Differential Attainment in Career Progression for Doctors in the UK A Scoping Review
Main Article Content
Differential attainment in career progression in the NHS is a complex issue with many interplaying factors apart from individual protected characteristics. In this paper, we examine the attainment gap, causes for these disparities and some recommendations to reduce the gap.
Our review shows that there is significant DA between groups of doctors on the basis of gender, ethnicity, race and country of primary medical qualification. The likely causes are bias, lack of opportunity, poor supervision, mentorship, sponsorship, dichotomous treatment of doctors based on training or non-training status and cultural exclusion. Data is not monitored or reported and there is little organisational accountability. Solutions are likely to include transparent data on recruitment as well as progression for benchmarking, training support for all doctors, initiatives which are sensitive to gender, parental responsibility, cultural heritage, language and robust supervision including mentorship and sponsorship.
This scoping review forms part of the Alliance for Equality in Healthcare Professions project on Differential Attainment chaired by the British Association of Physicians of Indian Origin (BAPIO) and will be integrated into the Bridging the Gap project undertaken by BAPIO Institute for Health Research (BIHR). This work is part of six domains of doctors' careers in the NHS.
This work is licensed under a Creative Commons Attribution 4.0 International License.
2. McArdle J. Medical training pathway [Internet]. The British Medical Association is the trade union and professional body for doctors in the UK. [cited 2020 Dec 29]. Available from: https://www.bma.org.uk/advice-and-support/studying-medicine/becoming-a-doctor/medical-training-pathway
3. Shape of Training and the physician training model [Internet]. JRCPTB. 2015 [cited 2020 Dec 29]. Available from: https://www.jrcptb.org.uk/imt
4. Specialist applications and certificates statistics [Internet]. [cited 2020 Dec 29]. Available from: https://www.gmc-uk.org/about/what-we-do-and-why/data-and-research/medical-practice-statistics-and-reports/specialist-applications-and-certificates
5. Out of programme (OOP) [Internet]. [cited 2020 Dec 29]. Available from: https://www.gmc-uk.org/education/standards-guidance-and-curricula/guidance/out-of-programme
6. insight-paper---sas-and-leds.pdf [Internet]. [cited 2020 Dec 29]. Available from: https://www.gmc-uk.org/-/media/documents/insight-paper---sas-and-leds.pdf
7. Protocol for Thematic Synthesis of Differential Attainment in the Medical Profession - ‘Bridging the Gap’ Series | Sushruta Journal of Health Policy & Opinion [Internet]. [cited 2020 Oct 31]. Available from: https://www.sushrutajnl.net/index.php/sushruta/article/view/91
8. The association between trainee demographic factors and self-reported experience: Analysis of General Medical Council National Training Survey 2014 and 2015 data - Dipender Gill, 2016 [Internet]. [cited 2020 Dec 29]. Available from: https://journals.sagepub.com/doi/10.1177/2054270416632705
9. Doctors with disabilities [Internet]. Health Careers. 2015 [cited 2020 Dec 29]. Available from: https://www.healthcareers.nhs.uk/explore-roles/doctors/career-opportunities-doctors/doctors-disabilities
10. Patterson C. Disabled doctors struggle with inclusivity, finds survey [Internet]. The British Medical Association is the trade union and professional body for doctors in the UK. [cited 2020 Dec 29]. Available from: https://www.bma.org.uk/news-and-opinion/disabled-doctors-struggle-with-inclusivity-finds-survey
11. Less Than Full-time Training in surgical specialities: Consensus recommendations for flexible training by the Association of Surgeons in Training - ScienceDirect [Internet]. [cited 2020 Dec 29]. Available from: https://www.sciencedirect.com/science/article/pii/S1743919115012030
12. Skinner H, Bhatti F. Women in surgery. Bull R Coll Surg Engl. 2019 Aug 31;101(suppl_6):12–4.
13. How to reduce the stress of general dental practice: The need for research into the effectiveness of multifaceted interventions | British Dental Journal [Internet]. [cited 2020 Dec 29]. Available from: https://www.nature.com/articles/4813463
14. Independent review into gender pay gaps in medicine in England [Internet]. GOV.UK. [cited 2020 Dec 29]. Available from: https://www.gov.uk/government/publications/independent-review-into-gender-pay-gaps-in-medicine-in-england
15. Lachish S, Svirko E, Goldacre MJ, Lambert T. Factors associated with less-than-full-time working in medical practice: results of surveys of five cohorts of UK doctors, 10 years after graduation. Hum Resour Health. 2016 Oct 13;14(1):62.
16. NHS England » Workforce Race Equality Standard data reporting – 2019 [Internet]. [cited 2020 May 24]. Available from: https://www.england.nhs.uk/publication/workforce-race-equality-standard-data-reporting-2019/
17. 2019 survey of medical certificate of completion of training (CCT) holders’ career progression [Internet]. RCP London. 2020 [cited 2020 Dec 29]. Available from: https://www.rcplondon.ac.uk/projects/outputs/2019-survey-medical-certificate-completion-training-cct-holders-career-progression
18. Illsley A. Time to look more closely at attitudes to less than full time working? Br J Hosp Med. 2020 Feb 2;81(2):1–3.
19. ‘Mainstreaming’ of less than full‐time training - Jones - 2015 - Anaesthesia - Wiley Online Library [Internet]. [cited 2020 Dec 29]. Available from: https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/anae.13096
20. Part-time working: full-time professionalism | RCP Journals [Internet]. [cited 2020 Dec 29]. Available from: https://www.rcpjournals.org/content/clinmedicine/9/6/560
21. Rickard C, Smith T, Scallan S. A comparison of the learning experiences of full-time (FT) trainees and less than full-time (LTFT) trainees in general practice. Educ Prim Care. 2012 Jan 1;23(6):399–403.
22. Rippin H, Buckley EG. The educational needs of staff grade doctors and dentists in Scotland. Health Bull (Edinb). 1996 Jul;54(4):318–31.
23. sas-and-le-doctors-survey-initial-findings-report-060120_pdf-81152021.pdf [Internet]. [cited 2020 Dec 29]. Available from: https://www.gmc-uk.org/-/media/documents/sas-and-le-doctors-survey-initial-findings-report-060120_pdf-81152021.pdf
24. Retrospective granting of CCT to doctors granted a CESR through the combined programme [Internet]. [cited 2020 Dec 29]. Available from: https://www.gmc-uk.org/registration-and-licensing/join-the-register/registration-applications/specialist-application-guides/retrospective-cct-for-doctors-with-cesr-combined-programme
25. Nunn S. Understanding differential attainment across medical training pathways: A rapid review of the literature. :89.
26. Schwartz SJ. Rethinking the concept of acculturation: Implications for theory and research. [Internet]. Vol. 65, American Psychologist. US: American Psychological Association; 20100510 [cited 2020 Dec 29]. p. 237. Available from: /fulltext/2010-08987-001.html
27. Brown R, Zagefka H, Tip LK. Acculturation in theUnited Kingdom. In: Sam DL, Berry JW, editors. The Cambridge Handbook of Acculturation Psychology [Internet]. 2nd ed. Cambridge: Cambridge University Press; 2016 [cited 2020 Dec 29]. p. 375–95. (Cambridge Handbooks in Psychology). Available from: https://www.cambridge.org/core/books/cambridge-handbook-of-acculturation-psychology/acculturation-in-theunited-kingdom/DB4DA8C6081A32B562D6948FF41701AA
28. Culture of the United Kingdom. In: Wikipedia [Internet]. 2020 [cited 2020 Dec 29]. Available from: https://en.wikipedia.org/w/index.php?title=Culture_of_the_United_Kingdom&oldid=995438707
29. Mallows D, British Council. Language issues in migration and integration: perspectives from teachers and learners. 2014.
30. Woolf K. Fair Training Pathways for All: Understanding Experiences of Progression - Final Report. :69.
31. Rich A, Viney R, Needleman S, Griffin A, Woolf K. ‘You can’t be a person and a doctor’: the work–life balance of doctors in training—a qualitative study. BMJ Open [Internet]. 2016 Dec 1 [cited 2020 Jan 21];6(12). Available from: https://bmjopen.bmj.com/content/6/12/e013897
32. Woolf K, Viney R, Rich A, Jayaweera H, Griffin A. Organisational perspectives on addressing differential attainment in postgraduate medical education: a qualitative study in the UK. BMJ Open [Internet]. 2018 Mar 9 [cited 2020 Jan 21];8(3). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5855204/
33. Humphries N, Tyrrell E, McAleese S, Bidwell P, Thomas S, Normand C, et al. A cycle of brain gain, waste and drain - a qualitative study of non-EU migrant doctors in Ireland. Hum Resour Health. 2013 Dec 9;11(1):63.
34. Singhal K, Ramakrishnan K. Training Needs Of International Medical Graduates Seeking Residency Training: Evaluation Of Medical Training In India And The United States. Internet J Fam Pract [Internet]. 2003 Dec 31 [cited 2020 Dec 29];3(1). Available from: https://ispub.com/IJFP/3/1/8127
35. 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. J Int Migr Integr. 2015 Aug 1;16(3):743–59.
36. Jones L, Halford S, Leonard P. Racism in the medical profession: the experience of UK graduates. 2003.
37. Meeuwesen L, van den Brink-Muinen A, Hofstede G. Can dimensions of national culture predict cross-national differences in medical communication? Patient Educ Couns. 2009 Apr;75(1):58–66.
38. Verma A, Griffin A, Dacre J, Elder A. Exploring cultural and linguistic influences on clinical communication skills: a qualitative study of International Medical Graduates. BMC Med Educ. 2016 Jun 10;16(1):162.
39. Cooper CL. Culture’s Consequences: International differences in work related values, Geert Hofstede, Sage Publications, London and Beverly Hils, 1980. No. of pages: 475. Price £18.75. J Organ Behav. 1982;3(2):202–4.
40. Morrow G, Rothwell C, Burford B, Illing J. Cultural dimensions in the transition of overseas medical graduates to the UK workplace. Med Teach. 2013 Oct 1;35(10):e1537–45.
41. Anekwe L. Harnessing the outrage: it’s time the NHS tackled racial bias. BMJ. 2020 Feb 11;368:m341.
42. Relationship between sociodemographic factors and selection into UK postgraduate medical training programmes: a national cohort study | BMJ Open [Internet]. [cited 2020 Dec 29]. Available from: https://bmjopen.bmj.com/content/8/6/e021329
43. Oroz C, Sands LR, Lee J. SAS doctors career progression survey 2013. Int J STD AIDS. 2016 Mar 1;27(3):231–4.
44. Lieberman MD, Rock D, Halvorson HG, Cox C. BREAKING BIAS UPDATED: THE SEEDS MODELTM. 2015;19.
45. Ng TWH, Eby LT, Sorensen KL, Feldman DC. Predictors of Objective and Subjective Career Success: A Meta-Analysis. Pers Psychol. 2005;58(2):367–408.
46. Wong A, Lohfeld L. Recertifying as a doctor in Canada: international medical graduates and the journey from entry to adaptation. Med Educ. 2008 Jan;42(1):53–60.
47. Shah R, Ahluwalia S. The challenges of understanding differential attainment in postgraduate medical education. Br J Gen Pract J R Coll Gen Pract. 2019 Sep;69(686):426–7.
48. Mountford-Zimdars A, Sanders J, Moore J, Sabri D, Jones S, Higham L. What can universities do to support all their students to progress successfully throughout their time at university? Perspect Policy Pract High Educ. 2017 Jul 3;21(2–3):101–10.
49. Woolf K, Rich A, Viney R, Needleman S, Griffin A. Perceived causes of differential attainment in UK postgraduate medical training: a national qualitative study. BMJ Open. 2016 25;6(11):e013429.
50. Woolf K, Rich A, Viney R, Needleman S, Griffin A. Perceived causes of differential attainment in UK postgraduate medical training: a national qualitative study. BMJ Open [Internet]. 2016 Nov 25 [cited 2020 Jul 8];6(11). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5168507/
51. R (BAPIO) v Royal College of General Practitioners & General Medical Council  EWHC 1416 (Admin) [Internet]. Equally Ours. [cited 2020 Aug 18]. Available from: https://www.equallyours.org.uk/0033-r-bapio-v-royal-college-of-general-practitioners-general-medical-council-2014-ewhc-1416-admin/
52. final-report-success-factors-in-training-211119-pdf_pdf-81634780.pdf [Internet]. [cited 2020 Nov 10]. Available from: https://www.gmc-uk.org/-/media/documents/final-report-success-factors-in-training-211119-pdf_pdf-81634780.pdf
53. addressing-the-barriers-to-BAME-employee-career-progression-to-the-top_tcm18-33336.pdf [Internet]. [cited 2020 Dec 29]. Available from: https://www.cipd.co.uk/Images/addressing-the-barriers-to-BAME-employee-career-progression-to-the-top_tcm18-33336.pdf
54. Atewologun D, Tresh F. Unconscious bias training : An assessment of the evidence for effectiveness [Internet]. 2018 [cited 2020 Jul 8]. Available from: /paper/Unconscious-bias-training-%3A-An-assessment-of-the-Atewologun-Tresh/509a580783bb5df10f3af42e8df720d8ad57dbd0
55. Duguid MM. Condoning stereotyping? How awareness of stereotyping prevalence impacts expression of stereotypes. [Internet]. Vol. 100, Journal of Applied Psychology. US: American Psychological Association; 20141013 [cited 2020 Dec 29]. p. 343. Available from: /fulltext/2014-43472-001.html
56. Devine PG, Forscher PS, Austin AJ, Cox WTL. Long-term reduction in implicit race bias: A prejudice habit-breaking intervention. J Exp Soc Psychol. 2012 Nov 1;48(6):1267–78.
57. Rai Y, Al-Uzri M. Medical Training Initiative (MTI) Psychiatry Scheme: Online survey of trainees’ experience. 2020;13(1):5.
58. Kehoe A, McLachlan J, Metcalf J, Forrest S, Carter M, Illing J. Supporting international medical graduates’ transition to their host‐country: realist synthesis. Med Educ. 2016 Oct;50(10):1015–32.
59. HEE supporting returners to work in the fight against the COVID-19 pandemic [Internet]. Health Education England. 2020 [cited 2020 Mar 21]. Available from: https://www.hee.nhs.uk/news-blogs-events/news/hee-supporting-returners-work-fight-against-covid-19-pandemic
60. Sandars J, Walsh K. The value of health professions education: the importance of understanding the learner perspective. Educ Prim Care. 2016 Jul 3;27(4):254–7.
61. Brown J, Kirton J, Shaw NJ, Murphy P, Clarke R. The training needs and career intentions of staff grade and associate specialist doctors. Br J Hosp Med. 2012 Sep 1;73(9):521–5.
62. Linton S. Taking the difference out of attainment. BMJ [Internet]. 2020 Feb 12 [cited 2020 Aug 6];368. Available from: https://www.bmj.com/content/368/bmj.m438