Open Letter from Medical and Non-Medical Cambridge Students

Dear Dr Diana Wood and Professor Patrick Maxwell,

We would like to bring to your attention some aspects of our clinical training that we would like to
improve to ensure that institutionalised racism and microaggressions within the workplace are not just
challenged, but eliminated. As Cambridge Medical School is training the next generation of doctors
and pioneers of medical research, we need to ensure that we set an example to all other medical schools
to protect our Black, Asian and Minority Ethnic (BAME) patients and colleagues. We thus need to go
beyond just accepting the statement that “all patients should be treated equally” as highlighted in the
GMC’s Tomorrow’s Doctors. Instead, we need to take active action to ensure that this is done.

Racism and racial bias does exist in our healthcare system today. The following statistics highlight
discrepancies in patient outcomes, patient treatment, doctor’s pay and even in student attainment:
BAME women have worse pre-, peri- and post-natal outcomes as shown by the following:
● Black women are 5 times more likely to die in childbirth than white women. South Asian
women are twice as likely to die during childbirth (MBRRACE 2019).
● BAME women are also more likely to have a poorer experience of healthcare during pregnancy
delivery and post-natal care (Henderson et al., 2013).
BAME patients are generally not treated the same as white patients by healthcare professionals.
Failures in treatment can result in direct consequences for BAME groups such as being more likely to
be detained for a psychotic illness:
● Black patients are 50% less likely to receive pain medication than white patients (Singhal et
al., 2016)
● Black patients are less likely to receive care and support during their cancer care (National
Cancer Patient Experience Survey).
● Doctors give different treatment options to hypothetical white patients than they do to
hypothetical black patients with the same symptoms (Boujie 2019, Zestcott 2016).
● African and African-Caribbean people who have a psychotic illness and who live in London
are between 4 and 8 times more likely to be detained than their white counterparts (Audini and
Lelliott 2002, p. 225)
The representation of BAME doctors in higher positions is much less than fellow white doctors.
Further, BAME doctors (females especially) are not paid the same as white colleagues for doing the
same job:
● 46% of white doctors are consultants, compared with 33.4% of Chinese doctors and 30.6% of
black doctors (Milner 2020).
● 92% of board members in NHS trusts are white. This compares to 55.6% of white staff working
in medical roles in the NHS. (NHS Workforce Statistics March 2019).
● For every £1 a black female doctor earns, a white female doctor earns £1.19 and a white male
doctor makes £1.38 (NHS Pay Gap Report 2019).
Even throughout training, both doctors and students have a higher fail rate than their respective white
colleagues.
 ● Ethnic minority medical students in the UK have 2.5 times higher odds of failing exams
compared to their white peers (Woolf 2011).
● 90.2% of white graduates of UK medical schools passed the Royal College of GPs membership
examination, compared with 75.5% of UK medical school graduates from BAME backgrounds
(RCGP 2018).
BAME doctors are more frequently reported to the GMC than white doctors. They are also more likely
to feel intimidated in their work environment by other colleagues.
● Black and brown doctors are reported to the GMC at more than twice the rate of white doctors
(GMC Fair to Refer 2019).
● Black NHS staff report the highest incidence of bullying and harassment from their colleagues
and leaders (NHS Workforce Race Equality Standard 2019).

To attempt to change these disparities between different ethnicities, we need to start our learning in
medical school. Racism goes beyond just the working environment and unfortunately does include
fellow colleagues' experiences at Cambridge Medical School in a professional and educational setting.
To illustrate this, we carried out a survey of 158 medical students in years 1-6 of the Cambridge
Medical course. We have summarised our results in the report attached and highlight some relevant
figures. For example, 28.5% of medical students have witnessed racial bias towards patients in a
clinical setting, with 75.6% of those being from clinical years. Furthermore, 58.2% of medical students
have witnessed or experienced racism either in a professional or educational setting at Cambridge. For
instance, clinical students describe several instances when patients refused to have medical procedures
performed by non-white (student) doctors. Multiple preclinical students mentioned explicit and
implicit racist comments and behaviour from anatomy demonstrators and supervisors. (Please refer to
the full report attached for further information and all qualitative accounts of students’ experiences).
This needs to change, and our BAME students need to feel represented and listened to. Here is what
we propose:

1. Eliminating and challenging our own implicit bias

Problem 1a: As evidenced above, BAME patients, students and doctors face massive gaps in
almost all aspects of the healthcare system. This also includes educational settings, where our
BAME colleagues have faced shocking examples of explicit racism in an environment where
they should feel safe (see report attached). We all need to be taught to recognise and challenge
our own implicit bias. Furthermore, all medical students need to feel confident enough to
challenge microaggressions in a clinical setting and need to be able to identify racial bias in
order to try to minimise these differences in patient outcomes.

Suggestions: We suggest implementing compulsory active racial bias training for

o All medical students in their clinical years
o All staff involved in teaching both preclinical and clinical courses
This should include unconscious bias and bystander skills, with the use of anonymised cases
based on real student and staff experiences.
Moreover, the racial bias aspect of the SECHI course could be improved and/or made
compulsory to highlight these inequalities early on and encourage us to actively change them.
To that end, assessment of the SECHI course should be changed such that, firstly, it is
appropriately recognised as important by the student body, and secondly, students are required
to engage with all topics taught in the SECHI course. This could include submitting a portfolio
of marked essays and presenting to other students in seminars throughout the six years of the
curriculum rather than writing just two essays under exam conditions. Exams have a focus on
testing fact recall, whereas coursework essays would allow more in-depth research and better
assessment of engagement and understanding. We believe this is a more appropriate form of
assessment when discussing such nuanced issues, for which there is no need for rote learning
of specific statistics, but rather engagement with and exploration of broader principles.

2. Medical education and decolonising the curriculum

Problem 2a: In our student questionnaire, many people reported that most clinical presentations
are based around white patients/cases and that there is little emphasis on the ways BAME
patients can present differently. The experience of many medical students has been a lack of
awareness regarding the presentation of various diseases on dark skin, as an example. Often,
we are not shown clinical presentations for the same disease in different ethnic groups, which
can be detrimental for diagnosing BAME patients in the future.
Some areas for improvement include:
o Cardiology – women and BAME patients are more likely to present a myocardial
infarction with atypical symptoms such as back/shoulder/jaw pain, sweating,
nausea and an upset stomach. Thus, white males are often more likely to be
diagnosed.
o Dermatology – using adjectives such as ‘pallor’ and ‘erythematous’ only refers to
white skin; the use of these descriptors does not apply to all patients. Further, most
examples of skin rashes and presentations on slides are on white patients.
o Psychiatry – failure to address that BAME patients are less likely to present, yet
more likely to be detained. We are clearly failing to cater for their needs or to get
treatment to them early.
It is also important to note that these are currently widely recognised problems in medical
school teaching, as emphasised by the petitions to the GMC and British Association of
Dermatology respectively below:
o http://chng.it/6BBTByQyQh
o http://chng.it/CWXwwFcCLf

Suggestions: We propose that it should be a requirement that lecturers include BAME

presentations, particularly in clinical school teaching. In pre-clinical school teaching there
should be more of an emphasis on BAME inequalities to allow medical students to be aware
of these differences and challenge them. Cambridge Medical School should also aim to
standardise parameters in clinical diagnosis across all patients, using symptoms such as ‘pallor’
only as auxiliary signs for diagnosis. Given that Cambridge is one of the leading contributors
to the global medical community, we should play a leading role in prioritising standardised
diagnosing procedures which should be taught in our clinical teaching.

Problem 2b: There are particular discrepancies in specialties such as Obstetrics & Gynaecology
and Psychiatry. For example, there is a higher rate of non-attendance in BAME communities
for cervical screening: Caribbean 62%, African 44%, Indian 66%, Pakistani 62%, Bangladeshi
71%, Caucasian 11% (Marlow et al., 2015). This clearly shows that we are not doing enough
to inform our BAME patients of the importance of cervical screening or to improve teaching
for these communities.
There are also inequalities in the field of eating disorders. Ethnic minorities are less likely to
be asked by doctors about eating disorder symptoms and receive a recommendation or referral
(Becker et al., 2003), and black girls are more likely to show symptoms of bulimia nervosa
than white girls, but are less likely to be diagnosed (Goeree et al., 2011).
Furthermore, black people are significantly less likely to seek treatment for depressive
symptoms, when compared to white people (Sussman, Robins and Earls, 1987). Fear of
hospitalisation was a commonly cited reason as to why treatment was not sought, which is not
unfounded as black people are significantly more likely to be detained under the Mental Health
Act. We are not taught about atypical presentations that could arise in BAME patients – for
example there have been significant findings of non-traditional presentations, such as
hypertension, when depression is experienced among black people (Thompson et al, 2000).
This knowledge could lead to earlier treatment and better outcomes.

Suggestion: We should therefore have a greater focus on teaching about these differences,
particularly in specialties where inequalities are much more prominent. Furthermore, we need
to be taught how to advocate for our BAME patients in a sensitive and appropriate way. This
could include teaching us ways to break down any myths or misconceptions they may have
about cervical screening in consultations and be accepting of their culture in order to work
towards a solution together.
For example, we are aware that the Improving Health course ran a session highlighting
inequalities within the LGBTQ+ community. A similar session, particularly for fifth years,
focusing on ethnic inequalities in Psychiatry and Obstetrics & Gynaecology would help us
understand and challenge the disparities in outcomes of BAME patients.

Problem 2c: BAME patients are underrepresented in medical research studies and clinical trials
(Harrison & Smart 2016) – in an extensive literature search to depict the differences in
ethnicities, just 11 pieces of literature were found that focused on BAME patients, and 98% of
research was conducted on Caucasians. This under-representation in research must be changed.

Suggestions: We should be taught to be mindful of this when discussing management options

and to think critically about why BAME patients may not be responding to certain treatments.
Furthermore, trends in patient outcomes across different ethnicities should be regularly
mentioned and included in lectures. Finally, as Cambridge is world-leading in medical
research, it should act to promote and encourage the promotion of BAME patients and
researchers to call for a more inclusive scientific environment.

Problem 2d: Many students have commented on the lack of BAME lecturers and faculty
members within the Department of Medicine, this is particularly the case in pre-clinical years
(see report attached). Our faculty should represent doctors from all different backgrounds.

Suggestions: Encouraging BAME staff to apply to Cambridge could be achieved through

workforce discussions and looking at diverse hiring practice; this includes the actor pool in our
clinical training. The aim should be to create more access opportunities for BAME staff and to
make them feel more welcome to come teach at Cambridge.

Problem 2e: A full commitment to decolonising the curriculum involves recognizing and
addressing 1) the roles that Medicine played in colonialism and how this continues to affect
populations around the world, 2) the way that medical knowledge has benefitted from
colonialism and oppression of non-white populations. Cambridge University prides itself on
academic success, but it is only by decolonising that we will create an environment that
includes everyone, and create doctors that interrogate knowledge to achieve better outcomes
for all patients. Other than passing comments by specific lecturers, this is not discussed during
the six year course.

Suggestions: There should be compulsory education and an ongoing discussion group about
how Medicine will be decolonised. This education could be added to the pre-clinical SECHI
course and the clinical Improving Health or Ethics and Law courses. Students should be
provided with a reading list for further education and critical thinking on the topic. Topics may
include the relationship between medical research and colonialism/racism (e.g. the discovery
and use of HeLa cells), the history of unethical research projects carried out on BAME groups
in the name of medical science (e.g. the Tuskegee syphilis experiment), the foundations of
global health within colonialism, discussion and action on how medical electives continue to
contribute to unequal relationships between the UK and previously colonised countries, and
ethical procurement of healthcare goods.

3. Challenging colleagues and patients when medical students are exposed to racism

Problem 3a: We must protect our students. Many BAME students are cautious about reporting
incidents of racism, particularly when their own supervisors or teachers are involved, out of
fear that it may affect their education. This is made evident as 65.8% of students feel that they
are unable to report incidents, and if they do, 76.2% of students feel as though they have not
received an appropriate response (see report attached). This unfair predicament leaves BAME
medical students in a very difficult position. The burden should not be on BAME students to
report these incidents, particularly as many worry about how this may reflect on them
professionally.

Suggestions: A clear and anonymous reporting system must be put in place to make our
students feel safe. This could be an external group of people in order to encourage medical
students to speak up when they feel that they have been marginalised. All teachers should also
be informed about this reporting system so that incidents are not just ignored, and that staff are
aware of how to handle the situation.
For incidents where students may not want to use the reporting system first, a BAME officer
who forms part of the welfare committee could be introduced. This officer could help support
students and provide a safe space for them to talk about incidents of racism before escalating
the situation further. Lastly, implementing consistent and thorough racial bias training would
also minimise these incidents.

Problem 3b: The issue of how to confront situations of racism has also been commonly raised
among BAME medical students, with 74.7% of students not knowing how to respond during
these incidents. It is not uncommon for a patient to request a different healthcare professional
purely based on their religion or the colour of their skin as seen by anecdotes from medical
students (see report attached). We need to be taught how to challenge these situations in a
professional way and to make sure that medical education opportunities are fair for all students.

Suggestions: Train all medical students and staff on how to appropriately challenge these
situations and equalise the opportunities available to all medical students. This could be a
component of the racial bias training mentioned above.
Another way to encourage dialogue regarding racism, could be to introduce a student led
Schwartz round (this could be led by the BAME officer) which focuses on experiences of
BAME students. This would help medical students become aware of racism within a clinical
environment and suggest ways to challenge it together.
Summary of Demands and Suggested Solutions

1. To eliminate and challenge our own implicit bias:

a. Compulsory racial bias and bystander skills training for
i. Clinical students
ii. Pre-clinical and clinical teaching staff
b. Alterations to the medical course
i. Increase the racial bias component of the course, such as by including a
portfolio of essays across our 6 years of study
ii. Ensure the SECHI course is appropriately recognised as important by the
student body, equal in significance to other aspects of MST1A, potentially
through changes to the way in which it is examined (e.g. shift from timed exams
to graded coursework essays)

2. To decolonise the curriculum and improve BAME-related medical education:

a. Include BAME presentations of disease in pre-clinical and clinical teaching
b. Emphasise inequalities of BAME individuals in healthcare to increase student
awareness in pre-clinical and clinical teaching
c. Encourage the standardisation of parameters used for diagnosis, which cover patients
of all ethnicities
d. Introduce an Improving Health session on BAME inequalities, particularly focussed
on Psychiatry and Obstetrics & Gynaecology
e. Teaching clinical students on the issue of reduced treatment adherence in BAME
populations, and how to tackle this
f. Highlight discrepancies in the ethnicities of participants in clinical studies, and how
this impacts current understanding of treatment methods and patient outcomes
g. Encouragement of hiring a diverse teaching workforce
h. Incorporate active teaching to decolonise the course by providing education on the
relationship between medical research and the impact of colonialism, and encourage
critical thinking in this regard

3. To challenge colleagues and patients when medical students are exposed to racism:
a. Incorporate an anonymous, third party reporting system for students to use when they
have been marginalised
i. Advertise this system and encourage its use by both students and teaching staff
b. Introduce a BAME officer as part of the welfare team within the ClinSoc committee
c. Training medical students and staff for instances of racial abuse from patients
d. Introduce a student-led Schwartz round focussing on BAME student experiences

Conclusion

As a world-renowned medical school, we need to take action and set an example to other medical
schools. We must enact change to ensure that our BAME patients are catered for appropriately and
their specific needs are met, and to ensure that our BAME colleagues feel safe and welcome in the
NHS. Other medical schools such as Bristol have already committed to similar actions, such as
decolonising the curriculum to include clinical presentations with darker skin, listening to BAME
voices by setting up a consulting BAME working group, and improving staff training by implementing
unconscious bias and bystander skill courses, among many other reforms.
If we are happy to spend time and resources teaching students about the intricacies of metabolic
pathways such as the citric acid cycle, incredibly rare diseases, or discontinued drugs, then we should
absolutely take the time to teach students how a rash may present differently on dark skin, or how
cultural factors may lead to misdiagnosis. We must accept that the medical community is just as guilty
as the rest of the world when it comes to racism and implicit racial bias, so we must act proactively to
better the experiences of BAME individuals in healthcare. If as a community we claim to wish to
improve the lives of others, we must do so both medically and in the context of social justice.

We look forward to your response, and towards a constructive dialogue in how we might address these
concerns. We recognise that these problems are complicated to address, and that our proposed solutions
would require a lot of work. We suggest that the Clinical School establish a working group consisting
of representatives from both Faculty and students so that we can work together to address these issues.
We ask that you might confirm your receipt of this letter and in your subsequent response that you:

1. Identify if the Cambridge Medical School recognises each problem identified here in this
letter,

2. Identify whether the Cambridge Medical School will undertake some or all of the
suggestions made here in this letter, and finally,

3. Should the Cambridge Medical School disagree with any points set out in this letter, that
reasons are provided.

Yours sincerely,