Background

For almost four decades, white and ethnic minority staff have reported significantly different lived experiences in the NHS [1]. Since 2015, the Workforce Race and Equality Standard (WRES) has published data, which recently demonstrated that black and minority ethnic (BME) staff in the NHS, compared with their white counterparts, are more likely to report bullying, harassment and abuse from colleagues (29.0% vs 24.2%), are more likely to experience discrimination at work from a manager, team leader or other colleague (15.3% vs 6.4%), are 1.22 times more likely to enter into a formal disciplinary process and are less likely to believe that their trust provides equal opportunities for career progression or promotion (69.9% vs 86.3%) [2]. A bespoke set of WRES indicators have been developed to capture the experience of the medical workforce (MWRES) [3]. Trainees from a BME background may feel especially vulnerable when experiencing discrimination.

We present the findings of a pilot survey conducted in August 2020, exploring the lived experiences of UK Black ophthalmologists in speciality training.

Method

A web-based structured questionnaire, using both open and closed questions, was created using LimeSurvey. Free text responses were allowed for open questions. Trainees from the UK Black Ophthalmology Training Network were invited to complete the questionnaire. Informed consent was obtained and all responses were anonymised.

Results

Ten ophthalmology trainees were invited to participate of which nine completed the survey.

Black ophthalmology trainee experiences

  1. (i)

    Perceived discrimination by training faculty

    Five trainees experienced discriminatory behaviour by ophthalmology trainers (Table 1). These were related to inconsistencies in clinical supervisor reports, lack of support or mentorship from senior clinicians and removal of research opportunities, compared to white colleagues. Trainee A stated:

    ‘I was advised very early on in my training to switch careers despite glowing supervisor reports from the same supervisor. There was no explanation as to why. I was also told that I wouldn’t make it as an ophthalmic surgeon despite excelling in cataract surgery in the early stages. I was encouraged to take a non-ophthalmic surgical route, again no explanation and no hard facts or evidence given. There have been many more incidences but most of the time it is indirect racism, harassment, low key bullying.’

    Table 1 Trainee responses to closed survey questions.
    Full size table

    Trainee U felt that discriminatory behaviour by trainers was not always overt:

    ‘I have not personally experienced overt, blatant racism by any training faculty; however, this doesn’t mean it hasn’t happened on a subtle subconscious level. Furthermore, it is sometimes difficult to tell between a “tough” supervisor /senior colleague and one that has underlying prejudices. A consultant has, on an occasion, shouted at me for seeking her advice.’

  2. (ii)

    Perceived discrimination by non-training faculty

    Three trainees reported discriminatory behaviour by managerial and administrative staff, two trainees by nursing staff and allied health professionals and one trainee by other NHS-based staff. Trainee Z recalled overhearing derogatory comments about refugees and immigrants by secretarial staff.

  3. (iii)

    Perceived discrimination of other BME colleagues

Three trainees witnessed discriminatory behaviour towards other BME colleagues. Trainee Z reported that “a trainee from China received a hard time” and trainee A declared, “BME trainees are often name dropped more than their white counterparts when it comes to difficult situations or clinical incidents with patients, or if things go missing.”

Raising concerns

Most trainees were comfortable raising concerns in their place of work, particularly when addressing concerns about bullying (Fig. 1). However, four trainees felt unable to raise concerns within their own training institution and two felt unsure. Some feared the repercussions of challenging discriminatory behaviour. Trainee X reported:

‘I feel very vulnerable and am not clear about how to raise further concerns about this without jeopardising my career and wellbeing. In my deanery, we have been told to raise concerns about public safety and trainee wellbeing, however from previous experience this has not resulted in any significant change. The NHS trust I work for is known for its bullying and harassment of staff at very senior level.’

Fig. 1: Raising concerns.
figure 1

Black trainee perspectives about raising concerns in their training institution and place of work.

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Trainee E reported a positive experience from NHS staff when highlighting discriminatory behaviour:

‘I haven’t experienced any discriminatory behaviour from NHS staff but have from a patient who objected to being reviewed by a non-white doctor. I sought advice from the consultant in charge who made it clear of the hospital policy –– racism is not condoned and the patient would have to seek care elsewhere should they object to being reviewed. I was supported with a chaperone during the consultation with no further issue. I felt very supported by the NHS.’

Impact on trainee wellbeing

All trainees were asked to describe the impact of negative experiences on their wellbeing. Trainee A stated:

‘Yes, I have suffered discrimination, bullying and harassment throughout my training. Not all of it has been direct though. I do believe that if I was white, I would have had a different experience. As a BME trainee, comments and actions that one may feel to be racist are subconsciously deflected on a day-to-day basis. So, we are constantly having to defend ourselves. As a result, I have constant bouts of depression and anxiety. This can sometimes manifest in perfectionistic tendencies when it comes to ophthalmic patient care as I am aware of the implications this may have as a BME trainee (Dr Bawa Garba and Mr. David Sellu). This can be exhausting and demotivating. So, when my colleagues say that I work too hard, I have my reasons why I do so. I have to work 10x as hard as my white counterparts but never really made to feel ‘part of the group’.’

Trainee C reported:

‘It really undermines your confidence! There is confidence and competency in ophthalmology. Even if you are competent and you are constantly undermined, you lose your confidence.’

Conclusion

Racial discrimination not only results in significant physiological and psychological effects on people, but also impacts patient care [4,5,6]. Acknowledgement, allyship and tangible action plans are important first steps in tackling racism in the NHS [3, 7]. As clinicians of a multi-ethnic workforce, we should be prepared to challenge discriminatory behaviour to protect the health and wellbeing of our colleagues and patients.