Thursday, 27 September 2012

RCGP Council Member defends CSA book published in 2010

I am indebted to GPOnline magazine for printing my full response to the CSA book controversy. If readers read the entire chapter instead of a passage taken out of context from an Amazon book preview, they would have read the start of the chapter discussing examples of how the world may perceive us (ie negative subjective bias) with ways to neutralise or turn into a positive and the end of the chapter discussing how my advice was just to change your image for one assessment and not who you are. The 'camp' category passage is not my bias nor that of the Royal College, but of how elements of society may still regard homosexuality in Great Britain and indeed the presence of homophobia in healthcare has been acknowledged publicly recently by the RCGP Chair Clare Gerada. The example cited in the passage taken out of context is of a young gay male resit GP trainee facing his 3rd exam attempt and was just an illustration how society may even perceive sexual orientation as a negative bias and therefore by neutralising any overt distractions, the doctor stands a fairer and better chance at passing a subjective exam in which he encounters 13 random actor patients and 13 random examiners, as he sits in his consulting room waiting for each actor patient to arrive accompanied by one examiner. He has 10 minutes to discover what the actor patient's concern or problem is and manage and repeats this for the next 12 strangers who will be knocking on his door. It is always the right of a GP trainee to complain to the Chief Examiner or Invigilator if he or she felt bias had affected their performance or marks, and I have raised the suggestion to the Chief Examiner that all 39 examining rooms have video cameras installed to record these simulated surgeries in the CSA exam to ensure candidates may provide evidence if they feel they have been discriminated or disadvantaged and have also suggested there be 2 examiners in each room, ie one marking and one shadow examiner as is the case for exams conducted by the other Royal Colleges, as another means of reducing observer bias. I am sorry there has been so much media attention over this. All I ask is that you actually read the entire chapter before passing judgement. Just as I advise GP candidates to neutralise their image so that they are not pre-judged before they have had a chance to demonstrate their communication and clinical skills in CSA, I ask that the world does not pre-judge me until you have read the entire chapter and not focus on a passage in the middle, taken out of context.

http://www.gponline.com/News/article/1151634/rcgp-council-member-defends-book-sparked-investigation/

http://www.independent.co.uk/voices/comment/dont-shoot-the-messenger--minorities-are-kept-out-of-the-top-jobs-in-medicine-8180679.html

RCGP council member defends book that sparked investigation

By Abi Rimmer, 25 September 2012

An RCGP council member has defended a controversial book designed to help students pass MRCGP exams.


Dr Una Coales: under investigation over MRCGP book
Dr Una Coales: under investigation over MRCGP book


Earlier this week it was revealed that RCGP council member Dr Una Coales was being investigated by the college over a book advising MRCGP candidates on how to 'neutralise bias' from the college's examiners. The college also distanced itself from the book.

In a response to the investigation, Dr Coales defended her advice. She said: ‘The bottom line is that however hard you try, and the RCGP tries very hard, you cannot ever be sure that you have eliminated subjective bias entirely. So what is the candidate to do?'

Dr Coales said that some of the examples she used in her book to demonstrate pitfalls faced by students, such as acting ‘overtly gay’, were ‘over-emphasised, simplistic and perhaps brutal’.

But she went on to explain the reasons behind using such examples: ‘This is deliberate as many candidates are in denial either about how they themselves come across or, at least in my opinion, of the importance of giving consideration to these issues.'


Senior GP responds: Racial prejudice, Homophobia and exam bias?           

Or ‘Don’t Shoot The Messenger’ by Dr Una Coales

Following my return to the UK, in 1994 (I am British by birth but brought up in the United States since the age of 11) I applied for a post at a leading London teaching hospital. The first question I was asked at interview was: “how would I feel as a mother leaving her child behind at home?” The second was "who is the Captain of the English rugby team?” I didn’t know and didn’t get the job.

Shortly thereafter, I obtained a post in a different department of the same hospital. Although entirely white and male, my colleagues in that department could not have been more different. They were decent, kind and thoroughly professional. Organisational culture tends to reflect the attitudes of those at the top and I suspect the difference between the two departments is explained by this.

Towards the end of this six month post, I found that in spite of multiple applications I was failing to be called for interview for surgical specialty training programmes. The head of my department, a renowned surgeon, offered to look at my C.V. He said that it was an extremely strong CV but that I should make one change. The change? Merely to delete my maiden name “Choi”. I did this and as if by magic, I started to be called for interview.

If you have never been the subject of discrimination, it must be difficult to understand the ghastly stomach-churning depression that results from not being wanted merely because of your nationality, ethnicity or sex.  For gay people, there is the added agony of deciding whether to be discreet (or even lie) about their sexuality.

For me, this discrimination came as a tremendous shock. In New York, I had worked in highly diverse (ethnically and sexually) departments. The level 1 trauma team, I had worked with in Harlem had, at one point, been all female. Our patients too were multi-cultural and open about their homosexuality.

Little did I know at the time, that racism in medicine or in particular, institutional NHS racism was being exposed publicly. In 1999, Dr Sam Everington, a GP and barrister, had researched and published on applicant selection bias by medical schools. In an interview with BBC news in 1999, he said,’ “This is institutionalised racism in the NHS - the deans have taken it to a new art form."

In a 1999 BMJ article 'Tackling Institutional Racism', Professor Joe Collier, blew the whistle and notified the Commission for Racial Equality about computer software being used in the student admissions process at a leading London teaching hospital/medical school that discriminated against ethnic minority candidates. This programme gave a lowered computer generated score for candidates with non-Caucasian names. As a NHS whistleblower, instead of being applauded for his bravery and courage, he was 'vilified and ostracised'.


The greatest barrier to racial and sexual equality is institutional denial.  For years, this was clearly the case in medicine in the UK, as the treatment of Professor Collier demonstrates. Working in NHS hospitals, I learned the phrase 'be a grey man' which means ‘don't cause waves, don't stand out, don't speak up, turn a blind eye, and keep your head low’. The consequence of not abiding by this unspoken rule was another phrase 'career suicide' which is self-explanatory. How strange to be working in such a hostile environment coming from New York City where an active effort towards positive discrimination for ethnic minorities was encouraged and a zero tolerance to racism or workplace discrimination was the norm.  When I was first elected to the Council of the Royal College of GP’s, I was given similar advice. Perhaps I should have taken it.

Over the last 10 years, there has been considerable progress in acknowledging the problem and much progress has been made in addressing it. In 2001, a Kings Fund report, “Racism in Medicine”, generated powerful debate after finding that bullying and discrimination were a daily fact of life for black and Asian doctors. Then in 2003, a British Medical Association (BMA) survey revealed that among ethnic minority doctors, who form nearly one third of the NHS workforce, more than 80 per cent believed that their ethnicity had a negative effect on their career advancement. In 2004, the Royal College of Psychiatrists accepted that racism existed in the NHS and in their institution. A recent report into Gay and Lesbian issues in British Medical Schools found that “there were impressive areas of good practice but that these were not widespread.”  Professor Clare Gerada, the current Chair of the Royal College of GPs’, has herself recently drawn attention “to the existence of homophobia and biphobia within healthcare”.

So to what is extent is racial and sexual bias a factor in medical exams today? In 2009, I published advice to doctors sitting RCGP exams. This has become the subject of considerable controversy in recent days. Shortly after its initial publication, a RCGP internal study identified the need for enhanced diversity training for examiners and patient actors. This has been implemented and the College continues to make great efforts to minimize subjective bias. The College, as a result partly of requests from myself and others within the College concerned about these issues, has recently commissioned the King’s fund to  study reasons for differences in exam outcomes, in order to identify racial bias, if any. Has overt subjective bias been eliminated from College exams? Yes I am sure it has.  Is there still a risk of subconscious subjective bias? Yes of course there is. We are all prone to subjective (observer) bias: examiners, candidates, actors, patients, the general public, you, me, everyone. Why? Because we all suffer from one fatal flawed characteristic: we are all human beings. The Nobel Prize winning psychologist and bestselling author Professor Daniel Kahneman has written, “In admission procedures for medical schools, for example, the final determination is often made by faculty members who interview the candidate. The evidence is fragmentary, but there are solid grounds for conjecture: conducting an interview is likely to diminish the accuracy of a selection procedure, if the interviewers also make the final admission decisions.

Because interviewers are overconfident in their intuitions, they will assign too much weight to their personal impressions and too little weight to other sources of information, lowering validity” (My emphasis).  Or  to quote from the British Journal of Medical Practitioners 2009, “As blatant forms of racism become extinguished, particularly in the current climate of political correctness, unconscious racial biases in subtle forms, known as ambivalent or modern racism , are appearing. This has been referred to as aversive racism occurring in people who possess strong egalitarian values, and who believe they are not prejudiced, but have negative racial feelings and beliefs that they are unaware of.”  The bottom line is that however hard you try, and the Royal College tries very hard, you cannot ever be sure that you have eliminated subjective bias entirely. So what is the candidate to do? If he or she adopts behaviour likely to reduce subjective bias, then not only has he or she lowered the risk of being effected by any such bias but also  the candidate is likely to be more self confident and thus perform better in the ordinary way. The advice I have given can be summarised as not drawing attention to any characteristic of your behaviour or appearance that may distract from a pure appreciation of your medical skills. In my articles and book, I have cited some examples which are somewhat over-emphasised, simplistic and perhaps brutal. This is deliberate as many candidates are in denial either about how they themselves come across or, at least in my opinion, of the importance of giving consideration to these issues. Some feel that to compromise one’s identity is wrong, and I have great respect for that point of view. I have made suggestions which have helped several hundreds of doctors pass this exam and am making no judgement on the underlying social issues, however important. These were merely some of numerous suggestions cited in an exam revision book to help a doctor reduce subjective (observer) bias and thereby put him or her on equal footing with others so that what is being assessed is his or her consulting skills without any distracting variables.