Racism in Post-grad Medicine
Many of the brightest doctors currently undertaking postgraduate medical programmes in New Zealand might never become your specialist, in spite of pouring thousands of hours and dollars into pursuing their specialisations. The reason? Based on the empirical evidence, it’s probably because they’re not Caucasian.
We sit down in the office at the end of a long week of undergraduate study with a medical registrar, off the back of an even longer week. “I’m supposed to be working 0.6 EFTS, but it’s really more like 0.7 or 0.8, because the hospitals are so understaffed.” They’ve got a young family at home, and have spent the last decade pursuing an education that now, at the postgraduate level, feels like it’s pushing back against them. In spite of the constant study, work and familial obligations, they’ve made time for advocacy, to sit down with us. This is their chance to share the story of not only themselves, but hundreds of other colleagues in their field.
It’s not a flattering picture of the pinnacle of medical education in this country. The Royal Colleges, the only option for those wishing to specialise in medical fields, wield all the power.In some cases they work well,but in the case of Royal Australasian College of Physicians, there are obvious failings. It seems a reasonably easy organisation to run, you do not have to provide much training—that happens on placement at hospital—and you pocket membership and licensing fees.
Their biggest money maker? The clinical exam, one of two major requirements to become a specialist in New Zealand. This non-anonymised test is a full day of clinician interviews between six different patients (two long form, and four short form) where every move you make is watched by six to nine examiners.
The fail rate differs astronomically, but only for some. In short, if you are European, you have a 7% chance of failing. If you are not, you have a 60% chance of failure. If you fail three times, you can not try again. With a 60% fail rate for non-European, your chance of being removed from the programme is three times higher than a European student’s chance of failing once.
Our source wholeheartedly believes the cause of this staggering difference to be institutional racism and bias. Almost all of the examiners are old, white men—a whopping 98% of current examiners are Caucasian. These are all volunteers who receive no training to examine, have little central oversight, and actually decide the scope of the examination on a case by case basis. This $3,000 non-standardised examination (notwithstanding the travel costs, as it can be held across the country) seems to be up to the whims of the examiners. These exams aren’t recorded, citing patient confidentiality, so there’s no way to appeal an adverse outcome. In a health system where different cultures have different needs and requirements in a holistic sense, it appears that examiners tend to bring a single minded attitude towards the assessment.
Our source also highlights an issue compounded in New Zealand by the relatively small medical field: everyone tends to know, or at least know of, each other. Because there’s no standardised assessment rubric, the outcome of a test can depend on whether the examining panel likes you as a person or not: “if you’ve done two or three years of working with someone, and they know you really well, and you’ve had a really positive relationship with them, that tends to go much, much better than if you work with someone that has just failed you in a run.”
That’s without considering the effect on the participants, the dehumanised case studies of this practise. They have to sit and listen to individual after individual point out everything that is “wrong” with them, from facial disfigurement to weight. Many of these people feel indebted to our health system, and feel pressure to take part because of this. Our source also notes that participants tend to be Caucasian families, which might have a link to the fact that participants are also unpaid for their time.
It’s often more difficult for people of colour, including Māori and Pasifika families, to take part in the test on their own volition, however, “if somebody pulls out at the last minute, often there’ll be families who are on the ward and that would often be the only way that we end up seeing a person of colour—essentially because they’re just sort of coerced into coming down for the exam.”
Towards the end of the interview, we sit solemnly with the injustice of it all. Someone, we think, must have done something. So we ask: “have these concerns been brought before the Royal Colleges before?”
Turns out, they have. Several times. In 2021, 35 written signatories made a formal complaint to the Royal Australasian College of Physicians. They received absolutely no response for over a year. In 2022, the Resident Doctors’ Association (the union for trainee doctors) made the same formal complaint. Only then did the College finally respond, agreeing to conduct an investigation.
However, it hardly seems as though they’re following due process in conducting this investigation. The College has said they will conduct an investigation going back 12 months from when they decided to take action, which does not even include the initial time period where the formal complaint was made. They’re also keeping the investigation incredibly quiet, both from the media, and within their own medical circles. They “haven’t even disseminated [the investigation] around their own members for comment”.
All our source asks for, their petition, is to standardise the test as much as it can be. Other colleges have already done so, and it’s simply the fairest way to ensure that bias is lowered. Training the examiners was raised too, exposing them to ways to manage their own prejudices, though there is a worry that it’ll wound their sense of self-achievement. Because at the end of it all, it seems the system exists to raise some people up, and stop others from doing the same.
And this is the system that our the medical students are walking into. Seven years into a degree, and new barriers keep appearing for those that already have to overcome so much. There is some suggestion that a case will be brought before the universities to offer a form of postgraduate medical course, but that remains as speculation. Perhaps in the future the University of Auckland may be able to put forward a training scheme to rival the Royal College of Physicians—after all, there are thousands of dollars waiting to be extracted from the future physicians of this country.