The under-representation of racially minoritised doctors in academic general practice training: a retrospective analysis

Summary

Based on the ACF intake levels in 2022, of whom, 71.1% were White British (of the 38 people who disclosed their ethnicity), one would expect a similar proportion of White speakers at the annual GP ACF conference. However, over a period of 6 years, on average, 82% of the speakers were White, which is disproportionately high. This would imply that the small proportion of doctors from racially minoritised backgrounds who are in ACF posts do not participate as a speaker at the national ACF conference; either by choice or lack of opportunity.

This work highlights clear racial and ethnic disparities in attainment within GP academia; extending from recruitment into GP ACF posts and continuing across the entire GP clinical academic pathway. Racially minoritised doctors become proportionally less well represented as the academic ladder increases in seniority, evidencing an ethnicity attainment gap. This reflects the 'leaky pipeline’ phenomenon, where there is a progressive loss of capable persons from academic clinical careers. This is particularly evident in Black groups in general practice. In 2021, 15% of the UK GP training cohort were Black but just 6% of all GP and trainee GPs in England were Black. Also, <1% of clinical lecturers, senior lecturers and professors in general practice were Black, with numbers too small to be more accurate. Even at ACF level, <2% of the 2022 cohort were Black.

Possible reasons for doctors from racially minoritised backgrounds not entering into academia include not being aware of these roles, being deterred from these roles, not having visible representation in role models or mentors, and perceived or experiential institutional racism. This starts in medical school, where students from racially minoritised backgrounds often feel that there is a lack of role modelling and mentoring.⁸ Early career researchers from racially minoritised groups have been noted to be disadvantaged owing to patronisation and paternalism, lack of funding, and the ethnicity pay gap.^9–11 The losses multiply at each level culminating in capable doctors and potential academics from racially minoritised backgrounds being lost.

It is important to promote GP academia as an attractive career choice. A survey of medical students found that only 3% thought that a career in general practice would be intellectually challenging and 39% reported that tutors from other specialties had put them off a career in general practice.¹² In 2016, the Wass report¹³ made recommendations to raise the profile and improve the vision of general practice. This included a specific recommendation that academic training opportunities were properly supported and promoted. However, Lawson and Kumar specify five areas in which we are still failing, including widening access in medical schools and role modelling in general practice,¹⁴ both of which could be relevant to removing barriers for doctors from racially minoritised backgrounds and IMG trainees.

Strengths and limitations

Limitations of our method include race and ethnicity assigned to those included in the analysis was not self-reported but rather assigned by the researcher, based on their appearance and their online profile. We recognise that this might not always be the same race and ethnicity that the speaker might assign for themselves. We used three broad race and ethnicity categories but we acknowledge that there are far more than this and that by doing this ourselves we are being reductionist, failing to account for the vast heterogeneity of the workforce. As such, we understand that this method will lose granularity and nuanced differences will be missed. However, we believe that this is an important start in highlighting the problem.

Comparison with existing literature

A recent systematic review and qualitative study exploring the inequalities in UK clinical academic careers by Brown et al found that women and doctors from so-called ‘BME’ backgrounds are less likely to progress through clinical academic careers.⁹ Unfortunately, most work in this area comes from the US and work needs to be done within the UK to understand the barriers and facilitators into an academic clinical career. Their study was extensive and emphasised a real inequity in clinical academia in the UK. However, it was broad and it focused more on sex than ethnicity.

Previous research by the authors of this study at Queen Mary University of London assessed the intersectionality of presenters at conferences and analysed how this affected conference participation. The work showed that when there is more diversity on the panel, there is more participation from the audience.¹⁵ Having better representation of racially minoritised clinical academics at conferences may not only increase participation, but also lead to role modelling within racially minoritised groups.

Implications for research and practice

Our work shines a spotlight on the ‘glass ceiling’ affecting GPs from racially minoritised backgrounds within academia, especially for Black or Black British GPs entering into or progressing through academia. The WRES 2022 report¹ shows that so-called BME staff are less likely to think that their trust provides equal opportunities for career progression or promotion (58.7% of White staff compared with 44.4% of staff from so called BME backgrounds). This is even lower for Black staff groups, with only 35.4% believing there are fair opportunities. This is problematic and work needs to be done to explore this lack of opportunity further. However, the WRES report excludes the experiences of GPs and it would be interesting to know if the same patterns apply in primary care. We have highlighted a gap in the research and present on the racial and ethnic disparity at GP ACF level, which, to the authors’ knowledge, has not been done before.

The reasons behind these findings are important and worthy of study. Further work should explore whether ACF trainees from racially minoritised backgrounds are submitting abstracts and getting rejected or if they have not submitted abstracts at all. Qualitative research to better understand the issues may be helpful in exploring themes around lack of role modelling, lack of confidence, micro-aggressions, and institutional racism.

Further work should also include qualitative research on the experiences of GP ACF trainees from a range of racially minoritised backgrounds, early career researchers, and of those who have not been able to pursue a career in academia for whatever reason. This work should also disaggregate and distinguish between different so-called BME groups in order to highlight where further work needs to be done. This will enable us to better understand the barriers and facilitators to an academic clinical career as a GP.

By being complacent, we are being complicit in this injustice. We must call out racist structures, policies, and behaviour and ensure that we contribute to fair and representational recruitment into academic and senior roles. Not only is there a moral imperative, but also diversity in our workforce is good for patients, good for juniors, and good for the wider team. By harnessing the skills, knowledge, and perspectives of GPs from all backgrounds, we can move to providing truly holistic care for our patients. Research tells us that a diverse workforce improves performance, creativity, and can lead to more impactful research.¹⁶ It can allow patients from similar backgrounds to feel represented as well as providing junior colleagues from racially minoritised backgrounds with role models. We must be active in our pursuit of becoming an anti-racist institution, organisation, or entity. Not being actively racist is not enough.