This blog post is written by Sara Thompson (GP), Morounkeji Ogunrinde (GP), Zenni Emeka-Enechi (Medical student) and Natalie Amavih-Mensah (Medical student).

Racism in healthcare concerns everyone

Racism and racial inequality are deeply rooted in societies and institutions worldwide. Britain is no exception.

For many, 2020 was a clarion call to address various ills plaguing our society. Although the time in isolation and lockdown brought significant emotional stress, it also forced us to confront long-standing systemic concerns based on race and our misconceptions of one another. In 2020, the BMJ published its first special report on racism in healthcare since its inauguration in the 1800s.¹ In the UK, racial disparities occur in fields as varied as genetic counselling, artificial intelligence, and medical school admissions.² These inequalities expose ethnic minorities to a higher risk of chronic conditions.³

Racism, not race, perpetuates health disparities

The NHS is regarded as a fair and equitable tool for distributing health care services, and its accomplishments have been praised worldwide. Yet, despite this, one in five black women in the UK die in and around childbirth.⁴ Black men are ten times more likely to face discrimination when presenting with a mental health illness.⁵

Training on microaggressions and implicit bias have minimal effect on outcomes and cannot facilitate change without a corresponding shift in the system.⁶ Attempts to haphazardly reduce these disparities without addressing the root causes have been problematic e.g. the #NotsoNICE campaign.⁷ NICE proposed draft guidelines to reduce maternal mortality among Black, Asian and minority ethnic people by encouraging inducing labour.⁸ The guideline did not address the principal factors of racism and neglect, sparking outcry and disillusionment. Race-based medicine provides crude shortcuts to clinical judgement that is harmful to patients from BAME communities.⁹

World-renowned science journalist Angela Saini refers to race as a social construct that we should challenge. She reports that we “tailor” clinical decisions about patient treatment considering race without any substantial scientific basis of delineating what terms like “Caucasian” or “Black” mean¹⁰; we have created a subjective ‘science’ that is not scientific at all.

The healthcare and minority ethnic groups divide

Patients of colour are disproportionately vulnerable to misdiagnosis and undertreatment. Consequently, patients from ethnic minorities have poorer outcomes in healthcare and fewer opportunities to access healthy living.³

A lack of diverse, inclusive education precipitates insidious doubt and mistrust recently exemplified by the suspicion and hesitation of the ethnic minorities communities towards the COVID-19 vaccine.¹¹

Health Care Professionals (HCPs) and students come to accept racial biases and aggressions as the norm. Some  professionals from ethnic minority groups are reticent to voice concerns for fear of being undermined or receiving backlash. HCPs from ethnic minority groups are more likely to be blamed for errors and are victim to disproportionately more disciplinary action.¹²

Students from ethnic minority groups may not report racial aggressions because they believe their medical school will not take them seriously.¹³ There is a performance gap in UK medical schools. Black students are more likely to underperform compared to their white counterparts.¹⁴

People from ethnic minority communities are less likely to participate in research studies and initiatives to improve health outcomes. Thus, there is less data available, biasing research and policy.¹⁵

Natalie’s experiences as an ethnic minority patient

Feeling unheard and misunderstood is debilitating. I struggled with acne since high school. I was only referred to dermatology after three years. I cannot be sure if my race played a part intentionally, or unintentionally; however, significant distress was caused.

Insecurities, caused by acne, stifled my confidence. I believed that the condition defined me. My GP practice consistently dismissed my concerns making me think that the acne was my fault. I felt powerless and alone. Understanding the variations in presentation among different skin tones is not just about treating a single condition; it is also about preventing and remedying the subsequent destructive psychological thinking patterns.

The Diversifying Dermatology in Primary Care Working Group

We aim to understand the patient experience and to increase the diversity of educational resources available, we want to raise awareness that conditions as common as acne and eczema present differently on different skin tones and educate on how to better diagnose and manage these conditions on darker skin. We won a “Listen and “Learn” grant, with which we held interviews to understand service users’ experience. Mimms Learning has developed an e-learning module addressing several questions on how and when black skin will look significantly different. ¹⁶ Our collaboration with Black & Brown Skin aims to facilitate community members to continue to support each other by creating a forum for shared experiences and a growing image library accessible to clinicians worldwide.

We hope that, by increasing the variety of resources available, the quality of education will improve, leading to higher quality care for patients thus enhancing patients’ trust in the health care service created to treat and serve them.

Conclusion

Reform takes time. We need to overturn and redefine ideas about race that have persisted for centuries. There will be uncomfortable conversations and we will have to overcome indifference and resistance to change.

Decolonising the curriculum is not a fad; it is something that we must continue, even when the world is not watching. With dedication, persistence and unity, there is hope for a better future – for all skin tones.

Additional Information

Quiz on Dermatology in Black and Brown Skin

Bimpe and Zainab: Bimpe (UCL medical student) talking to Zainab about atopic dermatitis.mp4

Zenni and Malone:Zenni (UCL medical student) interviewing Malone Mukwende (Founder of blackandbrownskin.co.uk).MOV

Honey and Natalie:Honey (UCL medical student) talking to Natalie about acne vulgaris.mp4

References

1. https://www.bmj.com/racism-in-medicine
2. Adebowale, V., Rao M. Racism in medicine: why equality matters to everyone. BMJ [online] 2020;368:m530 . Available from: doi: https://doi.org/10.1136/bmj.m530
3. McKenna, H., 2019. Professor David Williams on racism, discrimination and the impact they have on health. [podcast] The King’s Fund. Available from: <https://www.kingsfund.org.uk/audio-video/podcast/david-williams-racism-discrimination-health>
4. https://www.bmj.com/content/372/bmj.n152
5. https://www.mind.org.uk/news-campaigns/legal-news/legal-newsletter-june-2019/discrimination-in-mental-health-services
6. Sharda S, Dhara A. It’s Time To Talk: Gender and Race in Medicine. CMAJ Blogs July 2019
7. Lewin, L. The #NotSoNice Campaign [online]. The OBS: England; 2021 [Accessed 30th August 2021] Available from: https://the-obs.co.uk/your-doula/
8. National Institute for Health and Care Excellence. ​​NICE recommends offering women induced labour earlier in new draft guidance [online]. NICE: London; 2021 [Accessed 20th August 2021]. Available from:https://www.nice.org.uk/news/article/nice-recommends-inducing-women-in-labour-earlier-in-new-draft-guidance
9. Chadha, N., Lim, B., Kane, M., et al. Toward the Abolition of Biological Race in Medicine. UC Berkeley [online] 2020; 4-6, 16-19. Available at: <https://escholarship.org/uc/item/4gt3n0dd>
10. https://www.angelasaini.co.uk/
11. Lockyer, B, Islam, S,  Rahman, A, et al;  the Bradford Institute for Health Research Covid-19 Scientific Advisory Group.  Understanding COVID-19 misinformation and vaccine hesitancy in context: Findings from a qualitative study involving citizens in Bradford, UK. [online]. Health Expect.  2021; 24: 1158– 1167. Available from: https://doi.org/10.1111/hex.13240
12. Majid, A. What lies beneath: getting under the skin of GMC referrals BMJ [online] 2020;368:m338 . Available from: doi: https://doi.org/10.1136/bmj.m338
13. Kmietowicz, Z. Are medical schools turning a blind eye to racism? BMJ [online] 2020;368:m420 . Available from: doi: https://doi.org/10.1136/bmj.m420
14. Jones, A. C. , Nichols, A. C. , McNicholas, C. M. & Stanford, F. C. Admissions Is Not Enough: The Racial Achievement Gap in Medical Education. Acad Med [online]  2021;96 (2):176-181. Available from: doi:10.1097/ACM.0000000000003837.
15. Smart, A., Harrison, E. The under-representation of minority ethnic groups in UK medical research. Ethnicity & Health [online] 2017;22(1): 65-82. Available from: doi: 1080/13557858.2016.1182126
16. https://www.mimslearning.co.uk/learning-paths/skin-of-colour-disorders-of-pigmentation-and-hair-and-scalp-conditions

In this post Marta Buszewicz discusses her recent trip to the WONCA European conference and her workshop on medically unexplained symptoms. 

It’s conference season and this is another blog about the benefits of travelling abroad to meet with colleagues. At the end of May I attended the WONCA Europe conference in Krakow, Poland. This had over 1,000 delegates, including from several non-European countries, as well as many European ones. The largest number of delegates came from Scandinavian countries and the Netherlands, with rather fewer from the UK.

I gave an oral presentation about our recent qualitative study exploring the distress and mental health difficulties experienced by a sample of English GPs and the barriers to getting effective support, which was well received. I also ran a workshop on the topic of ‘Encouraging clinicians to work effectively with people with medically unexplained symptoms’ which is the main topic for this blog.

I was concerned that this workshop might not be very well attended as it was placed late in the conference programme and there were many parallel sessions and workshops in each time slot. However, 20 clinicians attended from 8 different countries – (Belgium, Estonia, Finland, Indonesia, Israel, Moldova, Portugal and the UK) – which I was very impressed by, as well as the ability of most of those present to discuss complicated issues in English, despite it not being their first or sometimes even their second language.

I presented some background information about the high prevalence of medically unexplained / functional symptoms in primary care and a summary of findings from three qualitative studies conducted by members of PCPH – Mary Howman, Alex Warner and Katie Yon – exploring the attitudes of GP registrars, hospital clinicians and Foundation year doctors to working with such patients.

We then had time for a discussion about how to address the management of such patients, as well as the question of clinician attitudes. This is clearly a common issue internationally and no-one at the workshop had any difficulty identifying such presentations in the patients they see as GPs and quite often found them challenging. However, the discussion also brought up some interesting observations and perspectives from different countries.

Ideas I particularly took away included a clear wish from all those attending that this topic should be introduced from the beginning of the medical school curriculum, with the possibility of non-organic causes for patients’ symptoms and dealing with uncertainty being revisited throughout students’ training.

There was also an interesting discussion about working more effectively across the primary-secondary care interface, which is something which may be particularly relevant with such patients. There were clear differences in how easy it was to make good links with hospital specialists to enable discussions about individual patients – this seemed more likely in smaller less densely populated countries like Finland or Estonia. Several participants suggested that primary care clinicians probably had a better understanding of how to work with patients with unexplained symptoms and that there might be a role for them in educating the hospital clinicians! The importance of family history and past experiences of illness in taking a history from such patients was also emphasised and I’m not sure how often this is done.

I found discussing these issues with colleagues from different countries and health care systems very stimulating and thought-provoking and would strongly encourage junior researchers to present their work at international conferences where possible in order to get some new perspectives.

Krakow is a very beautiful city with a renowned mediaeval marketplace, a castle complex and cathedral on the banks of the river Vistula. The new state of the art conference centre is on the other side of the river and only 10 minutes walk from the castle and the beginning of the old town, so it was possible to include some cultural visits in my time there.

Very topical in the news right now are the recruitment rates of trainees into the specialties of general practice and psychiatry.  In the post Amber Appleton Amber  an NIHR Academic Clinical Fellow and GPST4 talks about her experience of choosing general practice and the experiences of other trainees. 

When I began as a GP Academic Clinical Fellow (ACF), I wanted to do something different and was keen to conduct my own research project. I had the idea for it not that long ago when I applied for my current GP training post, and at the same time I also applied for psychiatry training.  I struggled to choose between these two specialties, and although I did not choose psychiatry my interest has never dwindled. I still remember the day I became interested in psychiatry as a medical student when I was taught by an inspiring psychiatrist. Because of this, I wanted to find out what made others choose psychiatry and to explore whether it was also related to their medical school teaching experiences.

By designing and seeing through my own project, the research, teamwork, organisation and communication skills I have gained from the experience have been profound. Marta Buszewicz has supervised me along with Surinder Singh, both of whom have provided invaluable support and guidance throughout the project, which has really nurtured my learning throughout my ACF post.

So, to give a bit of background to the rationale behind the project…

One in four people in the UK will experience a mental health problem each year. The first person they may talk to is their GP who sees most of the people with mental health problems in the community, and then those with the most complex or severe cases may be referred to a psychiatrist if indicated. The overlap between psychiatry and general practice is especially significant as approximately a third of GP consultations are for mental health problems.

As a result, both GP and psychiatry are essential for ensuring good patient care and there is an on going need to recruit competent doctors into these specialties – throughout the UK. Unfortunately, both psychiatry and general practice have been experiencing real recruitment problems with one in three training posts in both GP and psychiatry currently left vacant.

I was interested in exploring some of the factors before, during and after medical school, which ultimately result in trainees choosing a career in psychiatry. I was hoping that this information might help to improve the way these specialties are taught at medical school, which could encourage more doctors to sign up to this important specialty and also potentially improve attitudes amongst all future doctors towards mental health problems.

I designed a web-based survey to explore the views of psychiatry trainees nationally, followed by conducting qualitative in-depth interviews with a group of 21 purposively sampled London psychiatry trainees. The whole research team analyzed the interview findings.

Many trainees said their attitudes had changed after being taught psychiatry at medical school and that the placement influenced their career choice, although the quality of the teaching was very important and some people had not had such good experiences.  A significant number of those interviewed described how doing a Foundation job in psychiatry (a 4 month post in the first two years after graduating from medical school) had had a significant impact on their career choice. Currently only around half of junior doctors do a Foundation year post in psychiatry, but this is under review. Most trainees felt positive about the idea of teaching about physical and mental health problems together during the curriculum, rather than separately (as has quite recently been introduced at UCL Medical School), but it was thought very important that this shouldn’t dilute the amount of psychiatry teaching overall.

One of the main barriers trainees described that they had to overcome when choosing psychiatry was stigma from colleagues/peers and family members. One respondent described the response she received when speaking openly about considering applying for a career in psychiatry.

P5 Female ST7:

I said: “I’m thinking of actually applying for psychiatry as well as general practice.” And she (Foundation year two supervisor) said: “What a shame.”

The “badmouthing of general practice and psychiatry” has been highlighted in a recent BJGP paper (1) as a subtle but important factor influencing graduates’ career choices: quite simply why would a junior doctor choose a specialty looked down upon by other members of their profession?

The psychiatry trainees interviewed had attended a range of UK medical schools and provided a range of recommendations for improving the way psychiatry is taught at medical school, as well as suggesting other strategies to improve recruitment to the specialty.

Summary of the key findings:

1. Medical school placements in psychiatry should be introduced early and integrated throughout the curriculum to help prevent negative attitudes developing.

2. Positive role models and mentors were described as key and there should be greater visibility of prominent psychiatrists within medical schools.

3. Barriers to choosing psychiatry that were described included: the stigma still associated with mental illness and feeling ‘not a proper doctor’, as well as the emotional stress and responsibility involved with decision making in psychiatry.

Recommendations:

• Outreach projects into secondary schools
• Buddy schemes and mentors should be offered widely
• Negative attitudes at medical school towards specialties such as psychiatry and general practice need to be challenged
• More Foundation posts should be offered in psychiatry

Recruitment into the twin specialties of psychiatry and GP continues to be problematic and the key messages from this paper suggest that appropriate interventions are needed at all stages, i.e. before, during and after students’ time in medical school.

The full published paper is now available from BMC Psychiatry 

1. Baker, M., Wessely, S., & Openshaw, D. (2016). Not such friendly banter? GPs and psychiatrists against the systematic denigration of their specialties. Br J Gen Pract 2016; 66 (651): 508-509.

In this months post Katie Yon and Dr Marta Buszewicz talk about their recent study of medically unexplained symptoms amongst junior doctors.

Straight after qualifying, junior doctors in their first two foundation years of training are expected to see and manage patients alone. Up to 40-50% of the patients that doctors see will have unexplained symptoms, i.e., there is no clear physical basis for their symptoms (often termed medically unexplained symptoms or MUS). Treating these patients can be challenging, as there is often no clear treatment plan or referral pathway. The complex nature of such presentations and the difficulties in their management can lead to frustration amongst both patients and clinicians, and can also result in doctors ordering expensive and unnecessary investigations in an attempt to identify the cause of their patients’ symptoms. There is currently very little teaching provided at undergraduate and postgraduate level on this subject, which is surprising given the high number of patients seen across all specialities.

Our recent study aimed to improve teaching for newly-qualified junior doctors on this topic using a number of methods. We used in-depth interviews to explore the junior doctors’ feelings about working with such patients and to find out what they knew about their management. We also investigated what teaching they were currently receiving on this topic, and what their postgraduate tutors thought about expanding this. The overall aim was to develop an educational intervention for doctors at this stage of their training.

In our interviews, the junior doctors were very frank when talking about the challenges they had faced when looking after patients with medically unexplained symptoms, and spoke about the impact of these difficulties on their own attitudes and management choices. They were very keen to gain more training in this topic, particularly during the first two Foundation Years post-qualification, as this is the time when they first have intensive exposure to patients as junior doctors. Both they and their postgraduate tutors gave a number of recommendations for teaching about this topic, in particular emphasising the importance of an interactive approach based around group discussions and clinical cases.

To our knowledge, our study is the first to look at junior doctors’ experiences of managing patients with such symptoms and to identify their training needs in this area. Most of the training described within the literature currently takes place with more senior doctors, but our study shows that junior doctors and their tutors consider that this teaching is required at an earlier stage. As a result of this study, we hope to raise awareness about the lack of training that junior doctors currently receive in this important area, and to encourage their tutors to integrate teaching about medically unexplained symptoms into core Foundation level curricula.

We will keep you updated about upcoming publications, in which our findings will be explained in greater detail. If you have any questions about the study please contact Katie Yon (Katherine.Yon.12@ucl.ac.uk) or Marta Buszewicz (M.Buszewicz@ucl.ac.uk).

This study is funded by the National Institute for Health Research School for Primary Care Research (NIHR SPCR). The views expressed are those of the author and not necessarily those of the NIHR, the NHS or the Department of Health.

Kethakie Sumathipala is a PhD student in the Mental Health Research Group at PCPH. Here she reflects on lessons learned at a recent UCL Grand Challenges in Global Health event. 

Non-Communicable Diseases (NCDs) refer to non-infectious diseases or medical conditions that are long lasting, such as heart disease, cancer and diabetes. They kill around 36 million every year, worldwide; more people than any other cause.  Once considered to be diseases of the West, 80% of NCDs occur in the world’s poorest countries and affects the most marginalised communities.

A few months ago, I attended the NCD makeover show, organised by UCL’s Grand Challenge of Global Health. The presenters worked in fields outside of the world of academia and were all interested in the use of effective communication. They brought forward ideas from their experiences in social enterprises and the BBC to provide suggestions on how we might effectively work towards communicating risk relating to NCDs. From the session, I was able to obtain some valuable lessons in communication.

Communicating risk

Fred Hersch worked for NCDFree, a global social movement which aims to influence public, scientific, and policy action, by using inspiring local narratives and the medium of film, to communicate the challenges, opportunities and solutions of NCDs. He highlighted that even when people are aware of the health behaviours that may be good for them, such as eating healthily, drinking less or exercising, it isn’t always easy to make these changes. For one, the cost of giving up something today is far greater than the perceived benefits in the future, whether it be exercising rather than going to the pub on a Friday night, or spending your limited resources on the basic needs of your family rather than preventative medications. Therefore one of the greatest difficulties and challenges in managing NCD’s is communicating risk. He suggested the following simple methods to achieve this:

1) ‘Rebranding NCDs’ to suite a new generation, and the use of new forms of communication, particularly social media.

2) ‘Refocusing on health’ and living healthier lives, rather than only focusing on expansion of ‘health care.’

3) Messages which are accessible to the people they are targeted towards, by taking to consideration the contexts in which people live and the challenges they face in different countries, communities and backgrounds.

Branding NCDs

Ed Gillespie, from Futerra Sustainability Communications explained that one of the key aspects of effective communication was branding. Using the example of ‘Apple’, he explained that a great brand should: include a meaning and purpose, be visually identifiable, include a compelling story, be honest about what it provides, and keep evolving to stay relevant. He emphasised the following recommendations:

1) ‘Branding NCDs’– by using examples of recognisable brands such as Nike, Ed explained how  many people are able to associate with a visual image (e.g. Nike’s ‘tick’), and a tag line (e.g. Nike’s ‘just do it’) with iconic brands, he suggested that this may be relevant for rebranding NCDs in the future.

2) Use of acronyms – Ed explained that most lay audiences are familiar with HIV, AIDS and SARS, even if they cannot tell you what the letters stand for, however, fewer people are familiar with the term ‘NCDs’. Ed thought that this familiarity was important and suggested that a good acronym could be one of the steps in raising the profile of NCDs.

3) Use of a compelling story – Ed used the example the Cancer Research UK 2014 campaign, which follows a young woman moving through life over the course of a minute, from a child to a teenager to motherhood as the disease starts to take hold, interspersed with shots of scientists working towards finding a cure. The commercial ends with a scientist who appears to make an important discovery and the young women being given some good news. The final message is ‘one day everyone will beat cancer.’ Ed felt that this poignant and compelling story had the key ingredients to engage with the target audiences in a very short time, following this young woman’s difficult journey followed by a happy and positive ending

Using stories

The use of a good story was further discussed by Frank Ash, a documentary maker from the BBC. Frank explained that the stories should be emotionally engaging, intriguing and exciting to the audience.  He also warned against bombarding people with too much information. If the story was compelling enough and not overloaded with information, people were more likely to take away and remember a few key facts.
 
I found this event really interesting, and it inspired me to think about the way in which I could communicate my research findings to different audiences in the future. I hope that these lessons provide you with some food for thought!