IMGs) in the UK—a Systematic Review of Their Acculturation and Adaptation. Journal of International Migration and Integration. 2014;16(3):743-59.

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18

21. Regan de Bere SN, S; Nasser, M. Understanding differential attainment across medical training pathways: A rapid review of the literature Final report prepared for The General Medical Council. Plymouth University, 2015.

22. Woolf K, Potts HWW, McManus IC. Ethnicity and academic performance in UK trained doctors and medical students: systematic review and meta-analysis. BMJ. 2011;342.

23. McManus IC, Elder AT, Dacre J. Investigating possible ethnicity and sex bias in clinical examiners: an analysis of data from the MRCP(UK) PACES and nPACES examinations. BMC Medical Education. 2013;13(1):1-11.

24. Denney M, Wakeford R. Do role-players affect the outcome of a high-stakes postgraduate OSCE, in terms of candidate sex or ethnicity? Results from an analysis of the 52,702 anonymised case scores from one year of the MRCGP clinical skills assessment. Education for Primary Care. 2015:1-5.

25. Mountford-Zimdars AS, D; Moore, J; Sanders, J; Jones, S; Higham, L. Causes of Differences in Student Outcomes,. Higher Education Funding Council for England, 2015.

26. Singh G. Black and minority ethnic (BME) students’ participation in higher education: improving retention and success. 2011 29-06-2011. Report No.

27. Stevenson J. Black and minority ethnic student degree retention and attainment. Higher Education Academy, 2012.

28. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3(2):77-101.

29. Barbour RS. Making sense of focus groups. Medical Education. 2005;39(7):742-50.

30. Billingsley MG, G Timeline of the junior doctors contract dispute. Student BMJ. 2015;23.

31. Eraut M. Informal learning in the workplace. Studies in Continuing Education. 2004;26(2):247-73.

32. Haidet P, Stein HF. The Role of the Student-Teacher Relationship in the Formation of Physicians. Journal of General Internal Medicine. 2006;21(S1):S16-S20.

33. Woolf K, Cave J, Greenhalgh T, Dacre J. Ethnic stereotypes and the underachievement of UK medical students from ethnic minorities: qualitative study. BMJ. 2008;337.

34. Vaughan S, Sanders T, Crossley N, O'Neill P, Wass V. Bridging the gap: the roles of social capital and ethnicity in medical student achievement. Medical Education. 2015;49(1):114-23.

35. Lambert T, Surman G, Goldacre M. UK doctors and equal opportunities in the NHS: national questionnaire surveys of views on gender, ethnicity and disability. Journal of the Royal Society of Medicine. 2014;107(10):398-408.

36. Gill D. The association between trainee demographic factors and self-reported experience: Analysis of General Medical Council National Training Survey 2014 and 2015 data. JRSM Open. 2016;7(4).

37. Nguyen HD, Ryan AM. Does Stereotype Threat Affect Test Performance of Minorities and Women? A Meta-Analysis of Experimental Evidence. Journal of Applied Psychology. 2008;93(6):1314-34.

38. Haidet P, Stein HF. The role of the student-teacher relationship in the formation of physicians. The hidden curriculum as process. Journal of General Internal Medicine. 2006;21 Suppl 1:S16-S20.

39. Atri A, Matorin A, Ruiz P. Integration of International Medical Graduates in U.S. Psychiatry: The Role of Acculturation and Social Support. Academic Psychiatry. 2011;35(1):21-6.

40. Woolf K, Potts HWW, Patel S, McManus IC. The hidden medical school:A longitudinal study of how social networks form, and how they relate to academic performance. Medical Teacher. 2012;in press.

41. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. The Lancet.374(9702):1714-21.

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Interview schedules

One-to-one interviews - trainees:

Thank you for taking part in this research, which aims to explore the experiences of doctors

in training, particularly concentrating on the fairness of training in relation to a doctor’s

ethnicity and the country in which a doctor went to medical school.

I’d like to audio record this interview and take some notes to help me accurately remember

what was said. The recording will be sent to a professional independent transcriber, and we

will remove identifiable features to anonymise the interviews. All notes will also be

anonymised. The data will be kept confidential and only published in a way that means it

cannot be attributed to you as an individual. Is that OK?

In a moment I’m going to be asking you a series of questions. There are no right or wrong

answers, I just want to hear your opinions.

[If phone interview TURN ON TAPE and ask: can you just confirm your consent to take part

for the tape?]

1. Tell me a bit about yourself

i) What’s your current job? (prompt: stage of training, specialty if appropriate,

deanery/LETB)

2. I’m going to ask some questions about the experiences you’ve had working as a doctor

in training in the UK.

i) Think of a time when you felt you really learned a lot. (if necessary: What happened?)

What was it about the experience that helped you learn? (prompt: supervision from

senior colleagues, other trainees involved?)

Did the experience change you in any way? (prompt: how motivated you felt? the

direction of your career?)

ii) Think of a time when you really didn’t learn much at all. (if necessary: What happened?)

What was it about the experience that hindered your learning? (prompt: supervision

from senior colleagues, other trainees involved?)



iii) Now I’d like you to think about a time when something happened that was difficult to

deal with. (if necessary: What happened?)

What was it about the experience that made it so difficult?

Did you get any support to help you deal with it? (prompt: Did you talk to anyone

about it? Who? Can you remember what they said to you about it?)

Did the experience change you in any way?

3. Sometimes you can get two trainees in what is essentially the same job but one learns a

lot and the other learns very little.

Why do you think that might be?

4. Thinking again about your own career working as a doctor in the UK

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i) What are the main challenges or hurdles that you have had to deal with professionally to

get to where you are today in your career? (prompt: getting through assessments, getting

through selection processes)

Did you get any help or support? From whom? (prompt: How about outside of

work?)

Did anyone or anything hinder you? (prompt: opportunities provided by the

workplace; peers, senior colleagues)

If they mention more than one challenge: Of all the challenges you’ve talked about,

which would you say was the most challenging? If necessary: what made it so

challenging?

ii) We are particularly interested in assessments, including ARCPs and Royal College

examinations.

What comes into your head when I say “ARCP”?

How fair do you think ARCPs are?

What about Royal College exams? How fair are they?

Have you ever failed an exam or an ARCP? (prompt: if exam, was it written or

clinical)

Why do you think you failed?

Do you think failing affected you in any way? (if necessary: How?)

b) Now let’s look to the future

i) Do you have an idea of where you ultimately would like to get to career-wise?

If yes: Where is that?

ii) What are the main challenges or hurdles that you are going to have to deal with

professionally in the next few years?

Will you need any help or support to deal with those challenges or hurdles? What

kind? From whom? (Prompt: other trainees, senior colleagues, anyone outside

work?)

How easy or difficult do you think it will be to get the help and support you need?

5. Thinking about trainees in general now

i) Evidence shows that UK-trained doctors from minority ethnic groups (in other words

people who would not tick the ‘white’ box on an ethnic monitoring form) are less likely to

be successful in recruitment and in assessments compared to UK-trained doctors who are

white.

What do you think about this?

Why do you think this might be the case?

What could be done to reduce this difference?

ii) Evidence also shows that doctors who trained outside of the UK are less likely to be

successful in recruitment and in assessments compared to UK-trained doctors.




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Focus group - trainees:




We are going to be audio recording this focus group and my colleague [name] will be taking

notes. This is to help us accurately remember what everyone says. The recording will be

sent to a professional independent transcriber, and we will remove identifiable features to

anonymise the interviews. All notes will also be anonymised. The data will be kept

confidential and only published in a way that means it cannot be attributed to you as an

individual.

We would also like you to agree to keep everything you your colleagues say in this room

confidential. Can we agree that? [make sure everyone agrees].


answers, we just want to hear your opinions. This focus group is not about reaching

consensus, we are interested in hearing a variety of different opinions.


i) What’s your name and your current job? (prompt: stage of training, specialty if

appropriate, deanery/LETB) [ask everyone in turn]

2. I’m going to ask some questions about the experiences you’ve had working as a doctor

in training in the UK.


What was it about the experience that helped you learn? (prompt: supervision from

senior colleagues, other trainees involved?)




What was it about the experience that hindered your learning? (prompt: supervision

from senior colleagues, other trainees involved?)



iii) Now I’d like you to think about a time when something happened that was difficult to

deal with. (if necessary: What happened?)


Did you get any support to help you deal with it? (prompt: Did you talk to anyone

about it? Who? Can you remember what they said to you about it?)




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i) What are the main challenges or hurdles that you have had to deal with professionally to

get to where you are today in your career? (prompt: getting through assessments, getting

through selection processes)

Did you get any help or support? From whom? (prompt: How about outside of

work?)

Did anyone or anything hinder you? (prompt: opportunities provided by the

workplace; peers, senior colleagues)

If they mention more than one challenge: Of all the challenges you’ve talked about,

which would you say was the most challenging? (If necessary: what made it so

challenging?)

ii) We are particularly interested in assessments, including ARCPs and Royal College

examinations.




Anyone failed an exam or an ARCP? (prompt: if exam, was it written or clinical)






ii) What are the main challenges or hurdles that you are going to have to deal with

professionally in the next few years?

Will you need any help or support to deal with those challenges or hurdles? What

kind? From whom? (Prompt: other trainees, senior colleagues, anyone outside

work?)






white.









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One-to-one interview – trainer




I’d like to audio record this interview and take some notes to help me accurately remember

what was said. The recording will be sent to a professional independent transcriber, and we

will remove identifiable features to anonymise the interviews. All notes will also be

anonymised. The data will be kept confidential and only published in a way that means it

cannot be attributed to you as an individual. Is that OK?


answers, I just want to hear your opinions.

[If phone interview TURN ON TAPE and ask: can you just confirm your consent to take part

for the tape?]

1. Tell me a little bit about yourself

i) Where did you go to medical school and when did you graduate?

ii) What’s your clinical job (prompt: specialty, deanery)?

iii) What responsibilities do you have as a trainer?

2. I’d like to ask you some questions about your experiences as a trainer

i) Think of a time at work when you felt your trainees, or one trainee in particular, learned a

lot (if necessary: What happened?)

Why was it that they learned so much, do you think?

Did that experience change the way you approach your role as a trainer in any way?

ii) Think of a time at work when you felt your trainees, or one trainee in particular, really

didn’t learn anything (if necessary: What happened?)

Why was it that the learning didn’t happen, do you think?





4. What are the main challenges or hurdles that trainees have to deal with in their careers?

Of all those challenges, which would you say was the most difficult? Why?

What help or support do you think trainees need in dealing with those challenges?

(prompt: How about outside of work?)

What do you think are the main things that hinder trainees’ progression? (Prompt:

opportunities provided by the workplace)

5. We are very interested in assessments, ARCPs and Royal College exams.


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white.









7. Anything else you wanted to say, or that you wish I’d asked you about?

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Focus group - trainers:




We are going to be audio recording this focus group and my colleague [name] will be taking

notes. This is to help us accurately remember what everyone says. The recording will be

sent to a professional independent transcriber, and we will remove identifiable features to

anonymise the interviews. All notes will also be anonymised. The data will be kept

confidential and only published in a way that means it cannot be attributed to you as an

individual.

We would also like you to agree to keep everything you your colleagues say in this room

confidential. Can we agree that? [make sure everyone agrees].


answers, we just want to hear your opinions. This focus group is not about reaching

consensus, we are interested in hearing a variety of different opinions.


i) What is your name? Where did you go to medical school and when did you graduate?




i) Think of a time at work when you felt your trainees, or one trainee in particular, learned a

lot (if necessary: What happened?)



ii) Think of a time at work when you felt your trainees, or one trainee in particular, really

didn’t learn anything (if necessary: What happened?)








What help or support do you think trainees need in dealing with those challenges?

(prompt: How about outside of work?)

What do you think are the main things that hinder trainees’ progression? (Prompt:

opportunities provided by the workplace)

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white.










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Perceived causes of differential attainment in UK postgraduate medical training: a national qualitative study

Journal: BMJ Open

Manuscript ID bmjopen-2016-013429.R1

Article Type: Research

Date Submitted by the Author: 20-Sep-2016

Complete List of Authors: Woolf, Katherine; University College London Medical School, Research Department of Medical Education Rich, Antonia; University College London Medical School, Research Department of Medical Education Viney, Rowena; University College London Medical School, Research Department of Medical Education Needleman, Sarah; University College London Medical School, Research Department of Medical Education

Griffin, Ann; University College London Medical School, Research Department of Medical Education

<b>Primary Subject Heading</b>:

Medical education and training

Secondary Subject Heading: Qualitative research

Keywords: EDUCATION & TRAINING (see Medical Education & Training), QUALITATIVE RESEARCH, postgraduate education, ethnicity, diversity, international medical graduate


BMJ Open on 29 A

pril 2018 by guest. Protected by copyright.

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Perceived causes of differential attainment in UK postgraduate

medical training: a national qualitative study

Dr Katherine Woolf, Senior Lecturer in Medical Education1

[email protected]

Dr Antonia Rich, Research Associate1

Dr Rowena Viney, Research Associate1

Dr Sarah Needleman, Clinical Teaching Fellow1

Dr Ann Griffin, Senior Lecturer in Medical Education2

1 Research Department of Medical Education

UCL Medical School

Room GF/664, Royal Free Hospital

London NW3 2PF

2Research Department of Medical Education

UCL Medical School

74 Huntley Street

London WC1E 6AU

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Structured abstract

Objectives

Explore trainee doctors’ experiences of postgraduate training and perceptions of fairness in

relation to ethnicity and country of primary medical qualification.

Design

Qualitative semi-structured focus group and interview study.

Setting

Postgraduate training in England (London, Yorkshire & Humber, Kent Surrey and Sussex) and

Wales.

Participants

137 participants (96 trainees, 41 trainers) were purposively sampled from a framework

comprising: doctors from all stages of training in General Practice, Medicine, Obstetrics &

Gynaecology, Psychiatry, Radiology, Surgery or Foundation, in four geographical areas, from

white and black and minority ethnic (BME) backgrounds, who qualified in the UK and

abroad.

Results

Most trainees described difficult experiences, but BME UK graduates and international

medical graduates could face additional difficulties that affected their learning and

performance. Relationships with senior doctors were crucial to learning but bias was

perceived to make these relationships more problematic for BME UKGs and IMGs. IMGs also

had to deal with cultural differences and lack of trust from seniors, often looking to IMG

peers for support instead. Workplace-based assessment and recruitment were considered

vulnerable to bias whereas examinations were typically considered more rigorous. In a

system where success in recruitment and assessments determines where in the country you

can get a job, and where work-life balance is often poor, UK BME and international

graduates in our sample were more likely to face separation from family and support

outside of work, and reported more stress, anxiety, or burnout that hindered their learning

and performance. A culture in which difficulties are a sign of weakness made seeking

support and additional training stigmatising.

Conclusions

BME UKGs and IMGs can face additional difficulties in training which may impede learning

and performance. Non-stigmatising interventions should focus on trainee-trainer

relationships at work and organisational changes to improve trainees’ ability to seek social

support outside work.

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Strengths and Limitations of this study

• This is the first study to explore how ethnicity affects UK-qualified doctors’ experiences

of postgraduate medical training. It therefore provides valuable insights into the causes

of black and minority ethnic UK graduates’ underperformance in postgraduate

assessments and recruitment, and provides a basis upon which interventions to reduce

differential attainment can be developed and evaluated.

• The study has a large and diverse sample, comprising trainees from white and Black and

minority ethnic backgrounds, UK and international graduates, across six medical

specialities, four geographical areas in England and Wales, and all training grades. It also

includes trainers, programme directors and postgraduate deans. This allows in-depth

analysis of the issues from a range of perspectives.

• Selection bias is a possibility, although the data showed a wide variety of views. Related

to that, data were collected in November and December 2015 during the junior doctor

contract dispute which may have led to trainees vocalising greater discontent with their

training than usual, although the findings did not suggest doctors from dissimilar

backgrounds perceived the new contract differently.

• Low recruitment from some specialties, for example Radiology, did not permit

comparison of potential differences between specialties.

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Introduction

International medical graduates (IMGs) are more likely to fail postgraduate assessments and

have poorer outcomes in recruitment in the United Kingdom (UK), United States (US),

Canada, and Australia (1-6). Doctors from black and minority ethnic (BME) groups also have

poorer academic and recruitment outcomes compared to white doctors in the UK, US,

Netherlands, and Australia (1, 7-9) and in higher education more generally (10, 11)(12).

These group differences are known as differential attainment and pose a significant problem

for the medical profession. Healthcare provision relies on IMGs (1, 13); and medicine is a

very popular choice for BME students (14). In the UK public authorities such as universities,

Royal Colleges, and the National Health Service (NHS) have a legal duty to address

differences between groups with and without the protected characteristic of ‘race’ (which

covers “race, colour, and nationality (including citizenship) ethnic or national origins”) (15).

In 2014 the Membership of the Royal College of General Practitioners (MRCGP) examination

and the General Medical Council were brought to judicial review over differential

attainment (16) (15) raising the profile of the problem.

IMGs are known to face challenges including adapting to a new culture and style of teaching

and learning, new language, change in hierarchy, discrimination, and the psychological

impacts of migration (9, 17)(18)(19). Much less is known about the causes of the ethnic

attainment gap among UKGs, and it is unclear whether IMGs and BME UKGs have

experiences in common. A 2015 GMC-commissioned rapid review of the literature (20)

highlighted a lack of consensus and research about the causes of the ethnic attainment gap

in UKGs. There is however general agreement that examiner bias or overt discrimination is

unlikely to be the sole cause in examinations in medicine because differential attainment is

seen in written machine marked multiple choice examinations (21) and research into two

postgraduate clinical examinations found no evidence of bias (22, 23). This has shifted the

focus of differential attainment research onto understanding experiences and opportunities.

This shift is reflected in a recent Higher Education Funding Council England (HEFCE)-

commissioned report into causes of ethnic differences in UK higher education (HE) (24).

Four categories of explanatory factors were identified: 1) students’ experiences of HE

learning, teaching, and assessment; 2) relationships that underpin students’ experiences of

HE; 3) psycho-social and identity factors and 4) cultural and social capital factors. This report

was important because it moves understanding on from the “deficit model” whereby

differences are attributed to student deficits such as poorer previous attainment, lower

motivation, poorer preparation for university, none of which can fully explain ethnic

differences (25, 26). The current study was part of a General Medical Council-funded

workstream on differential attainment, and aimed to explore trainee doctors’ experiences

of postgraduate medical training and their perceptions of its fairness, using the HEFCE

framework as a guide to identify causes of differential attainment by ethnicity and country

of qualification (UK vs non-UK).

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Methods

Design

We took a qualitative approach to gain understanding of trainees’ lived experiences of

training and progression.(27) Data were gathered in focus groups and one-to-one interviews

in person and over the phone, using a semi-structured interview guide (see Appendix),

which was piloted on two junior doctors. Trainee experiences were contextualised by views

of trainers, programme directors and postgraduate deans. All participants received a

certificate of participation and focus group members received refreshments.

Participant sampling framework and recruitment

In UK medical training, an undergraduate medical course is followed by postgraduate

training comprising two Foundation years and then specialty training. In England

postgraduate training is organised into geographical areas administered by Health Education

England (HEE) Local Education and Training Boards (LETB’s); in Wales it is organised by the

Welsh Deanery.

We sampled across five LETBs in England (Kent Sussex and Surrey; North Central and East

London, North West London, South London, Yorkshire and Humber), the Welsh Deanery,

and the corresponding Foundation Schools, all chosen because they have varying

proportions of IMGs/UKGs, and varying average postgraduate examination performance.

Our sampling frame included trainees from four ethnic/country groups (BME UKG, white

UKG, BME IMG, and white IMG), from six specialities with differing competition ratios and

proportions of IMGs/UKGs and white/BME doctors (Medicine, Surgery, Psychiatry, General

Practice, Clinical Radiology, Obstetrics & Gynaecology) plus Foundation Training, and across

training (Foundation, Specialty Training (ST) Years 1-3, and 4+) as well as doctors who had

failed to progress in their training, or who had completed their training within the last year.

Participants were eligible if they were currently in training, had recently completed training,

or had failed to progress, or were trainers in one of the specialties or Foundation in one of

the geographic regions.

Participants were recruited in three main ways: 1) all participating LETBs/Deaneries and

Foundation Schools emailed invitations to all their trainees and trainers; 2) we invited

people attending events (three GP events in KSS, one Radiology event in London, one

Orthopaedic Surgery event in London, one mixed specialty event in London) to take part

either immediately after the event or to express interest in taking part at a later date; and 3)

advertised in the Royal College of Physicians President’s newsletter. Aside from those who

took part immediately after an event, potential participants were asked to contact the

research team if they were interested in taking part, and those who did were sent an online

survey asking them their gender, ethnicity, country of primary medical qualification (medical

school), stage of training, specialty (if relevant), and whether they were willing to participate

in a focus group, interview or either.

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We organised four trainee focus groups in different towns in Yorkshire & Humber, three in

London, one in KSS, and one in Wales. Venues were local universities or hospitals. Eligible

participants who responded to the survey were invited to attend a local focus groups or to

be interviewed. Due to high interest we were unable to interview everyone and chose

participants deliberately to populate our sampling frame.

Analysis

Data were analysed using QSR NVivo 10 and following Braun and Clark.(27) KW (academic

psychologist), AR (health psychologist) and RV (linguist) read through all transcripts

individually and identified themes that emerged from the data, using Mountford-Zimdars et

al’s analytic framework as a guide. Specifically, we looked for evidence that Mountford-

Zimdars’ four main themes (‘curricula and learning’, ‘psychosocial and identity factors’,

‘relationships’, and ‘social, cultural, and financial capital’) were present and identified the

codes that made up those themes, and also allowed any additional codes and themes to

emerge from the data. We then met to discuss our findings, and agree a first coding

framework. KW, AR and RV coded three transcripts individually using the agreed coding

framework, which we then refined after further discussion. RV then coded the entire

dataset using the final framework. Subsets of the data were second-coded by each member

of the research team (including SN, a clinical oncology trainee and clinical teaching fellow,

and AG, a GP trainer and medical educator); consistency was ensured by discussing the

framework with all team members and agreeing descriptors for each code before coding.

Differences between RV’s and the other team members’ coding were resolved through

discussion, with RV making the necessary adjustments to the final coded version of the

dataset. This final coded dataset was used to write up the findings.

Ethical approval

Ethical approval was granted by the University College London Ethics Committee reference:

0511/11. Participants gave informed consent before taking part.

Results

Participants

392 trainees and trainers expressed interest and 137 (96 trainees including 1 post-CCT & 1

who failed to progress; 41 trainers) participated. Data were gathered in October, November

and December 2015 in 13 focus groups and 35 one-to-one interviews with trainees, and 3

focus groups (all GPs at HEKSS) and 14 one-to-one interviews with trainers. Participant

demographics are shown in 0.

Figure 1 about here

Figure 1: Participant demographics

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Perceived causes of differential attainment

Most trainees had experienced difficulties during training but several themes and

subthemes were identified that described how additional difficulties faced by BME UKGs

and/or IMGs were perceived to cause differential attainment - see 0.

Figure 2 about here

Figure 2: The main themes (left) and subthemes (right) describing the difficulties faced by BME UKGs and/or IMGs that could cause differential attainment. The subtheme ‘Relationships with seniors’ was linked to two subthemes within the main theme ‘Capital’ as illustrated by the curved lines.

Relationships with senior doctors

Relationships with senior doctors were perceived as crucial to learning. At best seniors gave

trainees confidence by providing them with opportunities to take responsibility for patients,

giving constructive feedback, and reassuring about problems including exam failure.

Building confidence was especially important in extremely busy, understaffed, or

disorganised environments in which trainees had little choice but to take responsibility.

When seniors did not believe in trainees’ abilities, were bullying, blamed trainees, or were

perceived not to care, trainees’ confidence could be damaged for months and the lack of

confidence could follow them into subsequent jobs. The same trainee could be treated

positively by one senior and negatively by another, hugely affecting confidence and success.

I had a six month experience with a boss where I learned how to be resilient, and I

learned how to take the knocks, but I didn’t learn a great deal […]. Whatever I could

do beforehand was questioned. […] I sort of just kept my head above the water. […]

After that [I] spent about a year basically getting my confidence back.

Asian Other UKG Male ST4+ Surgery

From day 1 it was criticism. I had a college tutor walk up to me once and told me

“Anaesthetics is not for everybody, you can get a job as a resident medical officer”.

So that stayed at the back of my mind for quite another 5, 6 months while I was there.

It was getting unhealthy for me, I was getting a lot of psychological emotional stress,

so I decided before I leave anaesthetics let me see if other hospitals are like that. […]

And within the first month of me working [at another hospital] […] the college tutor

there, called me and said “you seem to be not confident about anything, and we’ve

had someone assess you, she thinks your skills are good […] just relax and pay

attention to the work”. [laughs] […] I decided to stay on with that encouragement,

with a little bit of effort, and I went on to finish my final anaesthesia fellowship.

Black IMG Male ST1-3 GP

BME UKGs and IMGs in our sample were less likely to report support from seniors in

pressurised situations and more likely to say seniors did not believe in them. There were

several potential reasons for this, as described below.

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Cultural differences

Cultural differences could impede good educational relationships for IMGs. It was generally

agreed that IMGs who found it difficult to adapt to UK patient-centred care and who - even

if they spoke English as a first language - struggled with colloquialisms, would struggle with

colleagues. UKGs felt IMGs would struggle with patients too and trainers including an IMG

reported difficulties teaching trainees who behaved culturally inappropriately. IMG trainees

felt cultural difficulties affected their relationships with colleagues more than with patients.

They described how difficult it could be to learn new cultural norms especially if they had to

‘unlearn’ previously acquired knowledge or if UK norms were very different.

I’ve been in this country for more than a decade now. It’s still a learning journey […]

I personally think that maybe there must be some time given us to relearn what we

have learnt already and then learn what we are supposed to learn.

Asian Indian IMG Female ST4+ Psychiatry

Lack of trust

Many IMGs felt UKG trainers did not appreciate the challenges they faced and trainers

reported finding it challenging to help some IMGs - one white UKG trainer wondered

whether differences were sometimes too large to be overcome. Only one trainer, a BME

UKG, said more effort should be made to help IMGs adjust. Many UKGs were concerned

that IMGs’ prior training - especially in communication skills – did not prepare them for UK

medicine, and thought IMGs may have attended medical schools with lower standards.

Some UKGs felt IMGs in or coming from locum jobs were poor at communicating and/or

disinterested in education; however many IMGs found it very frustrating that locum jobs did

not provide training opportunities, and several non-EEA IMGs and one foreign national UKG

said difficulties getting a visa or ineligibility prevented them getting jobs with good learning

opportunities. A few white UKGs said BME UKGs and IMGs were more likely to be pushed

into medicine.

My experience probably comes from a lot of locum doctors who are trying to get

more established in the UK. I think perhaps there may be less trust from a senior

perspective to somebody coming into that environment and therefore you don't also

give them the time to help support as much as you would somebody who is in a more

permanent post here. […] I just feel a little bit unnerved when somebody hasn't

trained here.

Trainer White UKG Female Medicine

With time and effort trainers could bridge cultural gaps and get a better understanding of

trainees’ abilities. White UKGs trainers described how getting to know their IMG trainees

over several months built trust and understanding and led to positive outcomes; however

trainers did not always have that time. More junior trainees moved jobs frequently,

meaning relationships had to be formed quickly and trainees were under pressure to prove

themselves. This was perceived to disadvantage IMGs but also BME UKGs who were less

likely to “fit the mould” (Asian Pakistani UKG Female ST4+ Surgery).

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Bias, belonging and fitting in

Reports of overt racism were rare. Subtle bias on the part of those training, assessing, and

recruiting trainees - even if not deliberate - was widely considered to be a cause of

differential attainment, especially of the ethnic differences within UKGs.

I was with a GP a couple of weeks ago having a coffee with him. He's like, “Oh,

yeah, normally when we recruit people we look at whether they're going to mingle

with us, they're going to gel with the kind of background we are, whether they can

come to barbecues with my family”. I thought to myself, “That is what my dad had to

experience when he first came to this country and was rejected by society”.

Asian Pakistani UKG Female ST1-3 GP

F1: There’s still quite a lot of sponsorship that goes on. So rather than there being a

meritocracy in terms of mentoring, certain trainees will sponsored as the chosen ones.

And those factors that define chosen ones can be varied depending on speciality, so

they could include gender, ethnicity, where you went to school.

M1: Choice of sport.

F1: Who you’re married to.

F2: What your accent is.

F1: All sorts of things, I’ve seen it all, it still goes on.

F1: White UKG Female ST4+ Medicine

F2: White UKG Female ST1-3 Medicine

M1: White UKG Male ST4+ Medicine

Some BME UKGs remarked that it was only because they spoke with middle class accents

and went to a medical school with a good reputation that they did not suffer discrimination;

many IMGs felt their accent made people immediately question their ability, made them

less likely to be recruited, and more likely to fail exams. Several BME UKGs felt they had not

personally suffered discrimination, although in our sample BME UKGs were more likely than

white UKGs to believe that there was an ethnic attainment gap. One BME UKG described

why she did not want to think she had been discriminated against:

I'm not going to start assuming [discrimination], because if you start assuming that,

that's a very slippery slope. You just then think, you become very paranoid. You start

thinking that everyone is out to get you. […] If you try and - this sounds really awful

saying this - but if you try and blend in and just get on with everyone and, you know,

you come across less problems. No one likes the one who's going to kick up a fuss or

start saying “Oh, it's because I'm an ethnic minority this, that and the other”. No, you

start getting yourself into problems if you start thinking like that.

Asian Other UKG Female ST1-3 Medicine

Many trainers acknowledged that bias could exist but white trainers were more likely to say

medicine was unbiased. A GP trainer said that he felt as a white UK male he had the fewest

opportunities. By contrast, a BME trainer remarked “you are probably less likely to be

successful the more different you are from the people assessing you” (Trainer Black UKG

Medicine).

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Relationships with peers

Peers provided practical support and advice, solidarity, understanding, and emotional

support. Trainees tended to seek support from others within the same cultural group, even

within the UKG group:

Ever since medical school I’ve pretty much hung around with the ethnic minority

people, I don’t know why actually. And then you see other groups that are all white.

Mixed UKG Female ST1-3 GP

UKGs describe organising opportunities to get together in person or online to share

knowledge and provide emotional support – something they felt IMGs missed; however

many IMGs said they particularly valued the opportunity to meet other IMGs who could be

trusted to understand and not to judge, and described supporting junior IMG colleagues. A

few IMGs felt integration and immersion in UK culture was important.

Hidden curriculum: the culture of medicine

Medicine was perceived as a vocation that demanded hard work, long hours and personal

sacrifice, and where success or failure is largely determined by individual factors such as

motivation. Experiencing difficulties was a sign of weakness, meaning trainees felt they were

not always given the support needed to learn or were blamed for problems that were not

their fault. IMGs could feel stigmatised or disadvantaged by attending extra courses.

Reputations were thought to follow trainees between jobs, which made it hard to report

bullying including ‘race’-related problems. This was perhaps amplified for IMGs and BME

UKGs who were more likely to report seniors not believing in or trusting them.

I've gotten used to sometimes if I tell people I'm an ST7 in Medicine they almost

seem surprised.

Black UKG Female ST4+ Medicine

Just imagine someone starting on F2 being told to stay in an Acute Care bay, which is

the really deep end. […] The next morning I called the consultant, it was a professor,

and I told him that I struggled overnight, and unfortunately […] the registrar was not

very supportive that night, and I told him that I struggled overnight, I think I should

be in a place where I could grow. […]. But unfortunately that experience was

misinterpreted […] for being a weakness. […] [My educational supervisor] told me

that “Oh you need to go back to become an F1”. […] I was in tears.

Black IMG Male ST1-3 Medicine

Fairness of assessments and recruitment

Royal College examinations were generally perceived as more rigorous and fair than Annual

Review of Competence Progression (ARCP) assessments and recruitment. UKGs were more

critical of ARCPs than IMGs, who were more critical of Royal College examinations. UKGs

felt ARCPs could depend on good relationships with colleagues who would sign them off at

the last minute and complete their multi-source feedback positively, and this could be

harder for IMGs and BME UKGs; however IMGs were more likely to feel ARCPs were fair

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because all trainees have to tick the same boxes. Participants from all groups believed

recruitment processes were vulnerable to bias and some UKG trainers had concerns about

employing IMGs. IMGs described being ineligible for some training jobs.

The employers are going to look for someone who can be well integrated in their team

and they might not see that in you as an ethnic minority even though it's not

something that they would outright say. That's why I always say it's very subtle. They

might look for something else and blame it on that: “Oh, it's because you don't have

enough experience at this or that”. Even though your CV actually might match your

colleague or even be better than your colleague's.

Black UKG Female Foundation

If somebody had trained in another country and you didn't have confidence in the

registration of that qualification in that country, the people are going to be to the same

standard, you might be less happy to recruit people from that environment.

Trainer White UKG Male GP

IMG and BME UKG trainees thought communication in examinations was different from real

life and described learning to “play the game” (Black IMG Male ST1-3 GP) to pass.

Confidence was perceived as important to pass clinical exams but IMGs were less confident

because they worried their accent would disadvantage them, they knew they were

statistically more likely to fail, and they knew colleagues who were good clinically who had

failed. Reassurance and practical support from seniors was important to build confidence.

Trainers were more positive about ARCPs, the main criticism being that panels passed

trainees they should not. Trainers felt examinations were robust and fair (many were

involved in examining), even if they were harder for candidates who were unfamiliar with

UK culture and language.

Work-life balance

Trainees valued emotional and practical support from partners and families especially when

they were having difficulties at work; but long hours, inflexible training, and lack of family-

friendly attitudes made it hard to get this support. Trainees lacked autonomy about where

they worked and lived, especially those who did not score as highly at medical school or in

recruitment tests, which is perhaps why BME UKGs and IMGs talked more frequently about

ending up separated from family and the pressure this entailed.

M1: The year apart. We've tried a year so I deferred for a year but still couldn't start

and all my wife and kids couldn't move up. We spent a year commuting from

Sheffield to Bristol. […]

M2: You can't give up a [training] number, that's just a golden ticket. It's really career

or family sometimes. It's tough.

M1: Arab UKG Male ST4+ Surgery

M2: White IMG Male ST4+ Surgery

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Impact of work on wellbeing

BME UKGs and IMGs in our sample were more likely to mention mental health problems

caused by work stresses including problematic relationships with colleagues that lowered

confidence, burnout, social isolation, and lack of pastoral support. These problems impeded

learning and performance at work.

F1: I feel, like, on constant level of burnout […] So unless I either declare myself- if I

say I’ve actually got depression and I’m unfit to practice, then there is no way. I’ve

been quiet before about…

F2: […] I was at the point, like everyone is, when they’re working where just an

entire 3 months of just not sleeping at night because you’re just so worried about the

next day and how you’re going to manage.

F1: Asian Indian UKG Female ST1-3 Psychiatry

F2: Asian Indian UKG Female ST1-3 Medicine

I did not have any work experience, neither back home nor here. And also my

Foundation training was up North and then I left my daughter and my husband here in

London. […] I was really anxious during that time.[…] I could not pay attention to

what was going on. […] [My educational supervisor] said “Okay, if you cannot work

like this then probably you need to, you may need to think about changing your

career”’ […] Medicine has always been my passion. I cannot think doing anything

else apart from that. I got really upset.’


Fear of living up to negative expectations

Many IMGs and two BME UKGs talked about the psychological pressure of knowing that

they may be subject to negative stereotyping or failure, with one IMG wondering whether

“we just aren’t as clever as the local trainees” (Asian Other IMG Male ST4+ Surgery).

During my training I have seen lots of local trainees or white doctors, they are not

doing that much work, and then in fact the other doctors - we are immigrant doctors -

they have been given more work to do, and then they still do it, but they are still

considered inefficient. […] We need to work twice as much as, twice as hard as the

local trainees does to be half as good as they are.


I'm expecting to get a lower mark because I'm- I know it's a stupid way of thinking

but actually it got to the point where I was thinking “What is it? Am I…?” I wasn't

sure if it was my knowledge anymore, I wasn't sure if it was my confidence, I wasn't

sure if it was my skin colour. So you start-I think it creates almost like a nasty way of

thinking and how you perceive yourself to be. And if that someone's expectation of

you is low subconsciously, your performance will be low.

Black UKG Female ST4+ Psychiatry

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Discussion

Statement of principal findings

In this national study of trainees’ experiences of postgraduate medical training, most

trainees reported difficulties, but BME UKGs and IMGs faced additional difficulties that

impeded learning and performance. Relationships with senior doctors were considered

crucial to learning but were more problematic for BME UKGs and IMGs, which was

perceived to result partly from bias. IMGs faced cultural differences and lack of trust from

seniors, and many looked to IMG peers for support instead. A culture in which success is

determined by drive and ability, and difficulties are a sign of weakness could make it hard to

access support, and additional training for IMGs could be stigmatising. Workplace based

assessment and recruitment processes were widely considered vulnerable to bias whereas

examinations were considered more rigorous. Relationships outside work were an

important source of emotional support but lack of work-life balance and lack of autonomy

about geographical location of work could mean separation from family, especially for BME

UKGs and IMGs, several of who reported mental health problems that impacted on work.

Strengths and weaknesses of the study

This large-scale qualitative study provides new insights into the causes of ethnic differences

in attainment among UK graduates, which to date have been little understood, making it

difficult to develop interventions. This study points to several areas for interventions to

focus on. The study is novel in exploring similarities in the causes of differential attainment

within UKGs and between UKGs and IMGs, facilitating the development of interventions to

address both.

Our analysis was based upon factors identified in an international study of higher education

(24) reflecting that differential attainment is a widespread problem. Our study aimed to

understand the issues in depth rather than to provide statistical generalisations; however its

theoretical foundations allow theoretical generalisability (28). Trainee interviews were

contextualised by trainer interviews; interviewees were purposively sampled to provide a

spread across different specialties, geographic areas, and stages of training; and the data

were analysed by a linguist, psychologists, and two clinicians - all of which improved

reliability and validity.

Poor recruitment from some specialties, for example Radiology, did not allow us to look at

differences between specialties. The large number of GP trainers could have skewed the

trainer findings, although we also interviewed 14 trainers from hospital medicine. With all

research it is possible that participants had particular reasons for taking part. Data were

collected in November and December 2015 just after junior doctors in England voted to

strike over the Government’s imposition of a new contract (29). This may have encouraged

participants to speak negatively about their training, but there is little to suggest that white

and BME doctors or IMGs and UKGs view the concerns surrounding junior doctor contracts

differently.

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Strengths and weaknesses in relation to other studies, discussing important

differences in results

The central role of the teacher-learner relationship in medical and other adult education is

well known (30, 31), and teacher-learner relationships in medical students but not doctors

can be impeded by ethnic differences (32) (33). The perception that bias can affect learning

is reflected by national surveys reporting that newly-qualified BME UKGs were less likely to

agree “The NHS is a good equal opportunities employer for doctors from ethnic minorities”

(34) and were less satisfied with their training (35) although IMGs were more satisfied than

UKGs (35). It may be that IMGs have different expectations – one IMG in our study expected

to be discriminated against feeling it was natural to prefer one’s own (Black IMG ST1-3

Medicine). IMGs in our study reported worrying they were going to fail or be disadvantaged

in examinations – a form of stereotype threat that impedes minority students’ performance

in education generally (36) but has been relatively under-studied in medical education. The

culture of long hours, hard work, lack of work-life balance, and difficulties being a sign of

weakness is well-known (37) but previous research has not to our knowledge considered

whether it may adversely affect BME or IMG doctors particularly, although lack of social

support in IMG psychiatrists in the US is associated with increased mental health problems

(38). The finding that trainees tended to seek support among their own cultural group fits

with previous medical school research (33, 39).

Meaning of the study: possible explanations and implications for clinicians and

policymakers

Trainers need time to develop good relationships with trainees, which can be difficult due to

clinical pressures. The widespread belief that bias could affect trainers’ perceptions of

trainees during training, assessments and/or recruitment does not mean that trainers were

necessarily biased, however more could be done to raise awareness of the potential of even

quite subtle bias to affect minority trainees during training as well as during assessments;

but care should be taken to avoid stigmatising trainees with interventions. A lack of work-

life balance and autonomy over job locations could prevent trainees from benefitting from

social support outside work and affected their wellbeing. This may be especially problematic

for BME UKGs and IMGs who - because of poorer academic performance - may have even

less choice, and thus be more likely to be socially isolated and suffer mental ill-health, which

could impact patient care. Changes to systems to increase work-life balance and autonomy

therefore have the potential to reduce differential attainment.

Unanswered questions and future research

Further research is needed to determine the prevalence of the problems identified within

the entire population and to examine how organisational systems affect the relationships

and wellbeing of trainees from different ethnic and cultural groups, especially because

doctor wellbeing impacts patient care (40). There is increasing evidence about the fairness

of Royal College examinations, but more work is needed to examine the fairness of all

assessments especially workplace based assessments and recruitment. This research

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provides the basis for interventions but these need to be developed, trialled, and rigorously

evaluated.

Funding

The research was funded by the General Medical Council who were involved in designing

the study, were kept informed of progress with the collection, interpretation and analysis of

the data, and approved this report before submission. The researchers remained

independent from the funders.

Competing interests

All authors have completed the ICMJE uniform disclosure form at

www.icmje.org/coi_disclosure.pdf and declare: all authors except Sarah Needleman had

financial support from the General Medical Council who commissioned this research;

Katherine Woolf receives a fee as educational consultant to the Membership of the Royal

College of Physicians (UK) Examination. No authors have any other relationships or activities

that could appear to have influenced the submitted work.

Details of contributors

KW and AG designed the study in response to a tender from the General Medical Council.

RV, AR, KW and SN carried out the field work. RV, AR, and KW analysed and interpreted the

data with input from AG and SN. KW drafted the manuscript and is the guarantor. All

authors revised it critically for important intellectual content and approved the final version

for publication. All authors agree to be accountable for all aspects of the work.

Transparency Declaration

Katherine Woolf affirms that the manuscript is an honest, accurate, and transparent

account of the study being reported; that no important aspects of the study have been

omitted. This research was funded by the General Medical Council, and the report on the

full findings can be found here http://www.gmc-uk.org/about/research/23658.asp . The

current paper describes the main causes of differential attainment and a separate paper will

describe the protective processes that allowed BME UKGs and IMGs to achieve positive

outcomes despite this. There were no discrepancies from the study as planned.

Exclusive License

The Corresponding Author has the right to grant on behalf of all authors and does grant on

behalf of all authors, a worldwide licence

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(http://www.bmj.com/sites/default/files/BMJ%20Author%20Licence%20March%202013.doc) to the

Publishers and its licensees in perpetuity, in all forms, formats and media (whether known

now or created in the future), to i) publish, reproduce, distribute, display and store the

Contribution, ii) translate the Contribution into other languages, create adaptations,

reprints, include within collections and create summaries, extracts and/or, abstracts of the

Contribution and convert or allow conversion into any format including without limitation

audio, iii) create any other derivative work(s) based in whole or part on the on the

Contribution, iv) to exploit all subsidiary rights to exploit all subsidiary rights that currently

exist or as may exist in the future in the Contribution, v) the inclusion of electronic links

from the Contribution to third party material where-ever it may be located; and, vi) licence

any third party to do any or all of the above. All research articles will be made available on

an Open Access basis (with authors being asked to pay an open access fee—

seehttp://www.bmj.com/about-bmj/resources-authors/forms-policies-and-checklists/copyright-open-

access-and-permission-reuse). The terms of such Open Access shall be governed by a Creative

Commons licence—details as to which Creative Commons licence will apply to the research

article are set out in our worldwide licence referred to above.

Data sharing

No additional data available.

Acknowledgements

Huge thanks to all the participants who gave their time, to Catherine O’Keeffe and Lynne

Rustecki at London’s Professional Support Unit Health Education England for their support

and advice, the administrators at the LETB’s, the Welsh Deanery and UCL Medical School

who helped gather data, Marcia Rigby who managed the research process, and the project

steering group who guided the research.

References

1. The state of medical education and practice in the UK. London: General Medical

Council, 2015.

2. USMLE Performance Data 1996-2014. United States Medical Licensing Examination,

2016 [Available from: http://www.usmle.org/performance-

data/default.aspx#2014_step-1 ]

3. Leaving our mark: 2014-2015 Annual Report. Ottawa: Medical Council of Canada,

2015.

4. Falcone JL, Middleton DB. Performance on the American Board of Family Medicine

Certification Examination by Country of Medical Training. The Journal of the American

Board of Family Medicine. 2013;26(1):78-81.

5. Results and Data 2015 Main Residency Match®. Washington DC: National Resident

Matching Program, 2015.

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17

6. Karnik A, Venkatesh B, Angelico, D. Analysis of performance and predictors of success

in the final fellowship examination of the College of Intensive Care Medicine. Critical

Care and Resuscitation. 2015;17(1):3.

7. Kleshinski J, Khuder SA, Shapiro JI, Gold JP. Impact of preadmission variables on

USMLE step 1 and step 2 performance. Advances in Health Sciences Education.

2007;14(1):69-78.

8. Stegers-Jager KM, Steyerberg EW, Cohen-Schotanus J, Themmen APN. Ethnic

disparities in undergraduate pre-clinical and clinical performance. Medical Education.

2012;46(6):575-85.

9. Pilotto LS, Duncan GF, Anderson-Wurf J. Issues for clinicians training international

medical graduates: a systematic review. Medical Journal of Australia. 2007;187(4):225-

8.

10. Differences in degree outcomes: Key findings. Higher Education Funding Council for

England, 2015.

11. Zwysen WL, S. Labour market disadvantage of ethnic minority British graduates:

university choice, parental background or neighbourhood? Essex: University of Essex,

2016 .

12. Fletcher J, Tienda M. Race and Ethnic Differences in College Achievement: Does High

School Attended Matter? The Annals of the American Academy of Political and Social

Science. 2010;627(1):144-66.

13. Pettigrew LM. The NHS and international medical graduates. Education for Primary

Care. 2014;25(2):71-5.

14. Higher Education Statistics Agency. Table 6a - Full-time HE student enrolments by level

of study, subject area, sex, age group, disability status and ethnicity 2014/15. Higher

Education Statistics Agency, 2014 [Available from: https://www.hesa.ac.uk/free-

statistics]

15. Equality Act, 2010, London: The Stationery Office.

16. Richens D, Graham TR, James J, Till H, Turner PG, Featherstone C. Racial and Gender

Influences on Pass Rates for the UK and Ireland Specialty Board Examinations. Journal

of Surgical Education. 2016;73(1):143-50.

17. Chen PG-C, Nunez-Smith M, Bernheim SM, Berg D, Gozu A, Curry LA. Professional

Experiences of International Medical Graduates Practicing Primary Care in the United

States. Journal of General Internal Medicine. 2010;25(9):947-53.

18. Rothwell C, Morrow G, Burford B, Illing J. Ways in which healthcare organisations can

support overseas-qualified doctors in the UK. International Journal of Medical

Education. 2013;4:75-82.

19. Khan FA, Chikkatagaiah S, Shafiullah M, Nasiri M, Saraf A, Sehgal T, et al. International

Medical Graduates (IMGs) in the UK—a Systematic Review of Their Acculturation and

Adaptation. Journal of International Migration and Integration. 2014;16(3):743-59.

20. Regan de Bere SN, S; Nasser, M. Understanding differential attainment across medical

training pathways: A rapid review of the literature Final report prepared for The

General Medical Council. Plymouth University, 2015. [Available from http://www.gmc-

uk.org/GMC_Understanding_Differential_Attainment.pdf_63533431.pdf ]

Page 17 of 33


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MJ O


ovember 2016. D

ownloaded from



18

21. Woolf K, Potts HWW, McManus IC. Ethnicity and academic performance in UK trained

doctors and medical students: systematic review and meta-analysis. BMJ. 2011;342.

22. McManus IC, Elder AT, Dacre J. Investigating possible ethnicity and sex bias in clinical

examiners: an analysis of data from the MRCP(UK) PACES and nPACES examinations.

BMC Medical Education. 2013;13(1):1-11.

23. Denney M, Wakeford R. Do role-players affect the outcome of a high-stakes

postgraduate OSCE, in terms of candidate sex or ethnicity? Results from an analysis of

the 52,702 anonymised case scores from one year of the MRCGP clinical skills

assessment. Education for Primary Care. 2015:1-5.

24. Mountford-Zimdars AS, D; Moore, J; Sanders, J; Jones, S; Higham, L. Causes of

Differences in Student Outcomes. Higher Education Funding Council for England, 2015.

25. Singh G. Black and minority ethnic (BME) students’ participation in higher education:

improving retention and success. Higher Education Academy, 2011 [available from:

https://www.heacademy.ac.uk/resource/black-and-minority-ethnic-bme-students-

participation-higher-education-improving-retention ]

26. Stevenson J. Black and minority ethnic student degree retention and attainment.

Higher Education Academy, 2012 [available from:

https://www.heacademy.ac.uk/system/files/bme_summit_final_report.pdf ] 2012.

27. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in

Psychology. 2006;3(2):77-101.

28. Barbour RS. Making sense of focus groups. Medical Education. 2005;39(7):742-50.

29. Billingsley MG, G Timeline of the junior doctors contract dispute. Student BMJ.

2015;23.

30. Eraut M. Informal learning in the workplace. Studies in Continuing Education.

2004;26(2):247-73.

31. Haidet P, Stein HF. The Role of the Student-Teacher Relationship in the Formation of

Physicians. Journal of General Internal Medicine. 2006;21(S1):S16-S20.

32. Woolf K, Cave J, Greenhalgh T, Dacre J. Ethnic stereotypes and the underachievement

of UK medical students from ethnic minorities: qualitative study. BMJ. 2008;337.

33. Vaughan S, Sanders T, Crossley N, O'Neill P, Wass V. Bridging the gap: the roles of

social capital and ethnicity in medical student achievement. Medical Education.

2015;49(1):114-23.

34. Lambert T, Surman G, Goldacre M. UK doctors and equal opportunities in the NHS:

national questionnaire surveys of views on gender, ethnicity and disability. Journal of

the Royal Society of Medicine. 2014;107(10):398-408.

35. Gill D. The association between trainee demographic factors and self-reported

experience: Analysis of General Medical Council National Training Survey 2014 and

2015 data. JRSM Open. 2016;7(4).

36. Nguyen HD, Ryan AM. Does Stereotype Threat Affect Test Performance of Minorities

and Women? A Meta-Analysis of Experimental Evidence. Journal of Applied

Psychology. 2008;93(6):1314-34.

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37. Haidet P, Stein HF. The role of the student-teacher relationship in the formation of

physicians. The hidden curriculum as process. J Gen Intern Med. 2006;21 Suppl 1:S16-

S20.

38. Atri A, Matorin A, Ruiz P. Integration of International Medical Graduates in U.S.

Psychiatry: The Role of Acculturation and Social Support. Academic Psychiatry.

2011;35(1):21-6.

39. Woolf K, Potts HWW, Patel S, McManus IC. The hidden medical school: A longitudinal

study of how social networks form, and how they relate to academic performance.

Medical Teacher. 2012;31(7):9.

40. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. The

Lancet. 2009;374(9702):1714-21.

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Figure 1: Participant demographics

338x190mm (300 x 300 DPI)

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Figure 2: The main themes (left) and subthemes (right) describing the difficulties faced by BME UKGs and/or IMGs that could cause differential attainment. The subtheme ‘Relationships with seniors’ was linked to two

subthemes within the main theme ‘Capital’ as illustrated by the curved lines.

190x254mm (300 x 300 DPI)

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Interview schedules

One-to-one interviews - trainees:

Thank you for taking part in this research, which aims to explore the experiences of doctors in training, particularly concentrating on the fairness of training in relation to a doctor’s ethnicity and the country in which a doctor went to medical school.

I’d like to audio record this interview and take some notes to help me accurately remember what was said. The recording will be sent to a professional independent transcriber, and we will remove identifiable features to anonymise the interviews. All notes will also be anonymised. The data will be kept confidential and only published in a way that means it cannot be attributed to you as an individual. Is that OK?

In a moment I’m going to be asking you a series of questions. There are no right or wrong answers, I just want to hear your opinions.

[If phone interview TURN ON TAPE and ask: can you just confirm your consent to take part for the tape?]


i) What’s your current job? (prompt: stage of training, specialty if appropriate, deanery/LETB)

2. I’m going to ask some questions about the experiences you’ve had working as a doctor in training in the UK.


What was it about the experience that helped you learn? (prompt: supervision from senior colleagues, other trainees involved?)

Did the experience change you in any way? (prompt: how motivated you felt? the direction of your career?)


What was it about the experience that hindered your learning? (prompt: supervision from senior colleagues, other trainees involved?)


iii) Now I’d like you to think about a time when something happened that was difficult to deal with. (if necessary: What happened?)


Did you get any support to help you deal with it? (prompt: Did you talk to anyone about it? Who? Can you remember what they said to you about it?)


3. Sometimes you can get two trainees in what is essentially the same job but one learns a lot and the other learns very little.



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i) What are the main challenges or hurdles that you have had to deal with professionally to get to where you are today in your career? (prompt: getting through assessments, getting through selection processes)

Did you get any help or support? From whom? (prompt: How about outside of work?)

Did anyone or anything hinder you? (prompt: opportunities provided by the workplace; peers, senior colleagues)

If they mention more than one challenge: Of all the challenges you’ve talked about, which would you say was the most challenging? If necessary: what made it so challenging?

ii) We are particularly interested in assessments, including ARCPs and Royal College examinations.




Have you ever failed an exam or an ARCP? (prompt: if exam, was it written or clinical)






ii) What are the main challenges or hurdles that you are going to have to deal with professionally in the next few years?

Will you need any help or support to deal with those challenges or hurdles? What kind? From whom? (Prompt: other trainees, senior colleagues, anyone outside work?)



i) Evidence shows that UK-trained doctors from minority ethnic groups (in other words people who would not tick the ‘white’ box on an ethnic monitoring form) are less likely to be successful in recruitment and in assessments compared to UK-trained doctors who are white.




ii) Evidence also shows that doctors who trained outside of the UK are less likely to be successful in recruitment and in assessments compared to UK-trained doctors.




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Focus group - trainees:


We are going to be audio recording this focus group and my colleague [name] will be taking notes. This is to help us accurately remember what everyone says. The recording will be sent to a professional independent transcriber, and we will remove identifiable features to anonymise the interviews. All notes will also be anonymised. The data will be kept confidential and only published in a way that means it cannot be attributed to you as an individual.

We would also like you to agree to keep everything you your colleagues say in this room confidential. Can we agree that? [make sure everyone agrees].

In a moment I’m going to be asking you a series of questions. There are no right or wrong answers, we just want to hear your opinions. This focus group is not about reaching consensus, we are interested in hearing a variety of different opinions.


i) What’s your name and your current job? (prompt: stage of training, specialty if appropriate, deanery/LETB) [ask everyone in turn]

2. I’m going to ask some questions about the experiences you’ve had working as a doctor in training in the UK.


What was it about the experience that helped you learn? (prompt: supervision from senior colleagues, other trainees involved?)



What was it about the experience that hindered your learning? (prompt: supervision from senior colleagues, other trainees involved?)


iii) Now I’d like you to think about a time when something happened that was difficult to deal with. (if necessary: What happened?)


Did you get any support to help you deal with it? (prompt: Did you talk to anyone about it? Who? Can you remember what they said to you about it?)



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i) What are the main challenges or hurdles that you have had to deal with professionally to get to where you are today in your career? (prompt: getting through assessments, getting through selection processes)

Did you get any help or support? From whom? (prompt: How about outside of work?)

Did anyone or anything hinder you? (prompt: opportunities provided by the workplace; peers, senior colleagues)

If they mention more than one challenge: Of all the challenges you’ve talked about, which would you say was the most challenging? (If necessary: what made it so challenging?)

ii) We are particularly interested in assessments, including ARCPs and Royal College examinations.




Anyone failed an exam or an ARCP? (prompt: if exam, was it written or clinical)






ii) What are the main challenges or hurdles that you are going to have to deal with professionally in the next few years?

Will you need any help or support to deal with those challenges or hurdles? What kind? From whom? (Prompt: other trainees, senior colleagues, anyone outside work?)











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One-to-one interview – trainer


I’d like to audio record this interview and take some notes to help me accurately remember what was said. The recording will be sent to a professional independent transcriber, and we will remove identifiable features to anonymise the interviews. All notes will also be anonymised. The data will be kept confidential and only published in a way that means it cannot be attributed to you as an individual. Is that OK?

In a moment I’m going to be asking you a series of questions. There are no right or wrong answers, I just want to hear your opinions.

[If phone interview TURN ON TAPE and ask: can you just confirm your consent to take part for the tape?]


i) Where did you go to medical school and when did you graduate?




i) Think of a time at work when you felt your trainees, or one trainee in particular, learned a lot (if necessary: What happened?)



ii) Think of a time at work when you felt your trainees, or one trainee in particular, really didn’t learn anything (if necessary: What happened?)







What help or support do you think trainees need in dealing with those challenges? (prompt: How about outside of work?)

What do you think are the main things that hinder trainees’ progression? (Prompt: opportunities provided by the workplace)



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Focus group - trainers:


We are going to be audio recording this focus group and my colleague [name] will be taking notes. This is to help us accurately remember what everyone says. The recording will be sent to a professional independent transcriber, and we will remove identifiable features to anonymise the interviews. All notes will also be anonymised. The data will be kept confidential and only published in a way that means it cannot be attributed to you as an individual.

We would also like you to agree to keep everything you your colleagues say in this room confidential. Can we agree that? [make sure everyone agrees].

In a moment I’m going to be asking you a series of questions. There are no right or wrong answers, we just want to hear your opinions. This focus group is not about reaching consensus, we are interested in hearing a variety of different opinions.


i) What is your name? Where did you go to medical school and when did you graduate?




i) Think of a time at work when you felt your trainees, or one trainee in particular, learned a lot (if necessary: What happened?)



ii) Think of a time at work when you felt your trainees, or one trainee in particular, really didn’t learn anything (if necessary: What happened?)







What help or support do you think trainees need in dealing with those challenges? (prompt: How about outside of work?)

What do you think are the main things that hinder trainees’ progression? (Prompt: opportunities provided by the workplace)

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Table 1 Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist

No Item Guide questions/description

Domain 1:

Research team

and reflexivity

Personal

Characteristics

1. Interviewer/facilitator Which author/s conducted the interview or focus group?

RV, AR, KW, SN

2. Credentials What were the researcher's credentials? E.g. PhD, MD

PhD, PhD, PhD, medical doctor (MBBS)

3. Occupation

What was their occupation at the time of the study?

Research Associate, Research Associate, Senior Lecturer,

Clinical Teaching Fellow

4. Gender

Was the researcher male or female?

All female

5.

Experience and

training

What experience or training did the researcher have?

RV, AR, KW had previous experience of interviewing for

qualitative research. SN was provided with training for the

study.

Relationship with

participants

6.

Relationship

established

Was a relationship established prior to study

commencement?

No.

7.

Participant knowledge

of the interviewer

What did the participants know about the researcher? e.g.

personal goals, reasons for doing the research

Participants knew that the researchers were employed at UCL and

what their roles were in general and in relation to the research

project.

8.

Interviewer

characteristics

What characteristics were reported about the

interviewer/facilitator? e.g. Bias, assumptions, reasons and

interests in the research topic

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Interviewers’ professional backgrounds given, which include

psychologists, a linguist, a trainee doctor and a GP trainer.

Domain 2: study

design

Theoretical

framework

9.

Methodological

orientation and Theory

What methodological orientation was stated to underpin the

study? e.g. grounded theory, discourse analysis, ethnography,

phenomenology, content analysis

Thematic analysis following Braun & Clark, using Mountford-

Zimdars et al’s theoretical framework as a guide.

Participant

selection

10. Sampling

How were participants selected? e.g. purposive, convenience,

consecutive, snowball

Purposive sampling with a framework.

11. Method of approach

How were participants approached? e.g. face-to-face,

telephone, mail, email

Face to face and via email.

12. Sample size

How many participants were in the study?

137

13. Non-participation

How many people refused to participate or dropped out?

Reasons?

Nobody dropped out or refused to participate as such;

however many potential participants did not respond to our

invitation email for reasons unknown.

Setting

14.

Setting of data

collection

Where was the data collected? e.g. home, clinic, workplace

Universities or hospitals local to participants, and course

venues.

15.

Presence of non-

participants

Was anyone else present besides the participants and

researchers?

No.

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16. Description of sample

What are the important characteristics of the sample? e.g.

demographic data, date

Demographics (ethnicity, gender, country of primary medical

qualification) given in Figure 1. Interviews took place in October,

November, December 2015.

Data collection

17. Interview guide

Were questions, prompts, guides provided by the authors?

Was it pilot tested?

Interview/focus group schedules were piloted on two junior

doctors.

18. Repeat interviews

Were repeat interviews carried out? If yes, how many?

No.

19. Audio/visual recording

Did the research use audio or visual recording to collect the

data?

Audio.

20. Field notes

Were field notes made during and/or after the interview or

focus group?

Yes during and after interviews and focus groups.

21. Duration

What was the duration of the interviews or focus group?

Interviews lasted approximately 30-40 minutes. Focus

groups around 1 hour.

22. Data saturation

Was data saturation discussed?

No.

23. Transcripts returned

Were transcripts returned to participants for comment and/or

correction?

Not in general. One participant expressed concern about

some of his comments being used in the analysis. We

showed him the transcript and he gave his approval for it to

be used.

Domain 3:

analysis and

findings

Data analysis

24.

Number of data

coders How many data coders coded the data?

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Three researchers read all the transcripts. One coded them

all. 4 others double-coded segments.

25.

Description of the

coding tree

Did authors provide a description of the coding tree?

The main themes and subthemes are provided in Figure 2.

26. Derivation of themes

Were themes identified in advance or derived from the data?

Both. The main four themes were adapted from Mountford-

Zimdars et al, but the researchers also allowed themes to

arise from the data.

27. Software

What software, if applicable, was used to manage the data?

NVivo.

28. Participant checking

Did participants provide feedback on the findings?

No.

Reporting

29. Quotations presented

Were participant quotations presented to illustrate the

themes / findings? Was each quotation identified? e.g.

participant number

Yes, participant ethnicity, gender, country of primary medical

qualification and stage of training/ trainer.

30.

Data and findings

consistent

Was there consistency between the data presented and the

findings?

Yes. The dataset was very large so we have presented the

main findings in relation to the research questions. Other

write-ups have presented some of the other sub-themes that

arose from the data which relate to other research questions

(e.g. in relation to women and work-life balance, the validity

of workplace based assessments, and protective processes

that can help trainees progress well in spite of risks).

31.

Clarity of major

themes

Were major themes clearly presented in the findings?

Yes.

32.

Clarity of minor

themes

Is there a description of diverse cases or discussion of minor

themes?

Yes.

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