Are we doing our BAME patients a disservice in care due to a lack of diversity in the current medical curriculum?
An open letter written by: Jayden Gittens, Abigail Clynch, Portia Amoako-Tawiah, Kourosh Parvizi, Hazel Owusu-Yianoma, Jenrola Arawole, Fayo Ibidapo, Roksana Stobiecka
Science of Medicine (SOM) and Therapeutics 7
Communication for Clinical Practice 14
Public, Preventative and Global Health (PPGH) and Critical Analysis of Healthcare Research (CAHR) 16
Psychology and Sociology as Applied to Medicine 20
In every area of life, I can be seen differently, depending on the person behind the pair of eyes from which I am viewed. From my eyes, I see a woman, a student doctor, a person of colour. Although at times the colour of my skin is a topic of discussion and a reason for prejudice against me, my colour has not been adequately discussed in this space in which I find myself.
One might say that we are all the same and the fact that we sit side by side during lectures, clinical skills sessions and HARC practicals means that we, despite our ethnicities, have reached the same point in life and will continue to progress together. However, this is not the case.
Being accepted into medical school is a great achievement; however, as a BAME female in this environment it often feels as though I fail to be seen, with my values and outlooks failing to be clearly portrayed.
The curriculum as it stands teaches us a lot, so much of which I am grateful for. From public health to clinical skills, these are sessions I could only have dreamed of before entering medical school. Though appreciated attempts are made to help students understand the importance of inclusivity in university, as a Black woman I am still sometimes left feeling that our stories as BAME patients are not clearly heard in the field of medicine.
Since moving to Liverpool from Leicester, I have noticed a shift in the demographic. This has brought about interesting changes and discoveries; but one of the biggest challenges that BAME students may see is the lack of representation in the course content. Many students have had a stark realisation that the information we are given often focuses on a demographic which is likely not the same demographic we will be caring for as doctors. Although this is likely unintentional, it can have far reaching effects which will outlive our time in Liverpool and prevent us from being as good, as competent and as observant as we want to be in our future careers.
At some point this year, in a taught session, we discussed the implications of otherness and how that could be perceived in the medical profession. We discussed how being female or BAME could potentially affect the way in which we are treated by colleagues and patients. This single session was awkward, not only because the few BAME students felt that they were expected to answer, but because the class was quiet. This session designed to help students explore how we may respond to being a victim of, or a bystander to, prejudice had the perverse effect. It appeared from nowhere, without any prior discussion of racial disparities in healthcare, and left the BAME students feeling hypervisible; expected to be immediate experts on something that they may never have experienced.
One way I believe the outcome of this session could be enhanced would be to continually integrate the differences faced by both the patients and medical professionals throughout our curriculum. In this way, when we encounter people from different backgrounds in the future, we will be open and ready to understand how this may influence how they present. This understanding must be ingrained in us from our first year in Liverpool Medical School. Race and ethnicity play a part in the story of the patient that presents to us - we should be taught to appreciate this as much as the clinical understanding of the conditions we will one day treat.
This session was not an isolated experience; on another occasion, we discussed the difficulties various individuals would experience when obtaining goals in life. During the session, first year students represented many of the labels society places on individuals - labels which can lead to oppression, subjugation and ostracisation. Some of these labels included: homosexual man, female medical student and single parent. Looking back, this was a useful exercise to see the barriers present in the world today that impact marginalised people in our society.
One label that was not given was one associated with ethnicity. There was no label: ‘Black Woman’. This is part of who I am, and it always will be – whether this is acknowledged as being a defining characteristic or not.
Race can pose a profound barrier to individuals and communities which can have lasting impacts on the lives of a multitude of people. This is something that many people outside of our medical school environment may never have and perhaps never will experience. There are differences in how patients from different backgrounds express need, how they receive help and how they think. It is important we understand these differences so that when we graduate and become doctors, we are doctors of all ethnicities, of all walks of life, of all people.
In light of this, I would ask that changes are made to the curriculum - to the way in which we learn, who we learn from and the content from which we grow. I hope this letter helps in framing the conversation around such changes.
Hazel Owusu-Yianoma
The University of Liverpool’s School of Medicine (Liverpool Medical School) is one of the largest UK medical schools and one of the first to be incorporated into a university. As students, it is an institute we are forever proud to study at and we hope to aid in its continuous expansion and development.
Liverpool Medical School is diverse; hosting student doctors not only from all corners of the UK but from all over the globe. As an establishment, it is responsible for providing the best and most appropriate teaching to ensure that its doctors of tomorrow are equipped to care for patients of all ethnicities, cultures, sexualities, genders and backgrounds. This raises the question of how a prestigious institute designed to teach and raise the doctors of tomorrow, fails to acknowledge disease presentation and treatment in a patient group that currently makes up 14 percent of the UK population1.
We fear that due to this lack of education we are doing a great disservice to future Black, Asian and minority ethnic (BAME) patients.
In order to give our absolute best to all of our patients, we feel it is imperative to work with the medical school to formulate coherent and actionable improvements to the curriculum. As a small group of students, we speak on behalf of many others within the medical school in saying that we are absolutely committed to working on this with the school for the foreseeable future - not just for the sake of our education, but for the sake of fair treatment and outcomes for our future patients.
This paper aims to address racial issues within medical education and suggest improvements that are specific and pertinent to Liverpool Medical School’s current curriculum.
Racism as defined by the Oxford English Dictionary is the “belief in the superiority of a particular race”2. Attitudes of this nature affect students and staff on a daily basis. Black medical students are 2.5 times more likely to fail or drop out of medical school compared to their White counterparts3. This is sad and shocking as we all worked hard to be in the position we are today. What are the reasons for such discrepancies?
According to a 2020 BMJ investigation, medical schools are not well prepared to deal with racism and racial harassment experienced by ethnic minority students4. This statement could not be more true. There have been many racial incidents at the University of Liverpool and their partner hospitals, yet as student doctors we have little awareness of any scheme that aims to prevent and effectively deal with racial harassment. How are we as future doctors meant to feel empowered to call out racism in our workplace, advocate for our BAME patients and tackle health disparities if we do not feel empowered in our own place of study?
Before we begin the focus of this letter - how to change the current curriculum in order to improve BAME patient experience - we must look at one simple way of ensuring our university is a place in which all students feel confident, protected and empowered. There must be implementation of clear guidelines and support for addressing racial harassment.
The curriculum changes highlighted throughout this letter are all advantageous to student learning, however, if the university expects medical students and their peers to be educated on BAME health inequalities, they too must be educated on the issues facing their own BAME students regularly.
Therefore we ask the university, alongside the issues raised in this letter regarding curriculum content, to consider how students are supposed to respond when patients and staff make racist remarks towards them? Who do they go to when the institute supposed to be their safe haven fails to tackle this issue or take them seriously? It is a tough conversation to have and requires addressing.
This section of the letter focuses specifically on years 1 and 2 course content - offering analysis of the current themes and identifying areas for improvement within them.
In Year 2, the SOM and Therapeutics themes are present to develop our understanding about pathophysiology and drug treatment. Within these two themes, the learning outcomes (LOs) state that as student doctors we should be able to;
The content provided to allow us to reach these LOs is, as emphasised in the Year 2 handbook, done so with the intention of “expanding and deepening understanding of the sciences underlying clinical practice”6.
NHS England proudly serves a racially and ethnically diverse patient population, meaning that in itself clinical practice should recognise this diversity. Therefore, as the school’s intention is to prepare us for clinical practice, it should be expected that the scientific teaching we receive also recognises this diversity. The unfortunate reality is that up to now, the content the school has delivered across the SOM and Therapeutics themes has failed to do so.
Issues with the themes
The three key areas for improvement within the SOM and Therapeutics themes concern disease prevalence, presentation and drug treatment.
With regard to disease prevalence, the course fails to fully address important differences present between ethnic groups. The 2004 Health Survey for England assessed the health of ethnic minorities within the NHS patient cohort - the key messages from this survey state that subsets of the BAME population, versus the general population, have;
Despite these findings, lectures covering the pathophysiology of the above conditions largely failed to mention this. Both the T2DM and paediatric asthma lectures, delivered in the endocrine and respiratory blocks respectively, did not mention any differences in prevalence between ethnic groups. In the cardiovascular block, the ‘Hypertension: Clinical Outcomes/Treatment options’ lecture did reference the aforementioned ethnic variability however the ‘Acute Coronary Syndrome’ lecture (covering Angina and MI) did not. The school must make a concerted effort to incorporate differences in disease prevalence between ethnic groups into our teaching. This would no doubt be beneficial to our training by allowing us to develop our pattern recognition skills to be more patient-centred.
As far as disease presentation is concerned, the teaching at the school has failed to emphasise the importance of differences between BAME and Caucasian individuals. This omission of content is appropriately highlighted in the following lecture examples;
As the year that bridges the gap between pre-clinical and clinical medicine, it is of great importance that second year medical students are aware of the different external presentations of disease amongst ethnic minorities as well as the presentations in Caucasian individuals. The examples mentioned - and many other diseases - can have widely different appearances based on the skin tone of the patient and failure to teach us this leaves us concerningly unprepared for future study and clinical practice.
Lastly, the Therapeutics theme does not sufficiently discuss the ethnic variation in responses to xenobiotics. Throughout the theme ethnic variability is discussed only once in detail; within the ‘Pharmacogenetics’ lecture delivered in the Genetics/Paediatrics block. It is unrealistic to think that this subject matter can be delivered in a standalone lecture without omitting important content. Current research indicates that ethnicity is an important determinant in many drug responses, for example;
Of the three examples listed, the Therapeutics theme only explored Carbamazepine toxicity. This insinuates that the theme does not explore differences in drug responses between ethnic groups in enough detail. As the NHS strives towards personalised medicine9, it is important that doctors in training are aware of the markedly different effects of prescribed drugs between BAME and Caucasian patients.
Whilst there are select examples where the content delivered across the SOM and Therapeutics themes does include some form of BAME inclusivity, it is felt that this is currently not enough. This lack of consistency suggests that there is not enough encouragement from the medical school for this content to be considered by teaching staff. With this in mind, we propose a number of changes that we believe will help change this;
The examples used to demonstrate where taught content failed to consider disease in BAME patients was not an exhaustive list - this is a common theme. This may be due to lack of awareness by teaching staff; the patient population in Liverpool is predominantly Caucasian, meaning clinicians may be exposed to more Caucasian cases and this is reflected in their teaching. However, graduates from the medical school end up practising in a variety of diverse and multicultural environments outside of Liverpool and so the teaching should not just reflect the patient population of the surrounding area but of the whole of the UK. Regardless of whether graduates remain in Liverpool, BAME patients deserve student doctors who are being made aware of conditions and presentations affecting their specific ethnic group. The school needs to ensure there is cultural change so that teaching staff are aware that they have a responsibility to deliver content that is inclusive of all ethnic groups where clinically and epidemiologically relevant, whether or not this is common in their practice. This should include guidelines for staff to follow ensuring they research these differences and include it in their content where relevant. Furthermore, there should be regular communication with staff reminding them of this and randomised lecture reviews to check compliance.
Changing the LOs would not only help guide staff about the need to include this in their teaching but also put an onus on students to do some self-directed learning on the topic. This would further ensure that differences in disease amongst the BAME population are covered throughout the course. Updating the LOs should allow for integration of this content within current teaching and not treat it as an ‘optional add-on’. We believe addition of information in the form of extra lectures/foundation weeks would stop students from appreciating diseases from a multicultural standpoint. Furthermore, it would likely make the content more difficult to grasp. In order to achieve a multicultural learning style, it is vital that BAME-inclusive teaching is embedded within existing lectures and CBLs. To emphasise the importance of this, there should be an expectation that disease presentation and treatment in BAME individuals could be examined in formative and summative assessments.
This individual is ideally BAME, already within the pool of teaching staff, as passionate about these issues as we are and has enough time to give this role the attention it deserves. This individual should;
Creating this role for such an individual would serve as a statement of intent by the school - signalling that it has heard our complaints and is dedicated to creating a more well-rounded scientific curriculum.
It is recognised that Clinical Skills Teaching (CST) is an irreplaceable learning platform. It plays an important role in the curriculum as it is where students bridge the gap between theoretical and practical medicine. CST facilitates greater understanding of pathophysiology and disease presentation which allows us to treat our future patients more effectively. It fosters good habits such as always obtaining consent, use of aseptic technique and pattern recognition of signs and symptoms which encourages the best patient care.
Although there isn’t much patient diversity in Liverpool, BAME individuals make up a significant percentage of the patient population in UK hospitals. Liverpool Medical School has a duty to prepare their graduates, who take up foundation training posts all over the UK, so that they are well equipped to treat these patients. As such, the clinical skills curriculum should reflect this duty.
Clinical Skills Teaching plays a key role in building our investigative and diagnostic skills. Therefore, change is needed to ensure that as future doctors we do not continue to perpetuate the cycle of misdiagnosis and disservice to BAME patients. In order to implement long lasting change, it is important that the clinical skills curriculum acknowledges and addresses the inherent differences between BAME and Caucasian individuals which are clinically relevant, particularly in teaching sessions via integration of race discussions. Some examples of this include:
Introducing models of colour within the learning zone for example, brown venepuncture arms is a small but practical step in implementing the necessary change that must be made to the curriculum.
Differences in disease presentation and normal physiology between BAME individuals and Caucasians is clinically important yet rarely addressed in CST. Topics that could be touched upon are further discussed in the SOM section of this letter (see page 9).
The overall representation of BAME individuals as part of the general patient population is insufficient within CST resources (i.e. prep videos / teaching presentations / study guides). The incorporation of images and videos of BAME disease presentations in all CST resources is critical for change. Inclusion of this diversity as required reading material will ensure its addition will be significant.
Recruitment of CST staff/volunteers from BAME backgrounds will contribute to an inclusive environment in which BAME students feel as comfortable as their Caucasian peers in CST classes. It is hoped that this will have a positive feedback effect; encouraging more BAME individuals to volunteer as simulated patients subsequently increasing BAME student engagement and interaction during the classes.
Ultimately, it is felt that implementing these changes will shape us into conscientious doctors who are well equipped to treat BAME patients. Improving the curriculum will level the playing field for Liverpool graduates applying to training posts against other applicants who were more exposed to BAME patients. It will also improve BAME patients’ confidence in and perception of doctors and medical students.
At the very base of good medical practice is the doctor-patient relationship, and the trust the patient puts in the doctor is a direct result of this. Many of us would have mentioned witnessing a good doctor-patient relationship during work experience as one of our motivations for applying to medical school.
Unfortunately, this trusting relationship is not the lived experience of many BAME patients.
It has been reported that if patients feel that they are being treated differently by their doctors, they are less likely to place trust in them13. It is not enough for us to merely understand how our own actions may contribute to the lack of trust felt amongst BAME patients. We must have knowledge on how their previous interactions within the healthcare system may have negative ramifications on the subsequent trust they place in healthcare professionals, and be educated on how to deal with these feelings.
One of the potential solutions to this lies within the Communication for Clinical Practice (CCP) module. It is widely accepted that communication skills are fundamental to good, safe and benevolent practice14 and as students we really value the opportunity to hone our skills with Simulated Patients (SP) and tutors. It is felt however, that the experiences and take home messages could be ameliorated through the implementation of these changes:
Session 5: ‘Cues and Biases/Teamwork/Information Sharing’ - “Consider cognitive biases and thinking-styles and reflect on their role in diagnostic error”15
It is stated in the handbook that “cognitive bias is when inferences about situations or people are formulated in an illogical fashion”. Unfortunately this was mentioned without any tangible examples of actual cognitive biases. It is difficult to expect students to be conscious of cognitive bias without them having any formal idea of what these biases may entail.
From memory, this session had multiple learning outcomes and the focus of the session ended up being teamwork. It is recognised that teamwork is an invaluable part of medicine (trips to Altcar, placement groups and small-group CBL are all testament to this) however in the CCP module, cognitive biases seem to be an area that could be developed a lot more.
Unfortunately, none of the authors had any interaction with a BAME SP during the first two years of CCP. It is valuable for all students, especially those who come from rural areas with little racial diversity, to interact with BAME SPs. It is through these interactions that we as preclinical student doctors form primitive ideas of what our future patients look like. By not including BAME patients in our simulated consultations, one fails to show students the true diversity that they will encounter during their practice - particularly for those students who will complete Foundation Training in more diverse areas of the UK. It is feared that if medical students aren’t educated on this matter, this could amplify the current health inequalities already witnessed and experienced by those in the BAME community.
Given the established link between racial discrimination and its repercussions on mental health16, this is a prominent issue that training doctors will encounter in their future practice. Introducing students to this unfortunate and uncomfortable truth would aim to give students the tools needed to tackle this matter head-on. Students and graduates alike will therefore be able to contribute to an environment in which BAME patients feel more heard, valued and respected, thereby strengthening the doctor-patient relationship.
Session 4: ‘Emotions’ - “Demonstrate an ability to acknowledge and normalise emotions”15
In some situations, very ‘angry’ SPs complaining about their mistreatment in the past may give way to the trivialisation of their complaint, with the student doctors dismissing the true root of the SPs frustration in an attempt to diffuse the situation. Therefore, it is vital that the SP and tutor approach this matter in a sensitive way. It is likely that people who have been mistreated in the past will have anger or resentment towards healthcare professionals, but they are also likely to feel dejected or saddened by this. Presenting SP in this way - with the spectrum of emotions that they are likely to feel - will hopefully foster introspection in the student doctor and pave way for reflection on how they can better treat their patients.
These are a few measures that if interwoven in the CCP module could really improve the understanding of the effect of race on patients. However, in order for it to be a teaching opportunity, we suggest structuring the session to allow enough time at the end for students to explore the root of the patient’s emotions. Tutors can also use this space to give advice on how to deal with such situations in real practice.
The Public, Preventative and Global Health (PPGH) theme is designed to allow students to discuss the local, national and international health inequalities which impact upon patient experience, access to healthcare and health outcomes. Specifically, the PPGH learning outcomes describe how the theme aims to “discuss the advocacy role of health professionals, including in relation to the protection of vulnerable patient groups”17.
BAME individuals are one of the most vulnerable patient groups in the UK. The current pandemic has demonstrated this; Black and Asian individuals are more likely to die from COVID-19 (71% and 62% respectively) in comparison to White individuals18. The disproportionate vulnerability of BAME patients is not compensated for by our nation’s healthcare system, with BAME patients experiencing a higher rate of dissatisfaction within NHS services compared to Caucasians19. As the next generation of doctors responsible for providing high quality care, it is imperative we recognise BAME individuals as a vulnerable group when learning about population health. Failure to do so will only progress a system which has consistently failed the BAME community.
The current PPGH theme fails to acknowledge BAME individuals as a vulnerable patient group. This is demonstrated through a lack of discussion regarding racial inequalities throughout all teaching sessions, as indicated below:
These sessions offer examples of a general lack of teaching regarding racial inequalities across the PPGH theme. However, there are additional areas across the theme in which this topic is excluded. In order to continue producing a high standard of doctors there must be improvements made to the current curriculum.
At present PPGH teaching is delivered in the format of lectures and CAHR sessions; this constrains the ability for peer discussion and learning. The educational benefit and student engagement in the PPGH theme could be enhanced with the implementation of the following changes:
Although seminars can lack student engagement, we believe discussions which are semi-structured and cover a framework of themes will allow for more stimulating conversations thus more student participation. The seminars should aim to educate medical students on the inequalities existing for BAME patients in healthcare experiences, treatment access, screening access and study representation (alongside other PPGH concepts and themes). This would allow the aforementioned topics which have been excluded from lectures to be incorporated more regularly.
Alongside the CAHR worksheets distributed in sessions, there needs to be a transition to an environment which allows for more open discussion regarding the content of the papers analysed. From these discussions students must be able to broaden their understanding of the medical profession and the inequalities their future patients regularly face. It is crucial that these discussions cover the race-related inequalities and allow students to explore the implications this will have on their own future practice. It is only in these discussions that students will be able to practice introspection, identify their own personal biases and take action to ensure this doesn’t impact upon the experience of their future BAME patients.
PPGH concepts have a tendency to be interpreted as abstract ideas that must be learnt for our examinations. We fail to explore on a deeper level their impact on the general population. It is important that the PPGH curriculum incorporates discussions based on the key concepts of racial inequalities, applying these to real-life patient experiences within the NHS. Some areas in which this can be incorporated are:
Through implementing the changes set out for the PPGH theme, the medical school will allow for their students to contemplate on their own racial bias and how this may impact their future practice. Through encouraging self-reflection not only does the medical school produce competent doctors, it also fosters the ability of those same doctors to interrupt a system of institutionalised racism.
Psychology and Sociology as Applied to Medicine (PSM) encourages student doctors to acknowledge the differences that exist both within their cohorts and the wider community. Within PSM teaching sessions students analyse the way in which they interpret the world and explore a variety of subjects including professionalism, mental health and disability. The main aim is to develop tomorrows’ doctors ability to appreciate the non-clinical domains of healthcare.
Health inequalities, especially those concerning race, plague the UK health service22. A report published by Public Health England in 2018 summarised that, amongst other inequalities;
Despite this, PSM does not fully appreciate the professional and systemic failures in healthcare which lead to the disadvantages facing BAME patients. Without acknowledgement of this in the curriculum, students may not develop skills to counteract it.
The PSM theme is not devoid of discussions regarding racial inequalities; there are a number of areas in which diversity is mentioned. This includes assessments which aim to educate students on some of the racial disparities that exist in healthcare. However, we believe the content of these assessments is not sufficient to fully appreciate these disparities;
As of 2011, roughly 7.9 million (14%)1 people in the UK identified as BAME; learning about issues affecting BAME patients should be compulsory for student doctors.
At present PSM teaching sessions take the form of one hour, tutor-led group discussions on topics relating to psychology and sociology. There are a number of opportunities throughout these sessions to introduce conversations surrounding racial inequalities in healthcare. Despite this, there has been a lack of discussion around this topic in situations where it should appear. Examples of this are highlighted below:
Three ways in which the PSM theme can be improved are listed below:
At present, the current year 3 diversity essay feels more like a ‘tick box’ exercise, where only some areas of diversity will be covered. This essay is by no means irrelevant, however, teaching on diversity should not stop there. As previously discussed, racial inequalities should not be an “optional” aspect of our curriculum. If the university continues to require students to complete diversity essays, they must make these assessments in a way that requires students to educate themselves and their peers on the disparities BAME patients face in care.
The carers workshop held in year 2 was informative, interactive and engaging. The authors agree that seminars in which patient representatives are brought in to speak about their personal experiences are much more impactful than traditional lecture formats. It is thought that potentially having a BAME patient at one group speaking about their experience and allowing students to discuss and decide what was inappropriate about it will encourage peer discussion and critical thinking. The divergences in what students believe to be right and wrong will allow head-on confrontation of unconscious biases.
Education and self-awareness are key to delivering equitable health care to our patients. It must be stressed that this is not just important for the university setting - students will leave university more confident in calling out racial bias and discrimination in the workplace. By considering the changes that have been put forward, student doctors will graduate from Liverpool Medical School with the skills to advocate for all of their patients and begin interrupting a society which has for too long oppressed BAME individuals.
Race and its role in the progression of medicine has unfortunately been disregarded throughout the medical education system. By not educating medical students on how the content they study was discovered, how the content may be outdated and how the content can exclude patient groups, it closes the opportunity for our future doctors to learn and understand why racial bias can affect patient care.
Liverpool Medical School curriculum currently has limited teaching of medical history. Simply adding more teaching on the topic, opening up the conversation to racial bias and discussing its effects on patient care will have a positive impact on our education.
Examples of key topics that could be discussed are:
James Marion Sims developed pioneering tools and surgical techniques in women’s reproductive health and is therefore named the father of modern gynaecology. How did he conduct his research and achieve such merits? He performed seven experiments on enslaved Black women without anaesthesia or consent, in order to perfect gynaecology for White women. One young woman, a slave named Anarcha, underwent thirty operations by the hands of Sims under the racist notion that Black people did not feel pain.
This was a study of untreated syphilis in the African American male where participants were told they were receiving free healthcare from the federal government. Instead individuals were deceived by the public health service who disguised placebos and procedures as treatments. Participants were infected with syphilis, they were not told about the diagnosis despite it being infectious. The victims of the 40-year study - all African American men died, 40 wives contracted the disease and 19 children were born with congenital syphilis.
Henrietta Lacks was a Young African-American female diagnosed with a malignant cervical tumour after visiting her gynecologist with complaints of vaginal bleeding. Performed without her consent, the isolation of her cancer cells - now known as “HeLa” cells - led to the discovery of an immortal cell line. Due to this immortality, HeLa cells are used today across all forms of medical research, exploring the intricate details of cell processes. Despite their continued use in modern medicine, her family have received no form of compensation, it took twenty-five years after Henrietta’s death for them to be made aware of the cell use.
The ugly truths behind many medical revolutions are often overlooked by students training in this scientific field. Without formal teaching on this, we are at risk of retaining or repeating such misconceptions - as George Santayana once said: “those who cannot remember the past are condemned to repeat it”. The ramifications of a lack of education were shockingly illustrated through an American study of 222 medical students and residents. Half of respondents believed Black patients felt pain differently to their White counterparts - it was concluded that this could contribute to racial disparities in pain management24. Teaching of the history of medicine is crucial to dispelling false narratives about patient populations.
This section of the letter focuses specifically on years 3, 4 and 5 course content - offering analysis of specific themes and identifying areas for improvement within them.
Multiple studies have reviewed and produced data that prove the disproportionately negative experiences of the mental health sector amongst BAME patients. A 2019 meta-analysis and systematic review - aimed to investigate the ethnic variations of compulsory detention under the Mental Health Act, both in the UK and internationally25. The results are as follows:
Evidence shows that Black men are more likely to be diagnosed with severe mental health problems than their White counterparts. In order to begin breaking down this pattern of treatment amongst Black individuals, it is important we understand how these patterns arose and what can be done to alter this uncomfortable reality.
One such disparity is the increased admission rates aforementioned. ‘Modernising the Mental Health Act’, the final review of the Independent Review of the Mental Health Act 1983, aimed to understand the disproportionate number of BAME people compulsorily detained under the Mental Health Act26. Some of the review panel’s comments regarding this are as followed:
The official review also stated that some of the reasons for the disproportionate number of BAME patients compulsorily admitted are due to longstanding experiences of discrimination and deprivation, and significant gaps in trust between the service users and providers. The concept of complex patient-doctor relationships amongst BAME individuals is further discussed on page 14.
In 2019, Mind launched a new programme working with young Black men aged from 10-30 years old. The aim was to understand the mental health problems faced by this demographic and reduce the stigma surrounding these problems through education. The results of this study showed that there were many reasons for the disproportionate sectioning of Black people, including:
The studies listed above demonstrate a clear gap in clinician education, concerning both systemic racism and the individual bias present within the healthcare system. This lack of education has detrimental effects on the care Black patients receive and hinders their ability to receive help. Liverpool Medical School can address this by educating their students on this topic area, previously missing from the medical curriculum. Some proposed ideas that may help tackle this topic area within the current course are as followed:
It was explicitly stated in the Modernising the Mental Health Act review that culturally appropriate advocacy is essential in the improvement of Mental Health services, in particular for those of Black African and Caribbean descent26. Because of this, we believe that educating Liverpool medical students on the importance of advocacy for BAME patients in mental health and other fields of medicine is essential in the pursuit of becoming great doctors. Sessions in which discussions concerning culturally appropriate advocacy can be introduced are discussed further in the CCP, PSM and PPGH sections of this letter- see pages 14, 16, 20.
The Liverpool population is 2.1% Asian, 1% Afro-Caribbean or other Black ethnicity and 0.6% were ‘Other’ (data from 2011)28. As people from BAME backgrounds make up such a small part of the population of Liverpool, it is safe to assume that they also make up a small part of hospital admissions as well. Therefore, it is unlikely that medical students will interact with a large number of BAME patients during the course of their degree.
It is crucial that in order to be competent doctors, medical students are educated on the increased risks that their BAME patients may have. One anticipates an adaptation of current teaching sessions in order to accommodate for this lack of exposure to BAME individuals in alternative ways such as workshops and non-clinical teaching. This could be best implemented through CCP sessions (see page 15).
The NHS is a service for all, yet the system aiming to educate the future carers sadly does not include differing disease presentations and treatment in different skin tones. This can have detrimental effects with diseases not being identified in their early stages where intervention will provide a better prognosis.
A recent study finds that African American who contracted Lyme disease are 10% more likely to exhibit severe symptoms such as neurological and heart deficit than their Caucasian counterparts29. However, the cause of this was concluded from the study to be due to failure of clinicians to recognise the typical early stage rash of Lyme disease ‘a bull’s eye rash’ in pigmented skin. This meant that Lyme disease was only being recognised Black patients in advanced stages, conducive to a lack of treatment and worse prognoses. This systemic failure on our part can be easily addressed.
Our medical school can widen the curriculum and adapt teaching to include disease presentations in ethnic skin. DermNet NZ and others30,31,32, include vital information regarding pigmented dermatology and can provide further guidance. Key dermatological words such as ‘flushed,’ ‘cyanosis’, ‘pallor’ are all taught and shown but only on White skin. A simple inclusion of more diverse skin tones can help to educate us student doctors.
There is a concerning disproportionality in maternal and infant birth outcomes within the BAME community compared with their Caucasian counterparts in the UK. These disparities are highlighted in maternal mortality rates; the estimated White British maternal death rate is 8 per 100,000 maternities, compared to 28.05 for Black women (ethnicities combined)33. In recent statistics, it was shown that BAME women make up 55% of UK pregnancy hospitalisations with COVID-1934. This clearly highlights underlying issues and discrepancies between the communities. Evidence suggests that there is a lower threshold of diagnosis by medical professionals in the BAME groups leading to late disease detection and intervention.
Dr Rai Clarke, a consultant in Obstetrics and Gynaecology, spoke at the January 2019 ‘Pregnant Then Screwed’ conference. She said: “Black women may not feel that they will be taken seriously, which might make them less likely to disclose how they are feeling”35. This is rather disheartening. As medical professionals, we strive to build an excellent rapport with our patient and create a safe environment. However through the statistics and concerns of Black patients, it seems that we are currently failing some of our patients. As a healthcare community, we must work diligently to seek the root and address this issue so that more lives are not lost.
Conversations pertaining racial bias in maternal care are often disregarded as it is an uncomfortable topic, however it is felt that the detrimental effects of ignoring such a conversation are even more uncomfortable. We must address this issue for the best interest of our BAME patients.
As a medical institute, we could alleviate these pressures through educating, highlighting conditions that are more prevalent in BAME pregnant women compared to the rest of the population. Providing background to these statistics and how as future practitioners we can identify these conditions will be invaluable to the care of BAME patients in Obstetrics and Gynaecology.
Topics that could be covered are:
There is a higher prevalence of gestational diabetes in Asian women in contrast to White and Black women36. It is important to emphasise these when educating students about this topic alongside studies and evidence exploring why these differences may occur.
Obstetric cholestasis is a rare condition that causes pruritus, excessive itching and jaundice in patients has a higher prevalence in the South Asian and Araucanian Indians. This condition can result in preterm labour leading to premature birth. Therefore it is crucial for us as medical professionals to identify this disease.
In the lecture example: Early Pregnancy Problems in the Year 2 Urogenital block, it was stated that “15% of patients with recurrent miscarriage have antiphospholipid syndrome”. Affecting women:men with a 5:1 ratio, antiphospholipid syndrome is an important disease to learn about given its multisystem effects: increased risk of miscarriage, deep vein thrombosis, transient ischaemic attacks and strokes. However, there was no mention of the fact that Black and Hispanic women in particular are at an increased risk of having this syndrome.
The authors believe that a push for more epidemiological teaching behind diseases that affect BAME women more, would be a step towards preventing the misdiagnosis of pregnant BAME women. It is hoped that this small, but effective, change to the curriculum will improve the disparities that currently exist.
For six weeks we have been working on this letter of recommendations. Through a culmination of discussions, reflections and interviews, we have produced a document we feel offers a critical analysis of our current curriculum and shows it does not reflect the diversity of today’s society.
The aim of this letter is not to accuse or cast blame onto anyone for the racial disparities in healthcare, but rather to recognise them, discuss them and propose actionable ideas for change. Given the amount of effort we have put into the letter, we hope that these suggestions are taken seriously.
To reiterate, we are immensely proud to study at Liverpool Medical School and can confidently say that the university fosters an environment in which student doctors are encouraged and taught to advocate for their patients. Based on this, we are confident that this letter will be received with acknowledgement and appreciation.
People often talk about the healthcare system being flawed, but we are the system. As students we have begun to recognise this and we want to ensure we are the generation that implements true change.
References