Karen Stegers-JagerKaren Stegers-Jager is an educational scientist affiliated with the Institute of Medical Education Research Rotterdam (iMERR, Erasmus MC). She was awarded a PhD for a thesis on how medical students’ ethnicities and cultural backgrounds affect their performance. This summer she received a Veni grant allowing her to investigate how first impressions affect the way in which foundation doctors are assessed.

How ethnically diverse is Erasmus University?

“We are the most ethnically diverse university in the Netherlands. At Erasmus MC, where I work, about 30 percent of all students are from an immigrant background, meaning at least one of their parents was born outside the Netherlands. Twenty percent of Erasmus MC students hail from a non-Western background, while 10 percent hail from a Western background. At Erasmus University in general, 40 percent of students are from an immigrant background, with about half of those hailing from a non-Western background. We’re battling it out for the top position with VU University in Amsterdam. On the other side of the spectrum, there are still some bastions of whiteness in the Netherlands, such as Utrecht University and the University of Amsterdam.”

Let’s first discuss your own faculty. Thirty percent
– is that a lot?

“No, not if you compare it to Rotterdam’s demographics. Half of the city’s inhabitants are from an immigrant background. We’re doing a good job, but we could be doing a better job.”

How are students with an immigrant background

“In order to find out, we now track students from the moment they enter the faculty. It starts with their enrolment application, after which they are or aren’t selected on the basis of their secondary school marks, study skill tests and CVs. We found that students with an immigrant background were every bit as likely to be selected on the basis of their CVs. This came as a pleasant surprise, because we used to believe that students with an immigrant background were less likely to actively work on their CVs. During the bachelor degree, problems arise with several subjects – subjects in which linguistic fluency plays a large part and a lot of writing is required. The assimilation test presents an even more interesting example. This is not about how well a student has been assimilated in Dutch culture, but about how well he or she has assimilated all the subject matter discussed in the previous year. We’ve found that students with an immigrant background are more likely to fail such tests.”

Why is that?

“It’s the kind of test that encompasses so much material that students working alone can’t properly prepare for it. You need a network to do so. Previous studies have shown that students with an immigrant background tend to have less useful networks. It’s important that students stay in close touch with other well-prepared students, and with more advanced students and lecturers. The question really is: does your network know how things are done at uni, and is it able to arrange things for you?”

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Your study shows that the most significant problems
arise once students embark on their medical
internship. Why is that?

“That’s the moment you enter a hospital and spend three to ten weeks at each department. It’s like a work placement. At this stage, students are no longer assessed on how well they perform at exams, but on how well they function in a team. We sometimes jokingly say: if you joined in properly, you will receive an eight out of ten. If you did a fabulous job and the doctor wishes to keep you for specialist training, you’ll receive a nine. If you receive a seven, it means you didn’t stand out, and if you receive a six, it means they never wish to see your face again. Of course there’s a little bit more to it than that, but although we are actively seeking to improve student assessment methods, we’re still dealing with subjective opinions. It’s a fact that, as with work placements carried out at other departments, hardly anyone ever receives a fail mark. Nearly everyone successfully completes the medical internship, including students with an immigrant background. But their scores tend to be a lot lower, even if they obtained similar scores in the years preceding the internship programme. Some 90 percent of medical interns from a native background receive at least three eights in their first five placements, versus 55 to 70 percent of medical interns from an immigrant background. It’s stopping them from being selected for specialist training courses.”

To what extent is this true for other degree programmes?

“The discrepancies we have found can be found outside the Faculty of Medicine as well. Students from a non-Western background are lagging behind.”

Why is that?

“It’s a culture thing. Are you confident you’re fitting right in, or are you constantly having the nagging feeling that there are all these unspoken rules you seem to be unaware of? This is called the hidden curriculum – the way in which you address others, or where you position yourself while having a conversation. There are very clear ideas on how foundation doctors are supposed to behave, but no one will tell you about them. To give you an example: in Dutch operating theatres, surgeons expect their assistants to hand them their instruments before being asked to do so. If you wait for them to tell you what to do, your own-initiative scores will go down. It’s all about knowing what you’re expected to do.”

Whose job is it to make sure students are aware
of such things?

“Both parties are responsible for this sort of thing. Students must do their best to learn how things are supposed to be done, but the department must definitely help them. We must be aware of how we subconsciously reproduce certain patterns and privileges – the old ‘white-is-just-another-colour’ story. There are students who are told – often very subtly – at an early stage of their degree that a particular specialty is not for them. I know a woman from an immigrant background who, after working really hard for years, was invited to train as a surgeon, which in the hierarchical world of medicine is about the highest honour you can achieve, along with training as a cardiologist. But after a while, she quit. In order to fit in, she was expected to shed her own identity and culture. Just imagine – if you don’t join your colleagues on their skiing trips and don’t like drinking, you’re very likely to remain an outsider.”

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It’s easy to say: well, you’ll just have to learn to enjoy
a few drinks.

“We could do that, but that would be saying that we need to assimilate people rather than accommodate them. That’s not how I feel about it. We’re currently discussing it in a way that makes it appear like a problem, while I think we should regard it as an opportunity. It would be a waste not to make good use of the added value created by diversity. We consider it important that our students be prepared for a multicultural society. This requires that education be genuinely diverse, regardless of whether someone is training to be a doctor or a marketeer. We’ve had some issues lately with the Practical Clinical Skills course, during which students are expected to examine each other. Two female Muslim students refused to be touched by men. They even took us to court over it. Of course this physical examination is an integral part of the course, but it’s no use to force people to undergo it without any form of dialogue. It’s vital that we discuss such matters. By making our students and lecturers more aware of such cultural sensitivities, we will produce better doctors. I’m convinced of it.”

Are you proposing any specific measures?

“Just because we attract students from various backgrounds, doesn’t mean we are an ethnically diverse programme. Unless we take active steps, there will be some form of ethnic and cultural segregation. We will have to actively create moments of interaction, for instance by creating mixed tutor groups. We know from literature that problem-based learning and small-scale education work very well. Another thing that works well is having people – students and educators alike – voice their commitments at the start of their degree. They do so at the University of California in Los Angeles (UCLA), and it’s working for them. Michaela Schippers’s study has shown that the Rotterdam School of Management has had good results with this sort of goal setting as well. Furthermore, student representation should adequately represent the student population. We won’t attract the right kind of students by bragging during Eurekaweek about how many parties we throw.”