Open-Letter-from-Medical-and-Non-Medical-Cambridge-Students

Open Letter from Medical and Non-Medical Cambridge Students “all patients should be treated equally” as highlighted in the GMC’s Tomorrow’s Doctors.. For example, 28.5% of medical studen

Open Letter from Medical and Non-Medical Cambridge Students

“all patients should be treated equally” as highlighted in the GMC’s Tomorrow’s Doctors Instead, we need to

take active action to ensure that this is done

Racism and racial bias does exist in our healthcare system today The following statistics highlight discrepancies in patient outcomes, patient treatment, doctor’s pay and even in student attainment:

BAME women have worse pre-, peri- and post-natal outcomes as shown by the following:

● Black women are 5 times more likely to die in childbirth than white women South Asian women are twice as likely to die during childbirth (MBRRACE 2019)

● BAME women are also more likely to have a poorer experience of healthcare during pregnancy delivery and post-natal care (Henderson et al., 2013)

BAME patients are generally not treated the same as white patients by healthcare professionals Failures in treatment can result in direct consequences for BAME groups such as being more likely to be detained for a psychotic illness:

● Black patients are 50% less likely to receive pain medication than white patients (Singhal et al., 2016)

● Black patients are less likely to receive care and support during their cancer care (National Cancer Patient Experience Survey)

● Doctors give different treatment options to hypothetical white patients than they do to hypothetical black patients with the same symptoms (Boujie 2019, Zestcott 2016)

● African and African-Caribbean people who have a psychotic illness and who live in London are between 4 and 8 times more likely to be detained than their white counterparts (Audini and Lelliott

● 90.2% of white graduates of UK medical schools passed the Royal College of GPs membership examination, compared with 75.5% of UK medical school graduates from BAME backgrounds (RCGP 2018)

BAME doctors are more frequently reported to the GMC than white doctors They are also more likely to feel intimidated in their work environment by other colleagues

● Black and brown doctors are reported to the GMC at more than twice the rate of white doctors (GMC Fair to Refer 2019)

● Black NHS staff report the highest incidence of bullying and harassment from their colleagues and leaders (NHS Workforce Race Equality Standard 2019)

To attempt to change these disparities between different ethnicities, we need to start our learning in medical school Racism goes beyond just the working environment and unfortunately does include fellow colleagues' experiences at Cambridge Medical School in a professional and educational setting To illustrate this, we carried out a survey of 158 medical students in years 1-6 of the Cambridge Medical course We have summarised our results in the report attached and highlight some relevant figures For example, 28.5% of medical students have witnessed racial bias towards patients in a clinical setting, with 75.6% of those being from clinical years Furthermore, 58.2% of medical students have witnessed or experienced racism either in a professional or educational setting at Cambridge For instance, clinical students describe several instances when patients refused to have medical procedures performed by non-white (student) doctors Multiple preclinical students mentioned explicit and implicit racist comments and behaviour from anatomy demonstrators and supervisors (Please refer to the full report attached for further information and all qualitative accounts of students’ experiences) This needs to change, and our BAME students need to feel represented and listened to Here is what we propose:

1 Eliminating and challenging our own implicit bias

Problem 1a: As evidenced above, BAME patients, students and doctors face massive gaps in almost all aspects of the healthcare system This also includes educational settings, where our BAME colleagues have faced shocking examples of explicit racism in an environment where they should feel safe (see report attached) We all need to be taught to recognise and challenge our own implicit bias Furthermore, all medical students need to feel confident enough to challenge microaggressions in a clinical setting and need to be able to identify racial bias in order to try to minimise these differences

in patient outcomes

Suggestions: We suggest implementing compulsory active racial bias training for

o All medical students in their clinical years

o All staff involved in teaching both preclinical and clinical courses This should include unconscious bias and bystander skills, with the use of anonymised cases based on real student and staff experiences

Moreover, the racial bias aspect of the SECHI course could be improved and/or made compulsory to highlight these inequalities early on and encourage us to actively change them To that end, assessment

of the SECHI course should be changed such that, firstly, it is appropriately recognised as important

by the student body, and secondly, students are required to engage with all topics taught in the SECHI course This could include submitting a portfolio of marked essays and presenting to other students in seminars throughout the six years of the curriculum rather than writing just two essays under exam conditions Exams have a focus on testing fact recall, whereas coursework essays would allow more in-depth research and better assessment of engagement and understanding We believe this is a more appropriate form of assessment when discussing such nuanced issues, for which there is no need for rote learning of specific statistics, but rather engagement with and exploration of broader principles

2 Medical education and decolonising the curriculum

Problem 2a: In our student questionnaire, many people reported that most clinical presentations are based around white patients/cases and that there is little emphasis on the ways BAME patients can present differently The experience of many medical students has been a lack of awareness regarding the presentation of various diseases on dark skin, as an example Often, we are not shown clinical presentations for the same disease in different ethnic groups, which can be detrimental for diagnosing BAME patients in the future

Some areas for improvement include:

o Cardiology – women and BAME patients are more likely to present a myocardial infarction

with atypical symptoms such as back/shoulder/jaw pain, sweating, nausea and an upset stomach Thus, white males are often more likely to be diagnosed

o Dermatology – using adjectives such as ‘pallor’ and ‘erythematous’ only refers to white

skin; the use of these descriptors does not apply to all patients Further, most examples of skin rashes and presentations on slides are on white patients

o Psychiatry – failure to address that BAME patients are less likely to present, yet more likely

to be detained We are clearly failing to cater for their needs or to get treatment to them early

It is also important to note that these are currently widely recognised problems in medical school teaching, as emphasised by the petitions to the GMC and British Association of Dermatology respectively below:

o http://chng.it/6BBTByQyQh

o http://chng.it/CWXwwFcCLf

Suggestions: We propose that it should be a requirement that lecturers include BAME presentations, particularly in clinical school teaching In pre-clinical school teaching there should be more of an emphasis on BAME inequalities to allow medical students to be aware of these differences and challenge them Cambridge Medical School should also aim to standardise parameters in clinical diagnosis across all patients, using symptoms such as ‘pallor’ only as auxiliary signs for diagnosis Given that Cambridge is one of the leading contributors to the global medical community, we should play a leading role in prioritising standardised diagnosing procedures which should be taught in our clinical teaching

Problem 2b: There are particular discrepancies in specialties such as Obstetrics & Gynaecology and Psychiatry For example, there is a higher rate of non-attendance in BAME communities for cervical screening: Caribbean 62%, African 44%, Indian 66%, Pakistani 62%, Bangladeshi 71%, Caucasian 11% (Marlow et al., 2015) This clearly shows that we are not doing enough to inform our BAME patients of the importance of cervical screening or to improve teaching for these communities There are also inequalities in the field of eating disorders Ethnic minorities are less likely to be asked

by doctors about eating disorder symptoms and receive a recommendation or referral (Becker et al., 2003), and black girls are more likely to show symptoms of bulimia nervosa than white girls, but are less likely to be diagnosed (Goeree et al., 2011)

Furthermore, black people are significantly less likely to seek treatment for depressive symptoms, when compared to white people (Sussman, Robins and Earls, 1987) Fear of hospitalisation was a commonly cited reason as to why treatment was not sought, which is not unfounded as black people are significantly more likely to be detained under the Mental Health Act We are not taught about atypical presentations that could arise in BAME patients – for example there have been significant findings of non-traditional presentations, such as hypertension, when depression is experienced among black people (Thompson et al, 2000) This knowledge could lead to earlier treatment and better outcomes

Suggestion: We should therefore have a greater focus on teaching about these differences, particularly

in specialties where inequalities are much more prominent Furthermore, we need to be taught how to advocate for our BAME patients in a sensitive and appropriate way This could include teaching us ways to break down any myths or misconceptions they may have about cervical screening in consultations and be accepting of their culture in order to work towards a solution together

For example, we are aware that the Improving Health course ran a session highlighting inequalities within the LGBTQ+ community A similar session, particularly for fifth years, focusing on ethnic inequalities in Psychiatry and Obstetrics & Gynaecology would help us understand and challenge the disparities in outcomes of BAME patients

Problem 2c: BAME patients are underrepresented in medical research studies and clinical trials (Harrison & Smart 2016) – in an extensive literature search to depict the differences in ethnicities, just

11 pieces of literature were found that focused on BAME patients, and 98% of research was conducted

on Caucasians This under-representation in research must be changed

Suggestions: We should be taught to be mindful of this when discussing management options and to think critically about why BAME patients may not be responding to certain treatments Furthermore, trends in patient outcomes across different ethnicities should be regularly mentioned and included in lectures Finally, as Cambridge is world-leading in medical research, it should act to promote and encourage the promotion of BAME patients and researchers to call for a more inclusive scientific environment

Problem 2d: Many students have commented on the lack of BAME lecturers and faculty members within the Department of Medicine, this is particularly the case in pre-clinical years (see report attached) Our faculty should represent doctors from all different backgrounds

Suggestions: Encouraging BAME staff to apply to Cambridge could be achieved through workforce discussions and looking at diverse hiring practice; this includes the actor pool in our clinical training The aim should be to create more access opportunities for BAME staff and to make them feel more welcome to come teach at Cambridge

Problem 2e: A full commitment to decolonising the curriculum involves recognizing and addressing 1) the roles that Medicine played in colonialism and how this continues to affect populations around the world, 2) the way that medical knowledge has benefitted from colonialism and oppression of non-white populations Cambridge University prides itself on academic success, but it is only by decolonising that we will create an environment that includes everyone, and create doctors that interrogate knowledge to achieve better outcomes for all patients Other than passing comments by specific lecturers, this is not discussed during the six year course

Suggestions: There should be compulsory education and an ongoing discussion group about how Medicine will be decolonised This education could be added to the pre-clinical SECHI course and the clinical Improving Health or Ethics and Law courses Students should be provided with a reading list for further education and critical thinking on the topic Topics may include the relationship between medical research and colonialism/racism (e.g the discovery and use of HeLa cells), the history of unethical research projects carried out on BAME groups in the name of medical science (e.g the Tuskegee syphilis experiment), the foundations of global health within colonialism, discussion and action on how medical electives continue to contribute to unequal relationships between the UK and previously colonised countries, and ethical procurement of healthcare goods

3 Challenging colleagues and patients when medical students are exposed to racism

Problem 3a: We must protect our students Many BAME students are cautious about reporting incidents of racism, particularly when their own supervisors or teachers are involved, out of fear that

it may affect their education This is made evident as 65.8% of students feel that they are unable to report incidents, and if they do, 76.2% of students feel as though they have not received an appropriate response (see report attached) This unfair predicament leaves BAME medical students in a very difficult position The burden should not be on BAME students to report these incidents, particularly

as many worry about how this may reflect on them professionally

Suggestions: A clear and anonymous reporting system must be put in place to make our students feel safe This could be an external group of people in order to encourage medical students to speak up when they feel that they have been marginalised All teachers should also be informed about this reporting system so that incidents are not just ignored, and that staff are aware of how to handle the situation

For incidents where students may not want to use the reporting system first, a BAME officer who forms part of the welfare committee could be introduced This officer could help support students and provide a safe space for them to talk about incidents of racism before escalating the situation further Lastly, implementing consistent and thorough racial bias training would also minimise these incidents

Problem 3b: The issue of how to confront situations of racism has also been commonly raised among BAME medical students, with 74.7% of students not knowing how to respond during these incidents

It is not uncommon for a patient to request a different healthcare professional purely based on their religion or the colour of their skin as seen by anecdotes from medical students (see report attached)

We need to be taught how to challenge these situations in a professional way and to make sure that medical education opportunities are fair for all students

Suggestions: Train all medical students and staff on how to appropriately challenge these situations and equalise the opportunities available to all medical students This could be a component of the racial bias training mentioned above

Another way to encourage dialogue regarding racism, could be to introduce a student led Schwartz round (this could be led by the BAME officer) which focuses on experiences of BAME students This would help medical students become aware of racism within a clinical environment and suggest ways

to challenge it together

Summary of Demands and Suggested Solutions

1 To eliminate and challenge our own implicit bias:

a Compulsory racial bias and bystander skills training for

i Clinical students

ii Pre-clinical and clinical teaching staff

b Alterations to the medical course

i Increase the racial bias component of the course, such as by including a portfolio of essays across our 6 years of study

ii Ensure the SECHI course is appropriately recognised as important by the student body, equal in significance to other aspects of MST1A, potentially through changes to the way in which it is examined (e.g shift from timed exams to graded coursework essays)

2 To decolonise the curriculum and improve BAME-related medical education:

a Include BAME presentations of disease in pre-clinical and clinical teaching

b Emphasise inequalities of BAME individuals in healthcare to increase student awareness in pre-clinical and clinical teaching

c Encourage the standardisation of parameters used for diagnosis, which cover patients of all ethnicities

d Introduce an Improving Health session on BAME inequalities, particularly focussed on Psychiatry and Obstetrics & Gynaecology

e Teaching clinical students on the issue of reduced treatment adherence in BAME populations, and how to tackle this

f Highlight discrepancies in the ethnicities of participants in clinical studies, and how this impacts current understanding of treatment methods and patient outcomes

g Encouragement of hiring a diverse teaching workforce

h Incorporate active teaching to decolonise the course by providing education on the relationship between medical research and the impact of colonialism, and encourage critical thinking in this regard

3 To challenge colleagues and patients when medical students are exposed to racism:

a Incorporate an anonymous, third party reporting system for students to use when they have been marginalised

i Advertise this system and encourage its use by both students and teaching staff

b Introduce a BAME officer as part of the welfare team within the ClinSoc committee

c Training medical students and staff for instances of racial abuse from patients

d Introduce a student-led Schwartz round focussing on BAME student experiences

Conclusion

As a world-renowned medical school, we need to take action and set an example to other medical schools We must enact change to ensure that our BAME patients are catered for appropriately and their specific needs are met, and to ensure that our BAME colleagues feel safe and welcome in the NHS Other medical schools such

as Bristol have already committed to similar actions, such as decolonising the curriculum to include clinical presentations with darker skin, listening to BAME voices by setting up a consulting BAME working group, and improving staff training by implementing unconscious bias and bystander skill courses, among many other reforms

If we are happy to spend time and resources teaching students about the intricacies of metabolic pathways such

as the citric acid cycle, incredibly rare diseases, or discontinued drugs, then we should absolutely take the time

to teach students how a rash may present differently on dark skin, or how cultural factors may lead to misdiagnosis We must accept that the medical community is just as guilty as the rest of the world when it comes to racism and implicit racial bias, so we must act proactively to better the experiences of BAME individuals in healthcare If as a community we claim to wish to improve the lives of others, we must do so both medically and in the context of social justice

We look forward to your response, and towards a constructive dialogue in how we might address these concerns We recognise that these problems are complicated to address, and that our proposed solutions would require a lot of work We suggest that the Clinical School establish a working group consisting of representatives from both Faculty and students so that we can work together to address these issues We ask that you might confirm your receipt of this letter and in your subsequent response that you:

1 Identify if the Cambridge Medical School recognises each problem identified here in this letter,

2 Identify whether the Cambridge Medical School will undertake some or all of the suggestions made here in this letter, and finally,

3 Should the Cambridge Medical School disagree with any points set out in this letter, that reasons are provided

Yours sincerely,

Medics:

Bony Roy Queens' Medicine (Standard 6 year course) Year 5

Anna Carpenter Jesus Medicine (Standard 6 year course) Year 4

Kirish Rajaseelan Queens' Medicine (Standard 6 year course) Year 1

Lloyd Morgan Emmanuel Medicine (Standard 6 year course) Year 3

Vahgisha

Thirugnanasampanthan

Colette Russell Fitzwilliam Medicine (Standard 6 year course) Year 4

Alex Bartram Queens' Medicine (Standard 6 year course) Year 5

Vythilingam Siva

Shanmugam

Bethan Morris Homerton MB/PhD Year 3

Ahmed Mostafa Selwyn Medicine (Standard 6 year course) Year 4

Kaesi Opara Fitzwilliam Medicine (Standard 6 year course) Year 6

Emma Sun Emmanuel Medicine (Standard 6 year course) Year 2

Will Kitchen Clare Medicine (Standard 6 year course) Year 5

Kwan Wai Fung Pembroke Medicine (Standard 6 year course) Year 2

Henry Bennett Gonville and Caius Medicine (Standard 6 year course) Year 4

Nicholas Ivin Fitzwilliam Medicine (Standard 6 year course) Alumnus 2018

Leo Jurascheck Emmanuel Medicine (Standard 6 year course) Year 6

Cambridge

Jamie Brannigan Jesus Medicine (Standard 6 year course) Year 3

Success Oluebubechukwu

Anyanwu

Rayo Akande Christ's Medicine (Standard 6 year course) Year 2

Rushi Patel Robinson Medicine (Standard 6 year course) Year 3

Other subjects:

Kate Barber Corpus Christi ASNC MPhil Year 1

Medicine

Year 1