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

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 semistructured focus group and interview study.

Setting: Postgraduate training in England (London, Yorkshire and 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 and gynaecology, psychiatry, radiology, surgery or foundation, in 4 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 (UKGs) and international medical graduates (IMGs) 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.

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

Figure 1

Participant demographics. BME, black and minority ethnic; IMG, international medical graduate; PMQ, primary medical qualification.

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. BME, black and minority ethnic; IMG, international medical graduate; UKG, UK graduate.