Racism, Discrimination, and Harassment in Medical Schools in the UK: A Scoping Review
Abstract
:1. Introduction
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- To map the types and nature of primary research activities concerning the extent and experience of discrimination, harassment, stereotyping, bullying, and victimisation in undergraduate medical education since the UK Parliament passed the Equality Act (2010). This act has been designated as a crucial landmark and main source of legal protection in the UK from racial harassment for university staff and students. The 2010 Act ensures that medical education institutions must provide equal opportunities for all students, regardless of their background or protected characteristics. This means that students must be given the same access to education, training, and resources, regardless of their protected characteristics. By following up on research after the Equality Act (2010) in this review, we anticipate that researchers, policymakers, and practitioners may identify areas where discrimination and inequality persist and develop strategies to address them.
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- To summarise and disseminate the current state of primary research activities concerning discrimination, harassment, stereotyping, bullying, and victimisation in undergraduate medical education and areas of content focus.
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- To determine areas of focus for undertaking full future systematic reviews of content.
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- To identify gaps in the existing evidence base in the context of discrimination, harassment, stereotyping, bullying, and victimisation in undergraduate medical education, providing directions for future research for the content of primary and secondary research.
2. Methods
2.1. Stage 2: Identifying Relevant Studies
2.2. Stage 3: Study Selection
2.3. Stage 4: Charting the Data
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- Article identifiers (author(s), journal, and year of publication);
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- Geographic location;
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- Aim of the article, methods, ethics approval, and funding;
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- Number of participants;
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- Key findings in relation to the scope, conclusion, and limitations.
2.4. Stage 5: Collating, Summarising, and Reporting the Results
3. Results
3.1. Descriptive Findings: Characteristics of Included Studies
3.2. Characteristics of Participants
3.2.1. Prevalence of Discrimination and Harassment and Barriers to Reporting
3.2.2. Differential Attainment by Ethnicity in Medical Undergraduate Training
3.2.3. Barriers to Learning about Culture, Race, and Ethnicity
4. Discussion
5. Limitations
6. Conclusions
- The prevention and effective monitoring of harassment and discrimination in medical educational institutions;
- The standardisation of tools that measure harassment and discrimination;
- Detailed reporting on specific areas of any type of inequity in medical education are needed;
- One area of research here that requires quantitative analysis is the barrier to reporting; this may inform future interventions and reporting systems.
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
Appendix A
Study ID and Location | Aims, Objectives | Study Type | Recruitment, Sampling, Data Collection, and Analysis | Participant Description | Results | Limitations | Conclusions |
---|---|---|---|---|---|---|---|
Broad et al. (2018) Bristol | 1. Prevalence of harassment and discrimination 2. Reporting and factors that influence reporting | Mixed-method: quantitative survey, qualitative free-text reporting, and two single-gendered focus groups | 1318 medical students were e-mailed twice in March 2014. Convenience sampling was used to recruit eight male and eight female focus group participants for two focus groups. 16 students were included in the focus groups. Proportions and confidence intervals (CIs) were analysed using the Wilson score method, and associations were assessed with chi-squared analysis. The focus groups: framework analysis for the qualitative data and degrees of convergence. | 259 medical students all year groups. Gender: M 83 F 167, ethnicity: White 192, BME 61, heterosexual: 291, disability: 9 | 259 students responded to the survey (20%). Most participants experienced (63.3%, 95% CI 57.3 to 69.0) or witnessed (56.4%, 95% CI 50.3 to 62.3) at least one type of discrimination or harassment. Stereotyping was the most commonly witnessed (43.2%, 95%CI 37.4 to 49.3). Black and minority ethnic (BME) students witnessed and religious students experienced higher lack of provision (X2 4.73, p = 0.03; X2 4.38, p = 0.04); non-heterosexual students experienced higher joking, (X2 3.99, p = 0.04); students with disabilities experienced more stereotyping (X2 13.5, p < 0.01). Female students and students in clinical years had 2.6 (95% CI 1.3 to 5.3) and 3.6 (95% CI 1.9 to 7.0) greater likelihood of experiencing or witnessing all types of discrimination and harassment, respectively. Seven students reported incidents (5%, 95%CI 2.4 to 10.0); reporting was perceived as ineffective and victimising. | No validated questionnaire. The small sample size and the self-selected nature of the sample limit the conclusions. | Harassment and discrimination are prevalent in this sample and associated with gender, ethnicity, sexuality, disability, and year group. Reporting was rare and perceived as ineffective. |
Study ID and Location | Aims, Objectives | Study Type | Recruitment, Sampling, Data Collection, and Analysis | Participant Description | Results | Limitations | Conclusions |
Claridge et al. (2018) London | Exploring experiences of medical and biomedical science students and factors contributing to lower attainment | Qualitative, focus groups Audio-recorded, semi-structured interviews and ethnically homogenous student-led focus groups | An invitation was emailed to all ‘home’ students on undergraduate biomedical sciences and medicine courses (n = 1862) Exclusion: non-British non-domestic students. Participants for six focus groups were purposively recruited by ethnicity; Asian/Asian British (‘Asian’), Black/African/Caribbean/Black British (‘Black’), or White: English/Welsh/Scottish/Northern Irish/British. Staff range from lecturers to deans. | 41 students and 8 staff. 41 student participants with mean (SD, range) age = 21 (2.78, 18 to 31). Interviews were conducted with 24 students (12 female, 12 male, nine biomedical sciences, 15 medicine), with the following from each ethnicity: Asian: Bangladeshi (1), Chinese (1), Indian (5), Pakistani (3), and Other (2); Black: African (2) and Caribbean (1); White (8); and Irish (1) | Student data were best explained by two main themes: social factors and stereotyping, whilst staff data were also best explained by two main themes: social factors and student and staff behaviour. Social factors suggested that ethnically defined social networks and the informal transfer of knowledge impacted academic performance, isolating minority groups from useful academic information. BAME students may also be at a further disadvantage, being unable to attend social and academic functions for cultural or family reasons. Black students also mentioned changing their behaviour to combat negative stereotypes in a variety of contexts. | The gender, ethnicity, and age of the interviewer may have impacted how both students and staff responded in the interviews, with some perhaps uncomfortable discussing some topics in greater depth than others. It is possible that participants were not representative of all attainment levels. | Conscious or unconscious discrimination may negatively impact the abilities of BAME students, both in examinations and in coursework choice. Social networks are important for the transfer of academic knowledge and the impact ethnicity may have on their formation, with issues around segregation and information sharing outside defined groups. |
Study ID and Location | Aims, Objectives | Study Type | Recruitment, Sampling, Data Collection, and Analysis | Participant Description | Results | Limitations | Conclusions |
Yeates et al. (2017) West Midlands Medical School | Influence of students’ ethnicity (White vs. British Asian) on (1) the scores and feedback from OSCE examiners and (2) examiners’ cognitive processing of those performances, including their recollection accuracy and activation of an Asian stereotype when examining Asian students | Two-group, double-blinded, randomised, Internet-based experimental design | Participants were current UK undergraduate Objective Structured Clinical Exam (OSCE) examiners. Recruitment was undertaken by email; medical schools around the UK disseminated the invitation to OSCE examiners. Data analysed using ANOVA. | Scripted video materials of OSCE of medical students with different ethnic backgrounds were analysed. Examiners performed different cognitive tests (cf. Objective measures) | 159 OSCE examiners from 20 UK medical schools, broad range of clinical specialties, predominantly of White ethnicity.... 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. Student ethnicity had no influence on examiners’ scores, on the feedback examiners gave, or on examiners’ memories for one performance. | Study was conducted in a simulated context, rather than in a real OSCE. Cannot exclude the possibility that examiners’ judgements could be influenced by students’ ethnicity after a more prolonged series of performances due to (for example) fatigue or lapses in concentration, or that different samples of performance (displaying a different range of behaviours by Asian students) could produce an effect. | Examiners had a stereotype that was active at the time of judging performances, which does not appear to have been applied to their judgements. Examiner bias is not responsible for differential attainment by BME students. |
Study ID and Location | Aims, Objectives | Study Type | Recruitment, Sampling, Data Collection, and Analysis | Participant Description | Results | Limitations | Conclusions |
Roberts et al. (2010) Two medical schools in northern England | To explore the impact on students of two contrasting pedagogic approaches (a school offering early patient contact in the first 2 years was compared with one using paper-based patient scenarios only) to undergraduate learning about cultural diversity | An exploratory, qualitative research method was used, adopting an ‘inductive’ approach to data analysis and theory generation | Pragmatic recruitment. Focus groups were conducted at each site over a 3-month period, in small teaching rooms familiar to the students. Discussion was audio-recorded after seeking informed written consent from all participants. | Students (years 1 and 2) from seven selected groups (n = 49) were recruited pragmatically at sites A and B. Ethnic minority students = 20 (40.8%) | Barriers to learning about race, culture and ethnicity identified: (a) ‘institutional marginalisation’ of the subject, and (b) ‘student resistance’ to formal learning about cultural diversity. | The study was conducted using only year two medical students. Data collection was limited to two medical schools situated in northern England. Research team composition was British, White, and female. | The study found two potentially competing views. First, students claimed that although cultural diversity was important, their medical schools marginalised and failed to adequately support effective teaching. Second, in contrast, they claimed that the medical school was an ‘inappropriate’ setting for successful teaching about cultural diversity. Students did not consider the subject matter to be of central relevance to biomedicine. |
Study ID and Location | Aims, Objectives | Study Type | Recruitment, Sampling, Data Collection, and Analysis | Participant Description | Results | Limitations | Conclusions |
Morrison et al. (2019) | Examining the potential reasons for under performance by BME graduate-entry medical students, exploring their experiences of undergraduate medical training and their perceptions of barriers and facilitators to performance | Qualitative methods (focus groups with semi-structured interviews) | Graduate-entry MBChB students from all four cohorts were recruited using volunteer and snowball sampling. For each group, participants were randomly assigned a number to ease anonymisation during transcription. Participants were subsequently asked to self-report their ethnicity using the 2011 UK census categories. | 24 graduate-entry MBChB students self-identified as being from Black and Minority Ethnic (BME) backgrounds | Lack of BME representation and lack of understanding of cultural differences among staff impacted their experiencee. Students also reported a lack of trust in the institution’s ability to support BME students, with many not seeking support. Students’ narratives indicated that they had to mask their identity to fit in among their peers and to avoid negative stereotyping. Although rare, students faced overt racism from their peers and from patients. Many students reported feelings of isolation, reduced self-confidence, and low self-esteem. | BME students were not a homogeneous group: as individuals, they had unique identities as well as different ethnic, cultural, socioeconomic, and educational backgrounds. This study was not able to examine how these intersect to shape individual students’ experiences of medical education. | BME students reported experiencing relationship issues with other students and academic and clinical staff, lack of trust in the institution, and some racist events. |
Excluded Studies | Reason for Exclusion |
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Al-Haddad et al. (2022) | Meta-ethnography (systematic review) |
Joseph et al. (2021) | Narrative review |
Khan and Mian (2020) | Opinion letter |
Lim et al. (2021) | View of students on institutional discrimination—not a primary study |
Woolf et al. (2018) | Postgraduate medical education |
Gostelow et al. (2018) | Symposium workshop of students on institutional discrimination—not a primary study |
Nightingale et al. (2022) | No medical students included in this study |
Alwazzan (2018) | Review |
Clements et al. (2020) | Postgraduate students |
Denney et al. (2013) | Postgraduate students |
Woolf et al. (2018) | Postgraduate students |
Fyfe et al. (2022) | Guidelines |
Appendix B. MEDLINE EBSCOhost Platform
# | Query | Limiters/Expanders | Last Run Via | Results |
S22 | S14 AND S21 | Expanders- Apply equivalent subjects Search modes- Boolean/Phrase | Interface- EBSCOhost Research Databases Search Screen- Basic Search Database- MEDLINE with Full Text | Display |
S21 | S17 OR S20 | Expanders- Apply equivalent subjects Search modes- Boolean/Phrase | Interface- EBSCOhost Research Databases Search Screen- Basic Search Database- MEDLINE with Full Text | Display |
S20 | S18 OR S19 | Expanders- Apply equivalent subjects Search modes- Boolean/Phrase | Interface- EBSCOhost Research Databases Search Screen- Basic Search Database- MEDLINE with Full Text | Display |
S19 | “junior doctor” OR (MH “Physician Assistants+”) OR (MH “Medical Staff, Hospital”) | Expanders- Apply equivalent subjects Search modes- Boolean/Phrase | Interface- EBSCOhost Research Databases Search Screen- Basic Search Database- MEDLINE with Full Text | Display |
S18 | junior doctor | Expanders- Apply equivalent subjects Search modes- Boolean/Phrase | Interface- EBSCOhost Research Databases Search Screen- Basic Search Database- MEDLINE with Full Text | Display |
S17 | S15 OR S16 | Expanders- Apply equivalent subjects Search modes- Boolean/Phrase | Interface- EBSCOhost Research Databases Search Screen- Basic Search Database- MEDLINE with Full Text | Display |
S16 | postgraduate medical education | Expanders- Apply equivalent subjects Search modes- Boolean/Phrase | Interface- EBSCOhost Research Databases Search Screen- Basic Search Database- MEDLINE with Full Text | Display |
S15 | (MH “Education, Medical+”) OR (MH “Education, Medical, Undergraduate”) OR (MH “Education, Medical, Graduate+”) OR (MH “Education, Medical, Continuing”) OR (MH “Education, Premedical”) OR “medical education” | Expanders- Apply equivalent subjects Search modes- Boolean/Phrase | Interface- EBSCOhost Research Databases Search Screen- Basic Search Database- MEDLINE with Full Text | Display |
S14 | S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7OR S8 OR S9 OR S10 OR S11 OR S12 OR S13 | Expanders- Apply equivalent subjects Search modes- Boolean/Phrase | Interface- EBSCOhost Research Databases Search Screen- Basic Search Database- MEDLINE with Full Text | Display |
S13 | inequity | Expanders- Apply equivalent subjects Search modes- Boolean/Phrase | Interface- EBSCOhost Research Databases Search Screen- Basic Search Database- MEDLINE with Full Text | Display |
S12 | inequality | Expanders- Apply equivalent subjects Search modes- Boolean/Phrase | Interface- EBSCOhost Research Databases Search Screen- Basic Search Database- MEDLINE with Full Text | Display |
S11 | (MH “Discrimination, Psychological+”) OR (MH “Discrimination Learning”) OR (MH “Social Discrimination+”) OR (MH “Racism+”) OR (MH “Sexism”) OR (MH “Weight Prejudice”) OR (MH “Speech Discrimination Tests”) OR “discrimination” | Expanders- Apply equivalent subjects Search modes- Boolean/Phrase | Interface- EBSCOhost Research Databases Search Screen- Basic Search Database- MEDLINE with Full Text | Display |
S10 | (MH “Bullying+”) OR “bullying” OR (MH “Cyberbullying”) | Expanders- Apply equivalent subjects Search modes- Boolean/Phrase | Interface- EBSCOhost Research Databases Search Screen- Basic Search Database- MEDLINE with Full Text | Display |
S9 | S5 OR S6 OR S7 OR S8 | Expanders- Apply equivalent subjects Search modes- Boolean/Phrase | Interface- EBSCOhost Research Databases Search Screen- Basic Search Database- MEDLINE with Full Text | Display |
S8 | “stereotype” | Expanders- Apply equivalent subjects Search modes- Boolean/Phrase | Interface- EBSCOhost Research Databases Search Screen- Basic Search Database- MEDLINE with Full Text | Display |
S7 | stereotype | Expanders- Apply equivalent subjects Search modes- Boolean/Phrase | Interface- EBSCOhost Research Databases Search Screen- Basic Search Database- MEDLINE with Full Text | Display |
S6 | (MH “Stereotyping”) | Expanders- Apply equivalent subjects Search modes- Boolean/Phrase | Interface- EBSCOhost Research Databases Search Screen- Basic Search Database- MEDLINE with Full Text | Display |
S5 | stereotyping | Expanders- Apply equivalent subjects Search modes- Boolean/Phrase | Interface- EBSCOhost Research Databases Search Screen- Basic Search Database- MEDLINE with Full Text | Display |
S4 | “Intimidation” | Expanders- Apply equivalent subjects Search modes- Boolean/Phrase | Interface- EBSCOhost Research Databases Search Screen- Basic Search Database- MEDLINE with Full Text | Display |
S3 | S1 OR S2 | Expanders- Apply equivalent subjects Search modes- Boolean/Phrase | Interface- EBSCOhost Research Databases Search Screen- Basic Search Database- MEDLINE with Full Text | Display |
S2 | “harassment” | Expanders- Apply equivalent subjects Search modes- Boolean/Phrase | Interface- EBSCOhost Research Databases Search Screen- Basic Search Database- MEDLINE with Full Text | Display |
S1 | (MH “Harassment, Non-Sexual+” | Expanders- Apply equivalent subjects Search modes- Boolean/Phrase | Interface- EBSCOhost Research Databases Search Screen- Basic Search Database- MEDLINE with Full Text | Display |
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Inclusion | Exclusion | |
---|---|---|
Population | Undergraduate medical students | Studies not related to undergraduate medical training |
Exposure | Any type of harassment, discrimination, stereotyping, bullying, victimisation, marginalisation, etc. (as defined in the study) | NA |
Outcome | Impact on student attainment, wellbeing, perceptions, trust, experiences (or as described in the study) | NA |
Setting | UK (studies performed from 2010 onwards) | Any other country or year |
Study design | Primary research studies (qualitative, quantitative, mixed-method studies) | Guidelines, systematic reviews, literature reviews, ideas, editorials, opinion letters |
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© 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Montasem, A.; Gjuladin-Hellon, T.; Awan, H.; Aine, B.; Whyte, J.; Alqadah, N.; Ibeachu, C. Racism, Discrimination, and Harassment in Medical Schools in the UK: A Scoping Review. Genealogy 2023, 7, 32. https://doi.org/10.3390/genealogy7020032
Montasem A, Gjuladin-Hellon T, Awan H, Aine B, Whyte J, Alqadah N, Ibeachu C. Racism, Discrimination, and Harassment in Medical Schools in the UK: A Scoping Review. Genealogy. 2023; 7(2):32. https://doi.org/10.3390/genealogy7020032
Chicago/Turabian StyleMontasem, Alexander, Teuta Gjuladin-Hellon, Hassan Awan, Brian Aine, Julian Whyte, Norah Alqadah, and Chukwuemeka Ibeachu. 2023. "Racism, Discrimination, and Harassment in Medical Schools in the UK: A Scoping Review" Genealogy 7, no. 2: 32. https://doi.org/10.3390/genealogy7020032