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Introduction Systematic and structural inequities in power and privilege create differential attainment whereby differences in average levels of performance are observed between students from different socio-demographic groups. This paper reviews the international evidence on differential attainment related to ethnicity/race in medical school, drawing together the key messages from research to date to provide guidance for educators to operationalize and enact change and identify areas for further research. Methods Authors first identified areas of conceptual importance within differential attainment (learning, assessment, and systems/institutional factors) which were then the focus of a targeted review of the literature on differential attainment related to ethnicity/race in medical education and, where available and relevant, literature from higher education more generally. Each author then conducted a review of the literature and proposed guidelines based on their experience and research literature. The guidelines were iteratively reviewed and refined between all authors until we reached consensus on the Do’s, Don’ts and Don’t Knows. Results We present 13 guidelines with a summary of the research evidence for each. Guidelines address assessment practices (assessment design, assessment formats, use of assessments and post-hoc analysis) and educational systems and cultures (student experience, learning environment, faculty diversity and diversity practices). Conclusions Differential attainment related to ethnicity/race is a complex, systemic problem reflective of unequal norms and practices within broader society and evident throughout assessment practices, the learning environment and student experiences at medical school. Currently, the strongest empirical evidence is around assessment processes themselves. There is emerging evidence of minoritized students facing discrimination and having different learning experiences in medical school, but more studies are needed. There is a pressing need for research on how to effectively redress systemic issues within our medical schools, particularly related to inequity in teaching and learning.

Introduction Solving disparities in assessments is crucial to a successful surgical training programme. The first step in levelling these inequalities is recognising in what contexts they occur, and what protected characteristics are potentially implicated. Methods This scoping review was based on Arksey & O’Malley’s guiding principles. OVID and Embase were used to identify articles, which were then screened by three reviewers. Results From an initial 358 articles, 53 reported on the presence of differential attainment in postgraduate surgical assessments. The majority were quantitative studies (77.4%), using retrospective designs. 11.3% were qualitative. Differential attainment affects a varied range of protected characteristics. The characteristics most likely to be investigated were gender (85%), ethnicity (37%) and socioeconomic background (7.5%). Evidence of inequalities are present in many types of assessment, including: academic achievements, assessments of progression in training, workplace-based assessments, logs of surgical experience and tests of technical skills. Conclusion Attainment gaps have been demonstrated in many types of assessment, including supposedly “objective” written assessments and at revalidation. Further research is necessary to delineate the most effective methods to eliminate bias in higher surgical training. Surgical curriculum providers should be informed by the available literature on inequalities in surgical training, as well as other neighbouring specialties such as medicine or general practice, when designing assessments and considering how to mitigate for potential causes of differential attainment.

ObjectivesInternational medical graduates (IMGs) perform less well in national postgraduate licensing examinations compared with UK graduates, even in computer-marked multiple-choice licensing examinations. We aimed to investigate thought processes of candidates answering multiple- choice questions, considering possible reasons for differential attainment between IMGs and UK graduates.DesignWe employed a semistructured qualitative design using cognitive interviews. Systematic grounded theory was used to analyse data from ‘think aloud’ interviews of general practitioner specialty trainees (GPSTs) while answering up to 15 live questions from the UK Membership of the Royal College of General Practitioners Applied Knowledge Test (AKT).SettingEast Midlands, UK.Participants21 GPSTs including 13IMGs and 8 UK-trained doctors.OutcomesPerceptions of participants on how they answered AKT questions together with strategies used or difficulties experienced.ResultsWe interviewed 21 GPSTs (8 female, 13 male, 13 IMGs, 14 from black and minority ethnic groups, age 24–64 years) in years 1–3 of training between January and April 2017. Four themes were identified. ‘Theoretical versus real-life clinical experience’: participants reported difficulties recalling information and responding to questions from theoretical learning compared with clinical exposure; rote learning helped some IMGs recall rare disease patterns. Recency, frequency, opportunity and relevance: participants reported greater difficulty answering questions not recently studied, less frequently encountered or perceived as less relevant. Competence versus insight: some participants were over optimistic about their performance despite answering incorrectly. Cultural barriers: for IMGs included differences in undergraduate experience, lack of familiarity with UK guidelines and language barriers which overlapped with the other themes.ConclusionsThe difficulties we identified in candidates when answering AKT questions may be addressed through training. IMGs face additional difficulties which impede examination success due to differences in educational experience, content familiarity and language, which are also potentially amenable to additional training support.

Background Asian medical students and doctors receive lower scores on average than their white counterparts in examinations in the UK and internationally (a phenomenon known as “differential attainment”). This could be due to examiner bias or to social, psychological or cultural influences on learning or performance. We investigated whether students’ scores or feedback show influence of ethnicity-related bias; whether examiners unconsciously bring to mind (activate) stereotypes when judging Asian students’ performance; whether activation depends on the stereotypicality of students’ performances; and whether stereotypes influence examiner memories of performances. Methods This is a randomised, double-blinded, controlled, Internet-based trial. We created near-identical videos of medical student performances on a simulated Objective Structured Clinical Exam using British Asian and white British actors. Examiners were randomly assigned to watch performances from white and Asian students that were either consistent or inconsistent with a previously described stereotype of Asian students’ performance. We compared the two examiner groups in terms of the following: the scores and feedback they gave white and Asian students; how much the Asian stereotype was activated in their minds (response times to Asian-stereotypical vs neutral words in a lexical decision task); and whether the stereotype influenced memories of student performances (recognition rates for real vs invented stereotype-consistent vs stereotype-inconsistent phrases from one of the videos). Results Examiners responded to Asian-stereotypical words (716 ms, 95% confidence interval (CI) 702–731 ms) faster than neutral words (769 ms, 95% CI 753–786 ms, p  < 0.001), suggesting Asian stereotypes were activated (or at least active) in examiners’ minds. This occurred regardless of whether examiners observed stereotype-consistent or stereotype-inconsistent performances. Despite this stereotype activation, student ethnicity had no influence on examiners’ scores; on the feedback examiners gave; or on examiners’ memories for one performance. Conclusions Examiner bias does not appear to explain the differential attainment of Asian students in UK medical schools. Efforts to ensure equality should focus on social, psychological and cultural factors that may disadvantage learning or performance in Asian and other minority ethnic students.

Presenting the results from a mixed methods case-study, this paper draws together insight from the fields of ‘BME attainment’ and ‘student transition’ to explore how differential levels of degree attainment might be experienced within the context of a higher tariff university in England. Across a five-year period (2010/11–2014/2015) it compares the levels of degree attainment between UK-domiciled White and Black and Minority Ethnic (BME) students in relation to prior attainment, qualification type, and socioeconomic group (POLAR 3). A range of qualitative data then outlines a series of dynamic factors that can, when compounded, serve to constrain BME students’ capability to negotiate their way through very particular university landscapes. These include: academic expectation and preparedness; the pedagogic terrain; pastoral engagement and sense of belonging finance; and, the lived experience of diversity and ‘othering’. The paper argues that attainment gaps should not be viewed in terms of an individual deficit that needs to be ‘fixed’ or ‘filled’. Instead, greater attention needs to be directed toward enhancing the capacity of higher tariff universities to respond positively to the needs of a changing demographic.

Background Differences exist among doctors in examination performance, clinical and academic career progression, and prevalence of performance assessment by professional regulatory bodies. Some of these differences have been reported in relation to individual characteristics. The purpose of this study is to establish whether any specific individual characteristics are associated with performance in selection for entry into specialty training in Intensive Care in the United Kingdom. Methods We evaluated data of 509 candidates from the national recruitment rounds of 2018/19 and 2019/20. The outcome evaluated was “success at interview\". Variables reaching statistical significance at univariate logistic regression analysis were fed in the multivariable analysis to identify independent predictors of success, with additional exploratory analyses performed, where indicated. Results The candidates’ median age was 31.5 (interquartile range, IQR 30–33.7) years, 324 (63.7%) were male, 256 (50.3%) not married/in civil partnership, 6 (1.2%) pregnant. The majority (316, 62.1%) were White British, 99 (19.5%) of Asian background, other ethnicities represented less than 20% of the sample. Of the 509 candidates, 155 (30.5%) were Atheist, 140 (27.5%) Christian; most were heterosexual (440, 86.4%); 432 (84.9%) reported no disability, while 4 (0.8%) had a minor and 1 (0.2%) had a major disability; 432 (84.9%) candidates held a UK medical degree; 77 (15.1%) a non-UK degree. At univariate logistic regression analysis (LRA) multiple factors were found to be associated with a lower likelihood of success, the strongest being an international medical graduate (IMG, holding a non-UK medical degree); others were increasing age, male gender, being married, Asian or mixed ethnicity, specific religious beliefs (Buddhism, Islam and Hinduism). After feeding all factors significant at univariate analysis, the only two retained as independent predictors at multivariable regression were Asian ethnicity and holding a non-UK degree. Asian UK graduates success rate was 92.7%, comparable to the national average of 92.3%, the Asian IMGs success rate was significantly lower, at 45.5%. Conclusions As the imbalances seen within the candidates of Asian background are explained by considering the country of primary medical training, the variations in performance is likely to reflect differences in training systems and understanding of the UK NHS.

Background International Medical Graduates (IMGs) are known to perform less well in many postgraduate medical examinations when compared to their UK trained counterparts. This “differential attainment” is observed in both knowledge-based and clinical skills assessments. This study explored the influence of culture and language on IMGs clinical communication skills, in particular, their ability to seek, detect and acknowledge patients’ concerns in a high stakes postgraduate clinical skills examination. Hofstede’s cultural dimensions framework was used to look at the impact of culture on examination performance. Methods This was a qualitative, interpretative study using thematic content analysis of video-recorded doctor-simulated patient consultations of candidates sitting the MRCP(UK) PACES examination, at a single examination centre in November 2012. The research utilised Hofstede’s cultural dimension theory, a framework for comparing cultural factors amongst different nations, to help understand the reasons for failure. Results Five key themes accounted for the majority of communication failures in station 2, “history taking” and station 4, “communication skills and ethics” of the MRCP(UK) PACES examination. Two themes, the ability to detect clues and the ability to address concerns, related directly to the overall construct managing patients’ concerns . Three other themes were found to impact the whole consultation. These were building relationships, providing structure and explanation and planning. Conclusion Hofstede’s cultural dimensions may help to contextualise some of these observations. In some cultures doctor and patient roles are relatively inflexible: the doctor may convey less information to the patient (higher power distance societies) and give less attention to building rapport (high uncertainty avoidance societies.) This may explain why cues and concerns presented by patients were overlooked in this setting. Understanding cultural differences through Hofstede’s cultural dimensions theory can inform the preparation of candidates for high stakes bedside clinical skills examinations and for professional practice.

ObjectivesTo explore how representatives from organisations with responsibility for doctors in training perceive risks to the educational progression of UK medical graduates from black and minority ethnic groups (BME UKGs), and graduates of non-UK medical schools (international medical graduates (IMGs)). To identify the barriers to and facilitators of change.DesignQualitative semistructured individual and group interview study.SettingPostgraduate medical education in the UK.ParticipantsIndividuals with roles in examinations and/or curriculum design from UK medical Royal Colleges. Employees of NHS Employers.ResultsRepresentatives from 11 medical Royal Colleges (n=29) and NHS Employers (n=2) took part (55% medically qualified, 61% male, 71% white British/Irish, 23% Asian/Asian British, 6% missing ethnicity). Risks were perceived as significant, although more so for IMGs than for BME UKGs. Participants based significance ratings on evidence obtained largely through personal experience. A lack of evidence led to downgrading of significance. Participants were pessimistic about effecting change, two main barriers being sensitivities around race and the isolation of interventions. Participants felt that organisations should acknowledge problems, but felt concerned about being transparent without a solution; and talking about race with trainees was felt to be difficult. Participants mentioned 63 schemes aiming to address differential attainment, but these were typically local or specialty-specific, were not aimed at BME UKGs and were largely unevaluated. Participants felt that national change was needed, but only felt empowered to effect change locally or within their specialty.ConclusionsRepresentatives from organisations responsible for training doctors perceived the risks faced by BME UKGs and IMGs as significant but difficult to change. Strategies to help organisations address these risks include: increased openness to discussing race (including ethnic differences in attainment among UKGs); better sharing of information and resources nationally to empower organisations to effect change locally and within specialties; and evaluation of evidence-based interventions.

The unequal distribution of academic and professional outcomes between different minority groups is a pervasive issue in many fields, including surgery. The implications of differential attainment remain significant, not only for the individuals affected but also for the wider health care system. An inclusive health care system is crucial in meeting the needs of an increasingly diverse patient population, thereby leading to better outcomes. One barrier to diversifying the workforce is the differential attainment in educational outcomes between Black and Minority Ethnic (BME) and White medical students and doctors in the United Kingdom. BME trainees are known to have lower performance rates in medical examinations, including undergraduate and postgraduate exams, Annual Review of Competence Progression, as well as training and consultant job applications. Studies have shown that BME candidates have a higher likelihood of failing both parts of the Membership of the Royal Colleges of Surgeons exams and are 10% less likely to be considered suitable for core surgical training. Several contributing factors have been identified; however, there has been limited evidence investigating surgical training experiences and their relationship to differential attainment. To understand the nature of differential attainment in surgery and to develop effective strategies to address it, it is essential to examine the underlying causes and contributing factors. The Variation in Experiences and Attainment in Surgery Between Ethnicities of UK Medical Students and Doctors (ATTAIN) study aims to describe and compare the factors and outcomes of attainment between different ethnicities of doctors and medical students. The primary aim will be to compare the effect of experiences and perceptions of surgical education of students and doctors of different ethnicities. This protocol describes a nationwide cross-sectional study of medical students and nonconsultant grade doctors in the United Kingdom. Participants will complete a web-based questionnaire collecting data on experiences and perceptions of surgical placements as well as self-reported academic attainment data. A comprehensive data collection strategy will be used to collect a representative sample of the population. A set of surrogate markers relevant to surgical training will be used to establish a primary outcome to determine variations in attainment. Regression analyses will be used to identify potential causes for the variation in attainment. Data collected between February 2022 and September 2022 yielded 1603 respondents. Data analysis is yet to be competed. The protocol was approved by the University College London Research Ethics Committee on September 16, 2021 (ethics approval reference 19071/004). The findings will be disseminated through peer-reviewed publications and conference presentations. Drawing upon the conclusions of this study, we aim to make recommendations on educational policy reforms. Additionally, the creation of a large, comprehensive data set can be used for further research. DERR1-10.2196/40545.

Given our increasingly diverse societies, there is an urgent need for research into the causes of persistent ethnic disparities in undergraduate clinical performance. It is argued that causes for underperformance can be identified from two perspectives, namely that of the students (‘them’) and that of the academic environment (‘us’). Taking the ‘us’ perspective, Yeates et al. conducted a detailed experimental study aimed at understanding the processes underlying judgment and decision-making in clinical assessments. Contrary to their expectations, their study indicates that, despite the presence of active stereotypes, examiner bias does not explain ethnic minority students’ underperformance. Naturally, future studies are required to confirm their findings. It is suggested that these studies should take into account various rater and situational factors (e.g. rater experience, increased cognitive load) that may influence examiners’ reliance on stereotypes. However, future work should also focus on other potential impeding factors from both perspectives, including differences in communication styles. Knowing what leads to the ethnic disparities in performance is a prerequisite for designing interventions aimed at ensuring a level playing field for a diverse student population. Please see related article: https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-017-0943-0