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EM TV: Why medical interns with a migration background get worse grades
This week in EM TV: Medical students with a migration background face prejudice and…
At a consultation, medical intern Amira sits on a chair next to the gynaecologist. There is not a lot of space in the room and the gynaecologist does not seem very enthusiastic about having Amira accompanying her. She is helping with a physical examination. When the gynaecologist asks for a speculum, Amira grabs one and hands it over. “What are you giving me? You can’t do anything!” the doctor exclaimed. She obviously wanted something else. The consultation proceeds with difficulty. Amira comes across another problem. With white Dutch patients, the gynaecologist is kind and smiles along. With coloured patients, she acts gruff and strict.
The names of the students in this article are fictitious at their request, because they are worried about the consequences for their careers.
Elephant in the room
For many coloured medical students, it’s the elephant in the room. Research shows that students with a migration background structurally receive poorer evaluations, more often feel they are treated unfairly and have less confidence in their evaluator. Chantal van Andel obtained her PhD on the subject. “It is a problem. Not only because it’s unfair to these students, but also because a diverse patient population actually benefits from a diverse doctor population.”
Amira doesn’t consider it a pleasant learning environment and decides not to follow this gynaecologist anymore. A few weeks later, her internship supervisor tells her how the gynaecologist assessed her. The assessment consists of one sentence only: ‘She just sat there on that chair and I had to ask if I could pass’. Amira is shocked and tells her supervisor about her experience. About the unpleasant treatment, the snubbing and the racist attitude towards patients. Her supervisor doesn’t seem surprised, but doesn’t plan to take action either. “You know, there has been a student before with the same story. But she is not racist, I know her personally. Maybe it was a busy consultation hour.”
The fact that Amira dares to speak out about a doctor behaving unprofessionally is remarkable. It hardly ever happens in practice. That’s unsurprising when you consider that Amira received a note about her professional behaviour after the conversation with the internship supervisor, while the gynaecologist in question was not called to account at all.
In some cases it becomes crystal clear that there is an element of racism in the doctor or assessor. For example, in the case of an ear, nose and throat (ENT) doctor who judged intern Yasmin more harshly than other (white) interns on every marginal mistake, and who could talk about ‘Moroccan cunts’ and ‘Moroccan rats’ in the operating room without contradiction. “Then you stand there as a brown girl and you have to restrain yourself, because your grade depends on it. My internship supervisor thought this colleague was strict, critical and good,” says Yasmin.
In other cases it is about subtle prejudices and vague remarks. Like the internist who asked the only coloured girl in the group of interns what she thought about euthanasia, because ‘Turkish and Moroccan people in the outpatient clinic think differently about it than I do’. Or the surgeon who only asked Amira ‘how many brothers and sisters’ she had and ‘whether they also do uni’ and ‘what her parents actually do for a living’.
Fear of making mistakes
In the vast majority of cases, it is unclear to the students with a migration background what the reason is for their lower scores. “I received so many reactions after my research was published,” says Van Andel. “The gut feeling that many students had was substantiated by hard data. They become more cautious and focus more on avoiding mistakes when they feel they are in an environment where they might be disadvantaged or stigmatised.”
For student Roshni, the internship went smoothly. “I received good mid-term evaluations and got on well with the doctors. One of them even told me about her research and personal past. Towards the end of the internship I asked her to fill in an assessment. She gave me a fail on the component ‘ability to build collegial relationships’. I was very emotional about this, because at no time did I have the idea that something had gone wrong. I asked for feedback, but she avoided the issue and wouldn’t adjust the grade. In the end, my final assessor decided I was good enough to continue, but my grade was kept low.”
Marwa discovered a protocol error and pointed it out to the assistant physician three times, but was ignored each time. “When it turned out that the mistake had been made, the blame was put on me. ‘You should have spoken out a bit more’ they said. I was given a note on my professional conduct, that read I should be less shy. So I made sure that I followed the example of the other, white intern and I competed for shifts in the operating room. I also worked extra days on the weekends. My final assessor thought this was nonsense and wrote in the assessment that I was too eager. She said nothing about the other intern.”
Amira: “After six weeks of internship, the surgeons on the ward all gave me an ‘above standard’ assessment, which meant I should actually get an 8. But the internship supervisor, who had spoken to me once in the first week, thought, based on that conversation, that I was ‘still a bit unsure of how to talk to others’ and changed my grade to a 7. There was no room for discussion. He was in a hurry because he was going on holiday. I sat with another intern, a cheerful blonde girl who played hockey. She had received lower evaluations from the assistant physicians than me and was very disappointed about that, but she walked away from the final interview with a higher grade than I did.”
Erasmus MC is responsible for the students it sends to hospitals, but it does not offer enough tools to raise possible problems, the conversations with the students show. Amira: “They are all doctors who know each other and protect each other. What should you do about it? Erasmus MC should better protect its students.” Yasmin: “Confidential counsellors do not take action if students talk about their experience. The mentors can only give advice and the study advisors don’t know what to do either.”
According to Fop van Kooten, programme coordinator of the Master of Medicine, Erasmus MC is aware of the problem, but is unable to determine its extent. “We recognise that students may encounter problems during their internships, both in our own hospital and in affiliated hospitals. We mention this during information days, during white coat ceremonies and during the introduction day of the master’s programme. Then we also tell them that students with problems can report them and what the possibilities are to address these issues. Information about this can also be read on the website. Reporting can be done anonymously, via confidential advisors or the ombudsman, but we prefer that they report it to us via the student advisors, so that we can actually do something with the report. The moment students report it, we enter into discussion with them and try to solve the problems they have experienced carefully or to provide feedback in consultation with the reporting student.”
To make reporting even easier we are introducing an app’.
Yet there are still few incoming reports. Both the students and Van Kooten say that this is due to distrust towards the study programme among students. “What we do in individual cases, we cannot tell because of confidentiality, so students do not quickly see what is done with their complaints. To make reporting even easier, we are working on the introduction of an app. An information session about education this year will also be entirely devoted to this theme, precisely because we want our students to be educated in a safe and inclusive climate, which we would like to convey to all educators, also in the affiliated hospitals.” Van Kooten says there are recurring talks with the regional hospitals about how to work with students. “But it is about a change of mentality, and that does not happen overnight.”
Van Andel is now running a project for more diversity and inclusion in the master’s, which the faculty started some time ago. The intention is to implement a new system in which assessments are separated from progress decisions. Also, the possibility of adjusting grades will be abolished in the next academic year, as this could lead to grade inequality between students with and without a migration background. Furthermore, the ombudsman is working on a plan that should make it easier for students to identify unsafe situations, and evaluation forms are used to ask specifically about the atmosphere and learning climate of a department. “We hope that coassistants will more easily dare to be honest about their supervisor and colleagues and we hope that they will be able and feel allowed to be themselves, and are free to use their own unique, diverse talents in their development as a doctor. But this will be a culture change that needs time”, Van Andel concludes.