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Doctors at Work Podcast.

Episode #37

What can we do about the attainment gap? With Ricky Ellis

Mat Daniel


Doctors from different backgrounds have different success rates in postgraduate exams and in interviews, and different rates of representation in senior leadership roles. In episode 36, Ricky Ellis told me what differential attainment is, and how it arises. The this episode we discuss what we can do about it. There are things that we can change at system level, at regional level, and at the level of individuals to make our profession better.

Ricky is a medical educationalist with a PhD in the use of big data in Medical Education and an expert in differential attainment in post-graduate medical assessments.

Podcast Transcript

[00:00:00] Mat: Welcome to Doctors at Work. My name’s Mat Daniel. I’m an ENT consultant, a medical educator, and a coach specialising in helping doctors develop successful and meaningful careers. This episode is the second episode in my discussion with Ricky Ellis around the attainment gap or differential attainment. In the previous episode, he told me what the attainment gap is, why it’s problematic, and he eloquently outlined the need for change. In this episode, we move on, and we have a discussion around what we can do about it. We start off with talking about what we need to consider at system level. Then we talk about regional level. And then we can talk about individual level. I hope that it’s useful.

The systems level, you talked about bias and about structural discrimination. What can we do about that?

[00:01:01] Ricky: This is arguably one of the hardest because it’s almost slightly nebulous, isn’t it? And maybe my answers will be a little nebulous, but let’s be honest. We know we need systemic cultural change within medicine.

There is still a culture of bullying, of harassment. There’s still a culture of bias and discrimination. There’s still bias within policies. So, we need this systemic cultural change. We need, and that’s another thing that is affected by diversity within the senior and leadership positions. If everyone has a say, you reduce the risk of this echo chamber creating policies that are bias and discriminatory to those that aren’t in the room.

We. also need a national level, a nationally driven change to things like support programs, remedial training and outreach programs. Because we know from all of this data that some individuals are less likely to pass assessments, they’re less likely to progress in their careers than others. We need to be tackling this as early as possible.

We talk about this accumulation of opportunities and disadvantage. We need to be acting on this as soon as we can, as early as we can in people’s educational careers, so that we can have the maximum benefit. And make things more equitable as they go for their entire training programs. Early targeted support and outreach programs needs to come at the national level.

That, that can’t be done at a local level. And you need funding for that, there’s no doubt about that. And there are some initiatives that are starting now. But again, it’s mostly regional or local. It’s very few national initiatives. And in terms of funding, we also need more funding for things like educational grants and bursaries because there are undoubtedly socioeconomic barriers to progression for some groups and others.

If you’re less than full time, you have caring responsibilities. You may be a single parent. Training’s expensive. Assessments are expensive, revision courses, resources are incredibly expensive. We need more access to educational grants and bursaries at a national level to, to support people as early as possible.

And likewise, there’s huge differences in access to professional support locally and regionally. Huge differences in funding for what professional support units, end up giving out. This needs to be centralized. This needs to be, from the same rule for everyone in terms of, sorry, not the same rule for everyone, the same funding for everyone so that everyone has equitable access to resources and early access to resources.

For example, in, in one small study that we’ve done, which we haven’t published yet in one region, if you failed a written exam twice, you’d get referred to a professional support unit and they may do a screening for specific learning difficulties. Neurodiversity. And in another region, that didn’t happen unless you asked.

Your TPD for it, for a referral to the professional support unit or someone else flagged it up. It wasn’t an automatic thing after failing an exam a couple of times, which is surprising considering you’ve got in talent, incredibly intelligent, motivated, accomplished people taking these exams. It’s a real red flag.

If people start failing a written exam multiple times, either the training isn’t working, either they’re being let down from a training point of view, or there may be something else going on. It seems logical to me that early referral to a professional support unit is required. So, these are just things that can be put into place relatively quickly.

And they won’t cost the world, especially when you consider the financial incentive of people progressing through their careers at a steady more expected rate than what can sometimes happen to some groups of individuals at the moment.

[00:05:21] Mat: So the problem that I foresee with this, if I think of some of the national roles that I’ve been involved with and I can think of three separate meetings where I pushed to make them cheaper or free for medical students or foundation doctors, and overwhelmingly the whole committee that I was part of voted to make medical students pay and make it cheaper for qualified doctors. Yeah. So instead of, for example, rather than, I say I can pay a hundred pounds to go for a meeting if it’s free for medical students. What we said is we’ll charge medical students 30 pounds, and we’ll reduce my rate to 90 pounds. And I can think of three separate occasions in three separate contexts that’s happened. People that are on those committees are probably people that already have a lot of privilege. And at least in my experience, even, even when I say make it free for students, I can afford a hundred pounds to a meeting a student can’t. Even when that happens, then people don’t vote for that because people want it better for themselves. And that’s people that are already in positions of power. They have the power to vote, and they vote in a way that makes things better for themselves, whether that’s consciously or unconsciously. I’m not suggesting that there’s any Machiavellian agenda that they want to push people out. So, it’s not about that. It’s just about people vote with their wallets, wouldn’t they?

[00:06:41] Ricky: Yeah, absolutely. What a conflict of interest. People voting for something that would benefit themselves.

I would love to think that people would vote to help others, especially to lift as you climb. That’s certainly been one of the most rewarding parts of my career is every time, I’ve been able to help those that haven’t had the same opportunities as me. So, it makes me really sad to hear stories like that, but it doesn’t surprise me.

Really, the question is, Was there a medical student on in the committee? Was there a junior doctor? And I can almost guarantee the answer is inevitably no, it becomes an echo chamber of people in a similar privileged position, maybe at the senior years of their career, financially stable, probably data shows there’s often a lack of diversity within the group, so it does become an echo chamber.

And actually, you become completely devolved from what the people that aren’t in the room need.

[00:07:40] Mat: It’s interesting, Ricky, because it’s that’s been one of the major reasons why I’ve stopped being involved in any national committees, because I used to have, conversations like that. And it was obvious that I was the odd one out. So, I’m not singing my own praises, but maybe for anybody who is on those national committees listening. As somebody who used to sit on those national committees, I would invite you to look very closely at yourselves and what you’re doing, because in my experiences, those national committees do not serve the people that are at the beginning of their career ladders.

They serve the people that are at the top of their career ladders. And as I say, that’s the reason why I stopped being involved, because it just sat very uneasily with me.

I’d like to rewind a step, you talked about. individualism versus social constructionism or social constructivism. And what I mean by that is, is the difference philosophy. So, there’s a philosophy of you can be whatever you want to be, you go, you can pass this exam. It doesn’t matter where you’ve come from. If you just work hard enough, you can do this. You can have the same opportunities as everybody else, fine. But what you’ve outlined is that just isn’t the reality. And the reality is. That all of us are products of a system of structures that we’ve grown up with and yes, it’s good that we’re determined but the reality is that there’s an awful lot of stuff that works for us or against us.

And that for me is a very different view of human nature. Because cause the exam where we all sit the same exam and we all require the same exam that assumes that we’ve all had the same opportunities, haven’t we? Yeah. So that’s a very Western American. Yeah. version, you can be whatever you want to be, whereas, what you’ve outlined is your evidence suggests that simply isn’t the case, that, we haven’t all had the same opportunities.

Therefore, when it comes to assessment, then I’m always going to suggest you need a different pass rate for different groups. I know that doesn’t that it doesn’t feel right, but I think that kind of that feels like it’s a discussion to be had. What would be your thoughts on that?

[00:09:39] Ricky: Yeah, I will say when you start to question the meritocracy of achievement this is when people feel very threatened that, when, if, a lot of people with the privilege of never having experienced differential attainment will feel very threatened by their achievements being questioned if we say that someone may have had to work twice as hard to achieve the same amount, but that’s the reality.

The data doesn’t lie. And, when you see these numbers stacked up, you can’t argue with them. It is a very emotive topic and it’s a very difficult topic to discuss but ultimately different people are going through lives experiencing different barriers throughout their careers and their education.

They’re experiencing differences in opportunities, in training, in learning financially, the differences are huge. And this, these assessments, in a way, it’s an opportunity for us to see those differences because without the assessments, we wouldn’t see those differences if you weren’t, on the receiving end of them.

We could change this on ahead and say this, turn this on ahead and say this is our opportunity. To make things better. We have seen a problem that we wouldn’t have seen otherwise. It shouldn’t be there. It shouldn’t exist. Let’s work towards getting rid of it. And to be fair, we talked earlier about the fact that this has been known about for decades and very little has been done.

Things there are, quite a few of us rattling the cage now, and, the stakeholders, the decision makers, the policymakers, are starting to listen, things are starting to change, the GMC has created a very, ambitious, funding, funded project, determined to get rid of differential attainment with only a few short years, within only a few short years, each year.

This has been handed down to each of the colleges who each now have a mission to, to address differential attainment in their own exams. I, I don’t know because I’m not involved, but I hope it’s also been handed down to recruitment people in charge of recruitment programs and national selection as well.

And I expect it has been, a few years ago, attainment. But now we’re going to national, international meetings discussing this problem, discussing differences. that people have in the learning and training environments and differences in outcomes between them on assessments and in career progression.

It dedicated conferences just to this. So, change is happening, and I’ve spoken to so many people who did initially feel very threatened by the idea of questioning the meritocracy of exams and assessments within medicine. Actually, once you deal with that emotive response, and then you educate yourself by reading around the topic and having these, motive and uncomfortable discussions.

I haven’t met someone that disagrees with the data that disagrees with everything yet. And so, this is why changes slow to occur, but it is starting to occur, and we need to get out of our heads. The idea of everyone progresses on their own merit. And it’s just due to your revision.

It’s just due to how many courses you pay for. It’s just due to whether or not you buy that expensive text, but it’s not. There are so many other factors that impact on the likelihood of success at every stage in your career.

[00:13:15] Mat: And in medicine, we all have to meet. a certain standard, don’t we? When it comes to patient care, there’s a standard that’s set and there’s a standard that has to be met.

And it’s about recognizing that for some people that will be much easier to achieve. But the cost then would be a very underworks, un-diverse workforce where everybody looks the same and everybody is the same versus the other way, which is recognizing that actually there’s an accumulation of disadvantages that happens over a lifetime.

And that’s something that needs to be addressed because, that then is going to give us a much richer a much more diverse workforce, which is going to make healthcare better for us as colleagues, for each other and as well as for our patients. I hope you’re enjoying the show. If you are, please click subscribe so you will be notified when new episodes come out.

This podcast is part of my mission to help doctors create successful and meaningful careers. You can be part of that mission too by forwarding this show to any one person who you think might benefit from listening. Thank you. Now on with the show. Let’s move us on to the regional level. You talked about role models, coaching, mentoring opportunities what can we do at regional level to resolve this?

[00:14:30] Ricky: Yeah, sure. I think. The formalization of mentorship coaching opportunities I think is really key here. Actually, at this level, it crops up time and time again in the literature in qualitative studies, looking at differences in the learning environment, ultimately, I have no doubt that as a white man, when I walked into the operating theatre, there was probably far more chance of me getting mentorship opportunities than some of my colleagues may have experienced.

I may not have known it at the time, because this has been a journey in building insight into these issues for me over the last few years but. There are, people that will struggle to have to receive mentorship and coaching opportunities and interactions with role model personal interactions with role models as they go for their career in comparison to their peers.

Creating formalized programs. I think will enable more equitable access to these opportunities, helping people navigate training, helping people navigate career progression, because it’s not just training this exists afterwards as well. There’s a, like we said, there’s a real lack of diversity within leadership positions.

Does everyone have equal access to mentorship to coaching to get to those leadership positions after you finish your training, for example, the data says. Thank you. They don’t. There’s real inequity here. So, creation of and funding of a formalized process will, will make a huge difference.

And, talked about a lack of diversity within leadership and senior roles. It’s things like that is it’s mental is mentorship that helps get you there. That helps you navigate that, because let’s be honest, if you’ve never had much social capital throughout your entire career because of all of these factors, or you’ve got less than your peers, are you going to stand for election for a council role in an association or a college, for example?

The likelihood is that you wouldn’t. We need people. We need that greater diversity within college councils within leadership positions. There needs to be greater access and greater support to get there, because they’re involved once you’re there, you’re involved with decision making, you’re involved in policy making, you become one of the key stakeholders. You have a say, we can get rid of the echo chambers at the top of each medical specialty, making these rules that are actually bias or discriminatory towards other groups that aren’t in the room. And I will say, and this is not. bias because I’m a urologist is only because I have good insight into what they’re doing, but the British Association of Urological Surgeons are a really good organization to hold up as a case study.

Actually, they’ve done a lot of work trying to create formal mentorship and coaching opportunities that might not exist on a local level. Therefore, they’re trying to You know, give it an association level, provide it an association level but also not just for trainees to progress for consultants to progress into leadership roles.

They’re creating shadowing opportunities, so you can shadow council members, whether you’re a trainee or a consultant, they’re providing coaching, they’re providing mentorship, anyone that has considered. Having a leadership role, has these opportunities now to know how to get there and to be supported in their journey, and there’s no doubt that will result in greater diversity and leadership.

We’re already starting to see it in the association already. It is to be applauded as an effort and to be held up as a great case study is what can be achieved. The last thing. That I wanted to mention is the flexibility in training. That is one of the most difficult to address, undoubtedly.

It, where do you start in creating a training program that is more flexible that, that can achieve everything that everyone needs? I’ll be honest. I don’t know. I think it will be an iterative process over time. I think this is going to require a lot of people in a room, multiple times, with the key decision makers, listening to the needs of the people that are in training, that have been in training.

Listen to people that have struggled through training. Listen to people that have sailed through training. All of these perspectives will help change. The shape of training in the future, and that’s absolutely necessary. Yeah, we have a recruitment and retention crisis at the moment in the workforce in the medical workforce.

You only need to look at recruitment rates for any specialty and you see they’ve gone down year after year for the most part. This isn’t going to help in our recruitment is definitely not going to help in our attention, trying to get people through really inflexible programs that don’t meet their learning or their training needs.

And therefore, we’re surprised when they fail exams, that doesn’t make sense to me but in terms of how you achieve that’s beyond the opinions of one. person like me, one very privileged person. It has to be a group of all the key stakeholders. It needs to be these policies need to be decided.

The decisions need to be made in consultation with all of the groups involved.

[00:19:46] Mat: I’m perhaps a little bit more sceptical Ricky than you, because I’d say there’s a hidden agenda here, which is that. Most departments rely on their trainees to run the emergency service. And that’s the fundamental problem that, that flexibility just cannot happen because every department relies on trainees to fill rotas and to provide the emergency service. And you know that, that’s the elephant in the room that we’re not going to get rid of. If we got rid of that, yeah, if we got rid of, if we had so many more people that filling rota gaps wouldn’t be an issue. Then flexible training would be a lot easier to discuss. Yeah. And that’s, that’s the big the heads of service and the clinical directors probably don’t want to admit.

[00:20:30] Ricky: Absolutely. And it’s almost a bit of a chicken and egg scenario, isn’t it? Because, if you had more, if you had more welcoming, more inclusive, more flexible training programs, would you improve your recruitment and retention rates? I suspect so, so it’s a chicken and egg scenario.

And it’s a conundrum that’s too big for. Us to sit here and decide on or for anyone to sit and decide on without huge consultation with everyone involved.

[00:20:56] Mat: and also, a change in focus from what today’s rota needs versus what I’m going to need in five years. Yeah, and you know that for me is a problem because we never worked like that in medicine. We always work about today’s problem. It’s quite rare for people to think, okay, forget about today’s problem. Let’s do something about five years from now. Now you also mentioned about individuals. So what can individuals do about differential attainment?

[00:21:25] Ricky: Yeah, that’s a really good question. And that’s usually the one that most people want to know the answer to when I’m stood up on the podium presenting or, when a paper comes out. I would say that the first and most important thing is to stop and listen.

It’s a listen to others because you may have your lived experiences. You may have your privileges and your disadvantages, but everyone is different. And you can’t assume anything, it, for example, you may see a white man, with all the privilege of that encompasses but you don’t know what else.

What other disadvantages they’ve suffered throughout their life, they may be disabled, they may be disadvantaged in other ways they may be, socio economically held back from progressing and training, for example, so don’t assume anything. I would say and listen to everyone else’s lived experiences because I think that’s and be open minded with it.

I think the first step is getting past the emotive reactions because this is a very difficult, very challenging, very emotive topic to be talking about. Disadvantage, bias, attainment it’s very emotive, it’s very difficult. So be open minded. And actually, get comfortable with feeling uncomfortable, get comfortable with having these difficult discussions, get used to the fact that you’ll make mistakes in this very difficult discussion.

I make them all the time, I will continue to make them, but when I make them, I’m genuinely sorry. I listened to. The feedback I’m getting is it’s the mistake I’ve made, and I try and improve the next time, all you can do is try your best to help to have these discussions to participate in these discussions.

And that’s the only way you learn, be comfortable with that and really it is about having a growth mindset. It’s about going on this journey of developing insight into your opportunities, your disadvantages, your biases. This is a journey really of developing insight and then working out how you can try and help, and when I say workout, listening.

asking, how can I help? What can I do? How can I be involved in this? And there’s always ways to be involved, whether that’s, there’s low local groups and local working groups, almost everywhere looking to address, equality, diversity, inclusivity issues, differential attainment, almost every deanery will have a differential attainment working group now, or certainly should do.

There’s national, Positions and that’s what leadership positions as well. If you really want to be involved in those big decisions and, be around the table, you can get involved at every level. And I encourage people to do because like we were saying earlier, you need that, you need people to have a seat at the table.

You need that diversity within those, decision rooms where the decisions are being made. EDI training is Obviously, it varies from the compulsory hostile e learning modules to, to some really good thought-provoking courses or e learning or podcasts or, vodcasts, et cetera It’s almost always free because most people working in this space aren’t doing it to earn money.

They’re doing it to try and improve things. So, you can seek EDI training and learning materials and it won’t cost you a thing. Okay. And it is, it’s there. They are usually very, a lot of them very high quality. And that brings me on to one of the last points, which is to read and to learn about this.

As important as it is to ask questions, I think before you can start asking questions and burdening people with having to answer your interest in your questions, actually go away, do some learning, do some reading. It’s very accessible. There are so many fantastic books out there now to, to take you on a journey of building insight in, into your bias and EDI issues.

Go and just have a read have a listen to some podcasts. There are some really amazing resources out there. Certainly, the one I usually, recommend people to start with just as a thought-provoking eye-opening book is it’s called The Person You Mean to Be:  How Good People Fight Bias. It’s a really good by Dolly Chug. It’s a really good starting point just to have a read and to start to, to think and reflect. So, it’s really important to stop and reflect in all of this. And I think ultimately, it’s important that, like we said earlier, even if you’re privileged enough for this issue not to have affected you personally you recognize that you can still help and you try and get involved with these conversations, you try and get involved with this work, you try and improve the system.

That’s really key because, yeah, ultimately. It’s going to require systematic change by everyone to combat the systemic inequalities that currently exist in our system, in our training, and in our workplace culture. And although we might not be able to undo a lifetime of accumulated disadvantage, we can all work towards mitigating its impact on success and career progression.

You know for our friends for our colleagues for our peers at work and for future generations of doctors as well.

[00:26:52] Mat: So, what you’re saying Ricky I should have stayed on those committees, and I should have kept banging on. Rather than opting out and saying you people are nothing like me, I have nothing in common with you, goodbye.

[00:27:03] Ricky: There’s still time to run for re-election.

[00:27:06] Mat: Okay, let’s bring us to a close then what would be your top tips for doctors at work.

[00:27:12] Ricky: Oh, top tips. That feels like a lot of pressure. I would say, listen you learn the most from listening and that’s not necessarily to the people more senior to you.

I’ve learned so much from my colleagues from people starting their training from medical students just by listening. And the people, the mentors that I’ve respected the most have done the same, mentors that, that ask you, oh, I haven’t seen anyone else do that before. Where did you pick that up from?

And I might try that. And just being open to listening and to learning from everyone. And enjoying the learning journey. It is a journey. And occasionally taking the time to look back and reflect, how much you’ve learned, how far you’ve come and how much you’ve achieved, how much you’ve, how many people you’ve helped whether that’s patients, whether that’s colleagues, whether that’s lifting as you climb just take the moment to reflect on the journey, really.

They would be my biggest tips; I think to enjoy a career in medicine.

[00:28:06] Mat: And in terms of differential attainment, what would be your summary and take-home message?

[00:28:11] Ricky: In terms of differential attainment, I’d say, again, listen, that needs to be the first and foremost, listen, don’t assume and go away and learn and start to think about these issues, start to reflect on your privileges, your disadvantages, your biases and then go from there. Think about how you can help and go from there.

[00:28:32] Mat: Thank you very much, Ricky.

[00:28:34] Ricky: Thank you very much for having me.

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