Conclusions and recommendations
What have we learnt?
The responses to the BMA’s briefing outlined in Part 2 – Examples of practice in equality and diversity education were varied. Those involved in undergraduate medical education – the General Medical Council (GMC) and medical schools – appear to have understood the concept of equality and diversity education and have structured their curricula with demonstrable outcomes. However, it is not always clear if or how these outcomes are assessed and what weight is given to equality and diversity. In postgraduate medical education – the Postgraduate Medical Education and Training Board (PMETB), medical royal colleges and faculties, and postgraduate deaneries – the responses, save some notable exceptions, appear to have failed to grasp the concept and concentrate on selection and monitoring to meet legislative duties.
One might question why, with a few exceptions, this different interpretation exists between curricula in undergraduate and postgraduate medical education? There are a number of possible factors. The GMC sets clear outcomes for equality and diversity in 'Tomorrow’s doctors'. Medical schools are part of, or attached to, universities which are academic institutions with professional educators and therefore understand how to reach set outcomes.
By contrast, the PMETB’s standard for equality and diversity is simply, to reiterate, 'The curriculum should describe its compliance with anti-discriminatory practice' [reference 6]. This statement does not compel curricula developers, currently the medical royal colleges and faculties, to tackle equality and diversity education or for postgraduate deaneries to ensure anything other than duties not to discriminate are applied. However, it must be acknowledged that a number of postgraduate deaneries and royal colleges who responded have gone further than this. Further, the statement does not reflect the specific duties to promote equality of opportunity required by equality legislation in the UK.
The PMETB is fulfilling its statutory obligations for equality and diversity by publishing its equality scheme and action plan, but neither of its standards documents sets out that training must include equality and diversity education for doctors for the benefit of their interactions with patients and colleagues. The PMETB asks that curricula address the GMC’s 'Good medical practice' guidance [reference 2], which sets outcomes for equality and diversity, but this reference passed from one document to another will inevitably be diluted when there are no explicitly stated outcomes for equality and diversity.
The willingness of the medical royal colleges and faculties to develop robust and thorough curricula is not in question. With Modernising Medical Careers (MMC), colleges and faculties have been asked to develop, in a short period of time, run-through training curricula and naturally the focus will have been on clinical content over what maybe seen as ‘soft’ skills. Elements of equality and diversity education may, or may not, be interwoven into curricula as part of communication skills, but they are not distinct or assessed as such.
Another problem for postgraduate education is its organisation, where a number of different organisations are involved in its implementation. The medical royal colleges, and faculties, and (with ultimate responsibility) the PMETB, all rely on postgraduate deaneries who, in turn, rely on centres of training, and trainers themselves, to implement and carry-out the curricula. There is, therefore, little control as to what is actually taught to a trainee doctor in, for example, a particular programme, managed by a particular postgraduate deanery, in a particular hospital, with a particular trainer. Medical schools are more fortunate in having more direct control over what should be taught because they are education providers as well as curriculum setters.
What should be done?
The onus must be on the regulators, namely the GMC and the PMETB, to ensure that standards of medical education are met. These standards should explicitly include education on equality and diversity with respect to relationships with patients and colleagues.
The responses show that the GMC’s explicit outcomes for equality and diversity are being included by medical schools in their curricula. The PMETB’s standards for equality and diversity, on the other hand, are not explicit and this is largely reflected in the lack of prominence of equality and diversity in postgraduate curricula.
It is vital that the GMC and the medical schools continue their commitment to equality and diversity. This is important in view of the current review of 'Tomorrow’s doctors' [reference 2]. The PMETB, medical royal colleges and faculties, and postgraduate deaneries should follow the lead given by undergraduate medical education, in order to build on existing education in equality and diversity, and define the outcomes expected at postgraduate level.
The main partners in equality and diversity education are of course the medical students and trainee doctors themselves. The University of Birmingham response highlighted two key challenges in making equality and diversity education work:
- that teaching in diversity should be relevant to clinical settings because this is what engages students
- that students consider dimensions of diversity with regard to professionals as well as patients.
Doctors should be required to demonstrate competence in equality and diversity throughout their medical career, and this should be addressed as part of assessment and appraisal, and consideration given for how it is incorporated in the revalidation process. This competence is a necessary component in delivering equality of healthcare access, service delivery and health outcomes.
The following areas of work should be progressed:
- the PMETB to set explicit standards and outcomes for equality and diversity based on Good medical practice which medical royal colleges and faculties must include in their curricula
- the GMC, or the Medical Schools Council, to facilitate the sharing of good practice in equality and diversity education between medical schools
- the PMETB to facilitate the sharing of good practice in equality and diversity education between medical royal colleges and faculties
- medical schools and medical royal colleges and faculties to develop assessments which measure whether the outcomes of equality and diversity education are being met
- the GMC and the PMETB to monitor the outcomes of equality and diversity education in order for its effectiveness to be reviewed
- all those involved in undergraduate and postgraduate medical education to seek guidance from, and work with, the Commission for Equality and Human Rights (CEHR) in developing equality and diversity education.
- bringing the importance of equality and diversity education to the fore
- being a critical friend to the various organisations involved in medical education
- enabling debate
- highlighting where good practice occurs
- providing resources for doctors and educators.
The original briefing talked about the assumptions people make and how those assumptions can be a barrier to equality. Another assumption is that medical students and trainee doctors, as academic achievers, have inherently intelligent and informed views. It must not be forgotten that most medical students and trainee doctors are young people who may have limited experiences and views which may be uninformed or are still being formed. The argument for equality and diversity education is illustrated with this piece of commentary from the University of Birmingham response:
'The appearance of topics such as racism, homosexuality and gender on the formal, core curriculum is good in and of itself: for some students there is clearly benefit in witnessing, for instance, an open discussion of what ‘being gay’ means, both for doctors and for patients. Giving students an opportunity to role-play a clinical consultation with an interpreter may be helpful in promoting reflection on the process of communication. For some students the [Human Diversity] module provides information, for instance there is widespread shock that same-sex relationships are legal, with an age of consent comparable to heterosexual relationships.'