03 Dec 2020

Where I come from: a reflection on discrimination in modern medicine

By Ritika Gera
Year 5, UK medical student

My first memory of racism is from the age of seven, when a man shouted a discriminatory epithet out of his car instructing my family to “go back to where we come from”. As I got older, I accepted and dealt with discrimination because it was part of being a female first-generation immigrant. I was fortunate enough to grow up in East London, where I was surrounded by a supportive BAME community, but incidents such as the above often happened outside my protective bubble of home and school. Consequently, the feeling of being isolated as an outsider persisted into medical school.

When I started medical school, I held unrealistic expectations. I thought that by entering the medical profession and becoming a doctor, I would be immunised against further discrimination. However, I quickly realised that medicine, like every other profession, is an intrinsically imperfect institution which still grapples with racism and sexism because it is a microcosm of our broader society.

There is widespread evidence indicating that racism and sexism are still deeply embedded in medical schools and hospitals. A recent investigation published in the BMJ found that medical schools rarely record student complaints of racial harassment¹. The Journal of Vascular Surgery recently published a paper which drew widespread condemnation because its evaluation of ‘unprofessional social media content’ unfairly discriminated against women in the field. Although this article was later retracted, it bypassed multiple layers of scrutiny before being published. This speaks to a worrying culture shielding outdated sexist attitudes in the medical field. Discrimination and a lack of diversity is damaging to patients as well as healthcare workers and, in the face of the BLM movement, it’s rightly become harder to ignore.

As a medical student, I have had first-hand experience of racism and sexism, spanning the gamut from macro- to micro-aggressions. I have overheard comments from colleagues about my size and how ‘big’ I am while scrubbed in for surgery. I have been called ‘over-eager’ and told to “calm down and be patient; you’ll get your dues” when I’ve put myself forward for learning opportunities, because being confident and passionate was interpreted as being overbearing and bossy. When I ask for advice about pursuing a certain specialty, there is often an addendum that ‘it is difficult to pursue this because it doesn’t leave much time for family’, a comment which is often unprompted and almost never directed towards male medical students. As a first-year medical student, I was told again to “go back to where I come from” by a member of the public.

Reflecting on my experiences thus, I have compiled a list of advice I wish I could have received as a first-year medical student. I wanted to create a safe space to talk about problems which are rarely discussed formally, because any issue must be acknowledged before it can be addressed. By discussing them and actively working to improve experiences, we will improve the working environment for future generations to come.

‘Do no harm’ is a principle which doctors must apply to themselves as well as their patients

‘Primum, non nocere’ (First, do no harm). These three words form the foundation of medicine because they signify the unshakeable tenet by which doctors abide to treat their patients. However, if we are discriminated against, or observe discrimination, we often sacrifice ourselves by saying nothing to avoid causing a disturbance. We do harm to ourselves to protect those who discriminate against us.

One of my biggest regrets as a medical student was to stay quiet. I feared speaking out against my seniors because I was terrified about angering them. I thought they would penalise me during a review process, so I said nothing, even as they made disparaging and discriminatory comments. It remains one of the things I am most ashamed of. This has galvanised me to do better, for myself, my colleagues, and my patients. Having these tough conversations, with patients as well as colleagues, can stimulate development to alter the culture and dynamic of the team and enact change for the better.

Find people who you relate to for advice to succeed in your chosen field

In 2016, women made up 58% of the medical student cohort, but across the UK, female surgeons comprised only 11.1% of all surgical consultants (now, in 2020, this has increased to 13.2%)². A publication from 2008 entitled Gender and Variation in Activity Rates of Hospital Consultants stated: “feminization of the profession could lead to reduced productivity over time”. It drew this conclusion from a data set of over 6,000 male physicians compared to approximately 1,000 female physicians³.

It was difficult to find the motivation to pursue competitive specialties when, as a medical student, I rarely saw BAME female consultants practicing them. However, I had the opportunity to meet such role models through mentoring schemes and medical conferences which are open to all medical students. One of the best decisions I made was to actively seek out mentors who I related to, from senior medical students to doctors, because I found they understood my challenges and ambitions better. With their guidance, I have gained experience in areas of interest and learnt how to develop my portfolio.

Equally, some of my best mentors have been men invested in inspiring medical students to become surgeons and researchers. Dr Deb Lees, a spinal surgeon, summed this up well: “Don’t always go in fighting, because you will find battles where there aren’t battles to be fought. Men have been some of my greatest allies in surgery”.

Respond to microaggressions

Sometimes, demeaning comments are delivered as unintentional throwaways which typically don’t appear discriminatory on the surface. They may feel small at the time, but they are still never acceptable, and are vital to address to help change the dynamic of the team.

I have let many comments slide in the past because I’m scared of coming across as unprofessional and “what’s the point in kicking up a fuss for nothing”. There is also a strange sensation of guilt which came with writing this article because it is written from a place of privilege; ultimately, I’ve gotten into medical school and been able to pursue research projects which interested me, so what right do I have to complain about feeling discriminated against? With time, I realised that even though I have a lot to be thankful for, I still have the right to raise discrimination in the workplace as a legitimate issue because it’s hurt myself and other colleagues in ways small and large. As I’ve gained experience and confidence in the clinical environment, I’ve also learnt that staying quiet helps no-one.

It is important to discern the impact of the comment(s) and understand how much of an investment responding to it will be because it’s not always our job to correct others’ presumptions⁴. If a microaggression occurs and I want to address it, I implement the advice given to me by a senior consultant; first, try to disarm the situation with grace and humour. I have found this works in most cases because it helps the other person question their assumptions in a non-confrontational and non-judgemental manner. If this doesn’t work, I step away from the situation and discuss it with another trusted senior colleague to debrief and reflect.

Speak up against members of the team if you think they have behaved in a derogatory manner against you, another member of the team, or a patient. Don’t brush off comments as small one-offs and don’t dismiss your concerns as ‘oversensitivity’ because your gut instinct is often astute at identifying when something is wrong.

There is no shame in asking for help

We are not superheroes. Like everyone else, we are vulnerable people who sometimes experience pain, anger, and loss. We feel fear when we are discriminated against and grieve when we lose opportunities because of our gender or the colour of our skin.

I found that talking to other students and doctors has been one of the most effective coping methods. Reaching out to trusted colleagues and senior medical students when I am put into uncomfortable situations helps validate my feelings and understand how to cope better. With their help, I’ve processed some difficult moments, which would otherwise have irreparably damaged my confidence. I’ve learnt from them that I should never apologise for my ambitions because it is an integral part of who I am.

Addressing imposter syndrome

It is difficult to pick yourself up from a discriminatory remark. These disparaging comments can knock your confidence and make you question whether you are good or worthy enough to belong in medicine. At their worst, they can cause imposter syndrome, a complex phenomenon defined by the feeling of inadequacy persisting despite success.

A valuable lesson I learnt from senior colleagues is that believing in myself- and defeating imposter syndrome - is a challenge which won’t end when I finish medical school. It’s something which I must mindfully practice every moment for the rest of my life. Although it is something I often struggle with, having colleagues I relate and look up to has been vital in tackling imposter syndrome. They have taught me that if I am an enthusiastic member of the team, polite, eager to learn, and keen to help, I deserve to practice medicine as much as anyone else.

Even if it sometimes doesn’t feel like it, things will get better

After having bad experiences, I’ve struggled with my motivation to become a doctor. However, taking a step back and appreciating that medicine is evolving to be better has been instrumental in pushing me to keep going.

A medical student at St George’s University of London created Mind the Gap, a handbook of clinical signs on black and brown skin, to combat white skin bias and improve the management of BAME patients⁵. The UCL Women in Surgery conference won the award for Best National Event of 2019/2020 because it dispelled widespread misconceptions about the gender barrier contributing to the scarcity of female surgeons⁶. Following the BLM movement, the RCS recently requested Baroness Helena Kennedy to chair an independent review of diversity in their professional leadership, because surgical leaders should better represent the community that they serve⁷.

These developments are signs of progress in addressing the systemic issues present in medicine. Nevertheless, more is still needed to encourage a comfortable and safe environment for professionals and patients.

As for being told to “go back to where I come from”...

It has taken me fifteen years to come up with a simple six-word response; “this is where I come from!”. As a first-generation immigrant fortunate enough to be a member of a prestigious medical institution, and as someone proud to be a female British-Indian medical student graduating into the NHS; I am home.

Acknowledgement

Many thanks to the UCL doctors and students who contributed to this piece; your feedback and advice were invaluable.

References

It's time to act on racism in the NHS. BMJ. 2020;368:m568. Available at: www.bmj.com/content/368/bmj.m568/rapid-responses.
Royal College of SUrgeons ENgland (2020). Womein in Surgery. Available at: www.rcseng.ac.uk/careers-in-surgery/women-in-surgery/statistics.
Bloor K, Freemantle N, Maynard A. Gender and variation in activity rates of hospital consultants. J R Soc Med. 2008;101(1):27-3.
Washington EF, Birch AH, Roberts LM. When and How to Respond to Microaggressions. Harvard Business Review. Available at: https://hbr.org/2020/07/when-and-how-to-respond-to-microaggressions.
Mukwende M, Turner M, Tamony P. Mind the Gap: a handbook of clinical signs on black and brown skin. Available at: www.sgul.ac.uk/news/mind-the-gap-a-handbook-of-clinical-signs-on-black-and-brown-skin
PI Media (2020). UCL Women in Surgery conference wins Best National Event. Available at: https://uclpimedia.com/online/ucl-surgical-societys-women-in-surgery-conference-wins-best-national-event-at-thenbspnational-societies-and-volunteering-awardsnbsp.
Royal College of Surgeons England (2020). Baroness Helena Kennedy QC to lead diversity review at Royal College of Surgeons of England. Available at: www.rcseng.ac.uk/news-and-events/media-centre/press-releases/hk-announcement.

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