It can be as blatant as a racist comment from a patient – or as subtle as not being invited for coffee at the debrief huddle.

In the world of medical education and training, all are not treated equally; ethnic minority doctors still face disadvantages, leading to poorer outcomes in exams and career progression.

Differential attainment was first diagnosed 30 years ago and – despite a rash of initiatives to tackle it and a diverse medical workforce – it remains endemic.

‘There is no evidence yet that the attainment gap between doctors of different ethnicities is significantly narrowing over time,’ says the 2023 GMC report, Tackling Disadvantage in Medical Education.

Dismayed by the statistics – and some personal experiences – GPs Faye Stockton and Shallini Subbu are determined to change this. These two associate deans for GP training with HEIW (Health Education and Improvement Wales) recognise that the system is at fault, not the resident doctors.

So they have set up Tyfu (‘to grow’ in Welsh), a ‘growth’ programme for ethnic minority female GP registrars, to help them realise their full potential. Most of the 15 registrars in this first Tyfu cohort are IMGs (international medical graduates), who are also navigating cultural differences, although some have done all their training in the UK.

They are ‘some of the most talented doctors in this country’, says Dr Stockton, who is also a GP in Powys, but ‘the odds are stacked against them’.

‘The culture needs to change and I say that as someone who was born and raised in Wales,’ Dr Subbu says. ‘Culture can change, but it takes a determined, collective approach to make that happen.’

The year-long Tyfu programme, which runs until March, offers regular training to build skills, confidence – and a sense of solidarity. Sessions, mostly online, are based around the stories of different women leaders in medicine who share personal experiences of overcoming barriers. ‘To see vulnerability in senior women is very powerful,’ says Dr Stockton.

One of these speakers is Denisse Morán, a GP partner in Llandudno. She chose to settle in this part of north Wales because the coastline reminds her of home in northern Chile.

While she has not faced discrimination, Dr Morán (pictured above) faced definite hurdles in navigating the British system and culture, right from her first job as a senior house officer in England and later in GP training.

Her CV, for example, was unlike others in her training cohort. After completing foundation training in Chile, she had spent seven years as medical director of the huge Collahuasi copper mine 4,400m above sea level in the Chilean Andes, responsible for 10,000 employees. The view from her office window was the Irruputuncu volcano.

‘Sometimes, in other countries, you can do more during medical school and foundation years [than here in the UK],’ Dr Morán says. ‘In my first job in the UK when I told that story to medical students and peers, they couldn’t adapt to that idea.’

There have been more subtle challenges too, such as the British tendency to speak indirectly and the way patients sometimes raise their real concerns only on the third appointment.

After more than 10 years in this country, Dr Morán experiences this cultural divide differently now, in conversations with straight-talking Chilean relatives.

‘I have changed so much that sometimes speaking with my relatives in Chile, we don't understand each other. I need my time to give my answers: my family want the answer in one minute, right now. “Tell me: is this blue or white?” I can't say: life is not like this.’

When starting GP training, Dr Morán had the advantage of being married to a Brit, having spent several years absorbing British culture, and having a strong mindset. She was so determined to pass every exam that she made time each week to read about British culture in the nearest university library. She had also decided to take negative feedback as ‘an opportunity to be better’, as she explains in her Tyfu talk about having ‘rhino skin’.

‘Maybe I need to study more than other doctors with medical training in the UK but you need to force yourself to do it because that is your goal,’ she says.

What helped more than anything, however, was her GP mentor in Denbigh telling her that, statistically, IMGs had higher failure rates, regardless of their aptitude, and support such as his willingness to discuss cases with her every week.

‘You need not only medical knowledge but also you need to know the culture, the system, the way of thinking and doing the job.’

Not all IMGs are ethnic minority doctors, of course but, for those who are, the hurdles can be particularly daunting.

As Prof Katherine Woolf of UCL (University College London) contends in her research on differential attainment, it has nothing to do with ‘learner deficit’ or examiner bias.

It is, she says, an ‘institutional problem’: the ‘learning experience’ for ethnic minority students and resident doctors is not as good, she writes in the BMJ.

Colette McNally, HEIW’s director of postgraduate GP education who oversees the Tyfu programme, gives the example of them missing out on ‘opportunities to understand application of knowledge’, such as sitting down with more senior doctors for coffee to discuss particular cases and how they handled them.

‘The data around differential attainment shows that it's the lack of belonging, the lack of feeling part of the team, the dissonance that people feel from the organisation, fuelled by all the micro-aggressions that they get from patients and other staff,’ says Dr McNally.

‘And there's a sense around international doctors that UK staff don't perceive their qualification is as valid as a UK doctor’s, that they don't think they're good enough.

‘And the way to address it, all the research shows, is building strong relationships, particularly with the educational supervisor, but also with colleagues.’

In the BMA’s 2022 racism in medicine survey, 60 per cent of respondents from Asian backgrounds reported that racism had had an effect on career progression and 57 per cent from Black backgrounds and 45 per cent from ‘mixed’ backgrounds said the same.

Dr Subbu, who is also a GP in Cardiff, has experienced this kind of racism and discrimination – and is determined to use her leadership position now to try to tackle inequalities.

‘How many times does a person need to be told they're not good enough before they believe they're not good enough?’ she says.  

For her, Tyfu is not about training women to pass exams, although three in the cohort have gained their certificates of completion of training during the year. Rather, it is about giving resident doctors skills and self-belief so they can thrive, sometimes despite the system.

Dr Stockton gives the example that IMGs from countries where resident doctors are not expected to contribute to discussions with more senior colleagues may be reticent in speaking up.

‘One of our Tyfu women said: “I'm from Egypt, and we're not expected to speak at all.” We see multi-source feedback for international graduates that frequently says: “Needs to engage more with the team, needs to speak up more,” and yet here, nobody's told them that they're expected to contribute. No one’s told them!’

In this way, Tyfu is also pointing up gaps in mainstream training. Dr McNally mentions that educational supervisors can be reluctant to say ‘culturally difficult things like: “Slow your speech because your accent becomes strong when you’re stressed and speaking fast.” People don't feel comfortable having those conversations but that means trainees don't necessarily get all the support they need’.

Dr Stockton agrees: ‘We’re realising the amount of work we have to do within our training community to start with, to understand these issues, but we're ready for it.’

Tackling differential attainment matters for the whole system, says Dr McNally.

Quite apart from the cost of recurring exam fees and the risk of burnout for the candidate, the cost to the NHS of a doctor extending their training by six months is about £60,000, she says.

Importantly, it also has strong negative repercussions for patient care. ‘If you've got somebody on your team that doesn't feel engaged, through burnout, through exam failure, through not feeling part of the team, then the efficiency and the effectiveness of the team will be lower. The most effective, best-functioning teams have the best patient outcomes.’

The ultimate goal for Tyfu is to encourage its resident doctors into fulfilling roles – even leadership roles – where they can help build more empathic teams where everyone feels valued.

The Tyfu team believe its residents’ grit and resilience show strong leadership potential. Dr Morán points out that IMGs have to acquire these qualities when their close families are overseas and they lack the practical and emotional support other residents can count on.

Dr McNally says: ‘What we don't want is for them to finish their training exhausted, and with just enough ambition to stay in work. We want them to have the ambition to look for jobs that really suit them. That’s not necessarily in formal leadership roles, but as a GP you have to be a leader for your team.’

Already, Dr Stockton and Dr Subbu have ambitions of their own, for Tyfu to extend beyond Wales’s borders, and beyond general practice. They are already collaborating internationally to extend its reach.

At the moment theirs is a community of practice to which Tyfu alumni will remain connected and contribute. But they are already using words such as ‘mission’ and ‘movement’.

‘We believe in the ripple effect,’ says Dr Subbu. ‘And the driver, the passion, is that with the culture we’re driving, the impact on teams will lead to exceptional care for our patients. But you cannot be a single voice. You must be a collective.’