We need to face uncomfortable truths about diversity in our medical workforce

In my region, including me, I know of only three black anaesthetists who have trained in the past 10 years. In England and Wales, only 22 of 2649 (0.8%) resident anaesthetists are black—down 40% from 2014.1 We are seeing the same trend in other specialties too, resulting in fewer ethnic minority doctors on the specialist register.1 We are doing our patients a disservice by not ensuring the workforce represents the population it serves.

Recent data from the General Medical Council show that for the first time there are more ethnic minority doctors than white doctors in our workforce.2 Diversity is one of the NHS’s greatest assets, with international medical graduates and ethnic minority doctors contributing a great deal. But scratching this veneer of apparent diversity reveals huge inequalities in the specialties and roles in which they are distributed.

There are 11 729 doctors on the specialist register in anaesthesia and intensive care medicine.1 Of these 179 (1.5%) are black, compared with 6.8% of all GMC registered doctors. Anecdotally, one explanation given for the limited number of black anaesthetists is that they are not attracted to this specialty. But evidence shows that, despite the high numbers of applicants, low numbers of black applicants are being accepted into training posts.3 In 2023, 302 black candidates applied to anaesthetics, with only five offers made, meaning only 1.66% of applicants were successful. For white candidates, 47% of applications were successful.3

A colleague and I found potential ethnic inequities in anaesthetic recruitment scores.4 Black, Asian, and ethnic minority applicants to anaesthesia scored lower than white applicants on average on both the multispecialty recruitment assessment (MSRA) and at interview.4 Anaesthetists have raised concerns about using the MSRA for recruitment, and the Royal College of Anaesthetists is due to analyse its validity.

Once doctors have made it into the anaesthetic training programme, the uphill battle continues. Doctors from ethnic minorities face more adverse outcomes in their Annual Review of Competency Progression2 and are more likely to fail specialty exams.3

In surgery, only 25-30 of 230 black British applicants to core surgical training received offers, compared with 221 of 520 white British applicants.3 Inequalities between the numbers of black and white British applicants are also seen in general practice.5 There has been a 239% increase in international medical graduate applications to the GP register since 2016, and the proportion of black trainees in general practice has tripled from 5% in 2012 to 15% in 2021.6

The increasing number of international medical graduates, many of whom are from ethnic minority backgrounds, obtaining training posts in various specialties is causing some disquiet among UK medical graduates.7 The rhetoric of “foreigners” taking British jobs is misguided and blames a marginalised group often treated poorly by our system, rather than the powers responsible for poor workforce planning.8 International medical graduates in anaesthesia have a 1 in 45 chance of receiving an offer, compared with roughly 1 in 3 for UK graduates.3

UK trained ethnic minority doctors and international medical graduates create a richly diverse workforce that is important for patients. Having a cultural understanding of patients and being knowledgeable about cultural and ethnic backgrounds contributes towards better patient outcomes. Appalling inequities of care exist, including in maternal health, cardiovascular disease, and diabetes.910 A diverse workforce that is representative of the communities it serves is vital in tackling these population health inequities.11

The phrase “you cannot be what you cannot see” applies in most specialties. By default, the small numbers of black anaesthetists have become role models and leaders. We should cherish, support, and mentor under-represented populations.

We need solutions for specialties, such as anaesthesia, with training bottlenecks and inequalities in recruitment numbers. The first step is being open and transparent about data. Responsible bodies and organisations must look at the data, ask questions, examine recruitment processes, challenge differential attainment, and develop processes that reduce systemic inequities. This may require work on widening participation for medical school applications, supporting bodies such as Melanin Medics (https://www.melaninmedics.com/) and similar initiatives. We need more leaders from diverse backgrounds. Interview panels, examiners, and those in training roles should reflect the population served, in ethnicity, gender, and all other protected characteristics.

We must ask questions and actively challenge the systems developing this inequity. We can mentor others, help with applications, exams, interviews, and much more. Amplify under-represented voices and champion under-represented groups, even if you are not part of the group yourself. Every effort counts, and allies are sorely needed.