Who goes on to become a paediatrician is determined by the clinical, in-person exam. Photo / 123rf
A major medical exam is discriminatory against candidates who aren’t white, a large group of doctors alleges.
The claim is set out in a letter obtained by the Weekend Herald, and concerns in-person assessments that decide who continues on the path to become a specialist in paediatrics (a branch of medicine that treats children and young people).
The Royal Australasian College of Physicians (RACP) has launched multiple investigations into the allegations, at the urging of a doctors’ union.
Paediatrics assessments include both a written and an in-person, clinical exam, and are sat by doctors (generally with about four to five years experience) to be accepted into advanced training.
A letter of protest to RACP, supported by more than 30 doctors, outlines claimed systemic problems with the clinical examinations.
“We find the current examination process discriminatory towards candidates of non-Caucasian backgrounds. We believe there is racial bias,” the February 2022 letter states.
“Within the Auckland clinical examination candidates, having reviewed the data for the past five years, the overall chance of passing the examination on the first attempt for a non-Caucasian candidate is 40 per cent. This is increased to 93 per cent for a Caucasian candidate.
“We believe that the vast discrepancy of pass rates reflects the existing racial bias and discrimination and that this is in breach of the NZ Human Rights Act.”
Fairness is vital because the exam determines who becomes a specialist in a health system attempting to increase the diversity of its workforce, to reflect society and help address inequities between Pākehā and other ethnicities, particularly Māori and Pacific.
The paediatric clinical exam involves doctors travelling to another hospital, where they assess real patients, and talk to their families. This takes the form of two more in-depth “long” cases and four short cases.
In the long cases, the doctor spends about an hour with a patient and their family (this isn’t observed or marked directly). They then spend up to 25 minutes presenting to two senior specialists, who act as the examiners.
The trainee describes the patient, their medical history and active problems, and identifies the key issues to focus on going forward. They answer questions of the examiners’ own choosing. (The examiners also spend time with the same patient and family, to compare the assessment against their own.)
In their letter, the group of doctors said NZ examiners were more than 90 per cent white.
“Overseas studies have shown that diversity of examination panels is essential to ensure a fair and unbiased process, especially in the setting of post-graduate clinical medical exams,” they wrote.
“The scoring framework is very broad with subjective marking. Pass/fail standards for each case are set by the pair of examiners allocated to the specific case. This means that the examiner’s own professional and clinical experiences, as well as personal views and beliefs, have significant influence in identifying key issues and management priorities.”
Other problems outlined in the letter include examiners often knowing the doctor they assess, and the “unacceptable levels of luck in terms of cases allocated”, with some being much more complex and difficult. There isn’t an adequate appeals or review process, the doctors state.
After little response, the doctors turned to the Resident Doctors’ Association (RDA) union, which confirmed the concerns were widely held among members, and followed up.
In May, RACP confirmed it would review the exam. It sent the Weekend Herald a statement from its Aotearoa NZ president, Dr Stephen Inns, which did not answer questions including whether the statistics cited in the letter were accurate.
“We note the issues raised in the letter, and they are viewed with concern by the college,” Inns stated.
“Senior college representatives have met with trainee representatives. As a result, the college now has commenced a board-led review of the examination, as well as a separate parallel, confidential process being conducted by an external third party.
“We will not be making any further comment while those investigations are underway.”
Dr Deborah Powell, national secretary of the RDA, said there hadn’t been recent communication from the college, and the union is concerned about the independence of the review, and how trainees can have meaningful input while remaining anonymous.
“You would expect a far higher degree of responsiveness, openness and transparency … we are not impressed.”
If RACP didn’t respond properly, Powell threatened to complain to the Medical Council, which will re-accredit the college’s training programme next year.
The doctors wrote the letter anonymously because they understandably feared career retribution, Powell said, and the apparent discrepancy in pass rates cited in the letter hadn’t been refuted.
“I believe the evidence supports the allegations that the trainees have made.”
Powell said the concern wasn’t about explicit or intentional racism at an individual level, but bias that might exist at an institutional or systemic level - when procedures or practices result in some groups being disadvantaged.
One of the doctors behind the protest letter, who asked to remain anonymous, said there was no disparity in pass rates in the written exam, which is assessed anonymously.
The real-life cases in the clinical exam could be complex with nuanced problems, the doctor said - for example, an 8-year-old with spina bifida, with wider family issues including insecure housing, maternal depression, sibling conflict and financial stress.
“When placed in the context of this exam these are then viewed from a Caucasian lens … we are essentially expected to ‘think, act and talk white’.
“The marking is based on how the candidate identifies the issues for the family, and how these are prioritised and discussed in comparison to what the examining pair have identified. The structure means that you can only pass if you agree with the examiner.”
Candidates have reported being asked “Where are you from?”, “When did you move here?”, and having their names mispronounced, the doctor told the Weekend Herald.
The doctor worried the form of the review, including it apparently being limited to the 2022 exam, is “clearly structured to produce the results the college desires”.
There has been controversy over exams in another medical specialty - in 2017, an independent review cleared the Australasian College for Emergency Medicine of discrimination, after foreign-trained doctors alleged systemic racism reduced their chances of passing.
However, the review did recommend clinical testing be overhauled, citing “concerns for the health and wellbeing” of doctors who were failed without adequate reason.
Ethnicity in healthcare has become an election-year flash point, after media coverage of the inclusion of ethnicity in a tool to help prioritise patients for some non-urgent procedures.
Most health services are actively trying to increase workforce diversity, to reflect the communities they serve. Research shows this can help reduce health inequities, and successive National and Labour Governments have funded schemes to increase workforce diversity.
Nicholas Jones is an investigative reporter at the New Zealand Herald. He won the best individual investigation and best social issues reporter categories at the 2023 Voyager Media Awards.
