By Shiv Kolhe1 and Berenice N A Armbruster2
1Newcastle University; BOTA Medical Student Representative Officer
2University Hospitals Coventry and Warwickshire
Published 06 October 2020
How do we approach what is a societal and contemporary issue and achieve diversity within medicine and surgery, notably Trauma and Orthopaedics (T&O)? The attention and focus of the solution must surely lie with events that occur before, during and just after medical school. In this article we discuss some of the issues we have encountered as well as possible solutions in order to promote inclusivity and increase diversity at medical school, in the undergraduate curriculum and within medical and surgical specialties.
As future healthcare professionals, we aim to deliver best practice that is only achievable through the combined effort of multiple team members, irrespective of future career choice. Throughout medical school we all learn a certain set of skills and knowledge; but it is our own life experiences and background which help us apply what we learn in medical school to work effectively as part of a multidisciplinary team as future doctors. It is therefore crucial to inspire a diverse and inclusive group of students to apply to study medicine in the first place. The Medical School Council (MSC) Selection Alliance Report 2019 reported an overall five-year increase in medical school entrants with demographic characteristics associated with socioeconomic disadvantage. However, as the numbers applying are proportionally so small, there is still much progress to be made to widen participation and increase outreach amongst these groups which include pupils from black and minority ethnic (BAME) backgrounds, state schools and whose parents have no higher education background. From our joint experience and involvement within multiple university societies; offering pupils at state schools and colleges in locally disadvantaged areas the opportunity to volunteer at undergraduate surgical conferences as well as organising youth engagement and outreach events such as talks and skills sessions - all provide a valuable experience and inspire students from more diverse education and socioeconomic backgrounds to apply to medical school.
Some medical schools have protected time every week to participate in extra-curricular activities. This time is usually the best opportunity for medical students to engage with outreach and widening participation events arranged by student surgical societies as it lies within school hours. However, this protected time tends to disappear in final clinical years making it more difficult to organise and engage with such activities and contribute to the wider society. As role models to many school pupils, it may be beneficial to allow those who are involved in widening participation activities to continue to do so in this free time.
There have been extensive discussions around how to diversify the medical workforce to cater for our multi-ethnic population in the UK. As future doctors how are we expected to represent and care for the population we serve, if as medical students we are being biased within the undergraduate curriculum itself? An example of this is the white normality within medical textbooks and the lack of clinical teaching and awareness around various disease presentations that differ between white and BAME patient groups. Medical teaching should be representative of the society we live in and this inherent bias not only risks leaving students exposed to uncertainty in the diagnosis and management of certain conditions in different patient groups; but also, given the existing low proportion of BAME medical school entrants, means that BAME students feel underrepresented and increasingly isolated within their own medical schools and wider society.
Recently though, we have seen the astonishing effort that medical students nationwide have been putting in to ensure a more diverse curriculum is taught at medical school. From raising awareness through social media campaigns of various dermatological conditions and their presentations in BAME patients, to uncommon presentations in certain sex groups such as gynecomastia in males. In addition to emphasising the necessity for medical councils and schools to increase BAME representation and promote inclusivity within the curriculum, we strongly believe that university surgical societies should also contribute their efforts to actively encourage and create an inclusive community in which underrepresented and marginalised groups are represented. This inclusivity at an undergraduate level will hopefully filter up to create more inclusive and diverse surgical specialties, particularly in T&O.
After medical school, there are several additional hurdles on the path to achieving a fully inclusive and diverse specialty. Repeatedly, we see how some specialties tend to attract certain types of people. If we take T&O surgery as an example, most peoples’ idea of the typical individual applying is a ‘white male rugby player’ and that of the specialty as having an ‘old boys' club’ ethos. We believe that this negative perception of the specialty is a deterrent for potential applicants and has historically produced an evident lack of diversity within the specialty, especially when it comes to the female gender. Currently 30% of core T&O trainees and 18% of specialist registrars are women, despite the consistently high proportion of female medical school entrants compared to their male counterparts. Luckily, we are seeing things gradually change; Health Education England (HEE) statistics now indicate British Asian is the largest single ethnic group at CT level in T&O with 32% White. However, we should still ask ourselves what we are doing right and what we could be doing better to prevent this stereotype affecting the next generation of T&O surgeons. We believe part of the solution is to increase visibility, promote inclusivity and only then can we boast diversity. If we work together and adopt this strategy from an undergraduate level onwards, we will inspire and retain a high quality of T&O trainees from a wide and diverse background.
Role models are not only key to inspire the next generation of T&O surgeons, but they also help to diversify the entire medical workforce. "You can’t be what you can’t see" is a well-known saying and whilst looking up to our own role models, we as medical students often forget that during medical school we have the opportunity to influence our peers, those around us and those who aspire to be us. From our experience, increasing the visibility of female role models within T&O is a simple yet effective solution to preventing deep-rooted stereotypes from influencing medical students career choices. We have seen this done well at undergraduate surgical and orthopaedic societies through women in surgery (WinS) themed events as well as by increasing the diversity of invited speakers at national conferences. This extends beyond medical school, where we are seeing an increasing proportion of female T&O surgeons take up leadership positions in national organisations such as the British Orthopaedic Association (BOA) and the British Orthopaedic Trainees’ Association (BOTA). Through actively combatting the lack of visible female role models within T&O and increasing their visual presence amongst medical students, we can and will correct misconceptions about women within orthopaedics and inspire those who may have otherwise been deterred from T&O. What is more, we are hearing phrases like "I cannot apply because I’m small and not strong" becoming outdated and replaced by phrases like "it’s technique, not strength". Though there is still lots of progress to be made, this is a really encouraging starting point, that as national student elects for BOTA we strive to raise awareness and make apparent to medical students all over the country.
As good as our efforts are to encourage and maintain a gender-diverse specialty, we still face many obstacles on our path to achieving overall diversity in several other ways. Funding and exposure to certain specialties, including T&O, being just two of them. As many know, building a surgical portfolio is expensive, whether you’re a medical student or a newly qualified doctor. Finding the available funding to attend courses or run events as part of a university society can be at times challenging to say the least. In our roles with BOTA, we have helped and directed students to find the right resources to fulfil their intended activities. However, not all national specialist associations have a medical student rep that can closely work with professionals in their field to help guide medical students their way. Including the role of a medical student representative within national specialist associations will not only ensure more students are exposed to various specialties and attend more networking events, but also acts to bridge the gap between surgeons and students promoting an inclusive environment for everyone.
The latter issue is exposed time within each specialty during medical school. It seems to vary hugely between medical schools, with some offering just a week’s experience within a specialty to three months in a single specialty. This huge variation will inevitably lead to students from specific universities applying to specific specialties. As many students tend to remain in the region they trained, this may also in turn create more competition for certain specialties and decrease the diversity of applicants entering certain specialties. This definitely appears to be one of the contributing factors for the lack of diversity in T&O; medical students from universities with less exposure to T&O do not have the opportunity to explore the specialty fully and must rely on other sources of information to form their own opinions about orthopaedics as a career. More often than not this tends to follow generalised stereotypes and unconscious biases that exist within society, consequently deterring interest, impeding inclusivity and resulting in a lack of diversity. We believe this variation between medical schools could be reduced by standardising the time students spend within each clinical specialty on a national scale.
We believe there is no single solution to achieving diversity within a specialty, however by recognising and valuing differences between individuals, not only in our patients but in our own colleagues, we will be able to achieve excellent patient care for future generations. In this article, we have commented on how as medical student we believe we can achieve diversity within any specialty, but in particular within T&O. As BOTA student representatives, past and present, we have strived to bridge the gap between medical students & orthopaedic surgeons. By flattening the hierarchy, we foster an inclusive environment for all medical students interested in T&O. We strongly believe increasing visibility and promoting inclusivity consistently throughout medical school and beyond, are key steps in order to engage and inspire the next generation of diverse orthopaedic surgeons.