R-A-C-E session at RCEM CPD conference

This was a really powerful session that took us on a journey from the past, to the present and left us with a feeling of hope for the future. I’ll try to summarise the main points below and then add a further reading section for your homework as one if the main lessons of this session is that we all have work to do if we want to make the world a fairer and more equitable place.

This is the first of two post from the RCEM conference. I’ve separated out this topic as it works well as a stand alone topic and the combined post would be too long.

As I was on stage for this session, Dave Hartin (EM consultant and long standing friend of the blog) took over the note taking. I’ve then expanded the notes and had checked by the session presenters. Any factual errors are likely in transcription and are mine and mine alone.

Estimated reading time: 10 minutes

Dr Rita Das talking about the history of race and medicine.

Dr Rita Das talked about the history of race and medicine. She already sounds interesting from her bio working in NHS Arran and Ayrshire AND St Mary’s MTC! She is very experienced in this area with a degree in medical sociology. She warned the audience that some of what she says will make us feel uncomfortable and that prediction was true.

She describes race as a social construct as we are 99.9% similar in terms of our DNA. Grouping people together by race goes back to Linnaeus in the 16th century and these groupings were subsequently used to justify slavery and colonisation.

White societies exhibited black and Asian bodies during the slave trade and colonisation,using them as living cadavers, or as prized specimens. Black and Indigenous people were often exhibited as a curiosity eg Sara Bartman also known as Hottentot Venus. Medically slaves bodies were used as way for doctors to learn anatomy.

There are numerous other examples of exploitation, with experiments, dissection and craniotomies, use of tissue without consent, medical procedures and experimentation performed on enslaved women (and men) without anaesthesia eg by the gynaecologist Marion Sims.

Issues remain today with studies demonstrating that the time to analgesia in black patients is longer than in white patients (also issues with sickle disease and endometriosis in non-white populations).

Dr Das went on to describe how the medical profession have been complicit in many unacceptable experiments on diseases such as smallpox vacccines, tetany, ECT, and the quite frankly unbelievable (we do believe of course) Tuskegee syphilis experiments.

Perhaps all these historical factors led to the caution we saw in black and Asian population with C19 vaccination, and also a reluctance to participate in trials.

Medical practitioners were also complicit in the erasure of established medical cultures during colonisation. Eugenics was a real speciality with it’s own journals, and was still occurring into the 1970s in the form of sterilisation by coercion.

Key facts
1.⁠ ⁠Race is an independent predictor of health outcomes
2.⁠ ⁠South Asian pop much more likely to die of CVS disease
3.⁠ ⁠Black patients 8x more likely to be restrained in a MH crisis
4.⁠ ⁠if you’re black – less likely to be offered psychological help.
5.⁠ ⁠Remember George Floyd and others arrested and killed by Police – I can’t breathe
6.⁠ ⁠Deaths in childbirth and pregnancy 4x higher in black populations
7.⁠ ⁠Higher infant mortality in Children born to Pakistani women

Racism is clearly a social determinant of health. What do we do to counter this? Shouldn’t we be outraged at the disparities? It’s right to be uncomfortable to hear this history, and so important to do so as history is often not discussed. Dr Das delivered an excellent talk and got us all thinking about why we are where we are. History tells us many things.

Dr David Chung on differential attainment (DA)

This really matters as there is structural inequality in health care that can be seen in exam results. It’s a big issue for us all as  44.1% of NHS medical staff are from an “ethnic minority”.

IMGs in particular are increasingly being employed by the NHS but we are struggling to retain them. This is not good for us, or for them.

In the UK your exam pass rates vary a lot if you are an IMG with much worse outcomes. Is EM doing better with DA than other specialities? The data would suggest that we are better than most but differences still exist. The GMC see us as a speciality that is doing well, but we cannot be complacent as the exam results do not show the full story.

Are the differences in IMG results easily explainable? Probably not. We need to look at how are the exams set? How are examiners trained? Is unconscious bias influencing results? We also need to think about the training program prior to exams and how different teaching styles may influence achievement and whether trainees from an IMG background can be supported to adapt.

David was very humble about terms he hadn’t heard of up until a couple of years ago. That’s something that many of us feel, but it’s also an opportunity to learn and change.

We should recognise that IMGs have extra pressure – supporting family abroad etc, social isolation – energy drain of not being authentic (a reallly interesting here – are they actually exhausted trying to fit in to an image which is not their authentic selves?)

Psychological safety appears to be key – empowering trainees to feel empowered or brave to point out problems or differences. A lot of this comes down to the competence and cultural humility of colleagues (and this can be learned/changed)

How do we know if we have DA in our department? You might feel that everything is OK, but it may be hidden from you. The bottom line is that we need to actively seek it if it exists and that takes effort. All too easy to cruise along thinking nothing is of any concern.

Dr Sivanthi Sivanadarajah It’s the journey not the destination

This was a great talk as it tackled the issue of what to actually do head on. What can we actually do to change things? A key message is that this is a journey for most people and not a destination. We all have much to learn, and we are all coming from different starting positions. A strong theme was that we have work to do ourselves, but we also have an opportunity to help others around us on their journey to better understanding and better actions. 

Exactly what we do will of course vary and in many cases depend on where we are in terms of prior position, privilege and opportunity. It may well be that you are in a position where you can help to make change, and these changes will be specific to your role. Senior staff are really important in setting a culture that can support change and development.

Many of those in positions of influence are also in positions of privilege. One definition of privilege is ‘a special right, advantage, or immunity granted or available only to a particular person or group’. There are many types of privilege, and if you have them then it does not mean you are a bad person or that you haven’t worked hard, but it does mean that you are likely to have fewer obstacles in life than those that don’t have those characteristics. The wheel of power is a useful visual description of this.

Wheel of power

The wheel of power also demonstrates how you can have more than one marginalised characteristic and how these can interact and amplify the potential disadvantage. Intersectionality can be defined as the interconnected nature of social categorizations such as race, class, and gender as they apply to a given individual or group, regarded as creating overlapping and interdependent systems of discrimination or disadvantage.

Positionality is another useful concept and is defined as where we see ourselves in the world in relation to our various social identities (gender, race, class, ethnicity, ability, geographical location etc.); the combination of these identities and their intersections shape how we understand and engage with the world. The main point here is that how we see the world and the future depends on the journey that we took to get to where we are now. It also means that all of us are unique and thus it’s important for us to try and understand other people’s perspective.

Positionality also affects our social lens, which is how we view a situation, others and the world around us. Again this is a reminder that we bring bias to our world view. Importantly, our lens can be positively adapted over time through observations, interactions, self-awareness and learning.

Questions that we need to ask are who has the power and influence in an organisation and who ultimately makes decisions? If that person is you, it doesn’t mean you’re a bad person, it simply means you have the power to readdress the inequity and make things better for those who do not.

A strong recommendation from this talk was to ensure that staff have active bystander training. It’s a really useful thing to have in the toolkit to safely challenge behaviours in the ED. This is great advice as I’ve met lots of people who want to do something, but don’t know what to do. The answer as always is training and then action.

To conclude, the talk reminds us that making mistakes and encountering setbacks might be a painful and unavoidable part of the learning and the journey. When the going gets tough take a break but don’t give up – and make sure you frequently go back to looking in the mirror because no matter who you are, there will always be one person that you can influence – and that is yourself.



One last suggestion from me (SC) is to re-read Stevan’s blog on recovering from racism here

1-9 are recommended by our presenters. 10 and beyond are ones are mix of those recommended to me by John Amaechi who is another superb speaker on this topic, and a few extras.

Top tip – in my world I often get sent a list of books to read and to be honest I don’t have the time to read everything, and sometimes I like fiction (currently in book 4 of the Inspector Hawthorne mysteries which is fabulous (Anthony Horowitz)). Ths solution has been to use one of the abbreviated book services to get an overall feel and then dive in deeper to those that really catch my interest. I use Blinkist, but others are available. The list below is probably 100 hours of listening/reading so consider abridged versions if you are short of time for these (and in other areas of your practice). I also use abridged versions to ‘revise’ a book that I really like after a few years.

  1. The Culture Map. This is the one I’ve downloaded as very strongly recommended by David and Siv. https://erinmeyer.com/books/the-culture-map/
  2. Also Human. I read this a few years back and I agree it’s an amazing book. https://www.penguin.co.uk/books/434075/also-human-by-caroline-elton/9780099510796
  3. How to be an anti-racist. I read this a few years back and learned a lot. What I like is that it talks about actions not just words. https://en.wikipedia.org/wiki/How_to_Be_an_Antiracist
  4. Me and white supremacy. https://en.wikipedia.org/wiki/Me_and_White_Supremacy
  5. The Good Ally. Another strong recommend from the speakers. https://www.amazon.co.uk/Good-Ally-Nova-Reid/dp/0008439486
  6. White Fragility. https://en.wikipedia.org/wiki/White_Fragility
  7. Divided. The roots of racism in medicine. https://www.theguardian.com/books/2023/apr/10/divided-by-annabel-sowemimo-review-the-roots-of-racism-in-medicine
  8. How to argue with a racist. https://www.theguardian.com/books/2020/jan/30/how-to-argue-with-a-racist-adam-rutherford-review
  9. GMC Differential Attainment report https://www.gmc-uk.org/education/standards-guidance-and-curricula/guidance/tackling-differential-attainment
  10. So you want to talk about race. https://en.wikipedia.org/wiki/So_You_Want_to_Talk_About_Race
  11. Why Are All the Black Kids Sitting Together in the Cafeteria? https://www.penguin.co.uk/books/444036/why-are-all-the-black-kids-sitting-together-in-the-cafeteria-by-tatum-beverly-daniel/9780141997445
  12. Whistling Vivaldi. https://mitpressbookstore.mit.edu/book/9780393339727
  13. Notes from a native son. https://en.wikipedia.org/wiki/Notes_of_a_Native_Son
  14. Why I am no longer talking to white people about race. https://en.wikipedia.org/wiki/Why_I%27m_No_Longer_Talking_to_White_People_About_Race
  15. A life exposed. The story of Saartjie Baartman https://www.nytimes.com/2007/01/14/books/review/Elkins.t.html
  16. Legacies of Eugenics. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)00330-6/abstract
  17. Simon Carley, “JC: More on pulse oximetry and racial bias. St Emlyn’s,” in St.Emlyn’s, December 3, 2021, https://www.stemlynsblog.org/jc-more-on-pulse-oximetry-and-racial-bias-st-emlyns/.
  18. Stevan Bruijns, “Colour of the wind,” in St.Emlyn’s, May 2, 2020, https://www.stemlynsblog.org/colour-of-the-wind/.
  19. Stevan Bruijns, “Equality and global health. What I learned from being a recovering racist… 2023 update. St Emlyn’s,” in St.Emlyn’s, September 28, 2023, https://www.stemlynsblog.org/equality-and-global-health-what-i-learned-from-being-a-recovering-racist-2023-update-st-emlyns/.

Cite this article as: Simon Carley, "R-A-C-E session at RCEM CPD conference," in St.Emlyn's, April 19, 2024, https://www.stemlynsblog.org/r-a-c-e-session-at-rcem-cpd-conference-st-emlyns/.

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