BME doctors: From recruitment to embitterment

THE ELEPHANT IN THE ROOM: the Life and Times of a BME Doctor in the NHS - from Recruitment to Embitterment

Suresh Rao

These are my personal observations and experience of working for thirty five years in countries of three continents (India, Canada and UK). Till I became the President of the Indian Orthopedic Society of UK (IOS-U-K) around 2005 I had no reason to acknowledge the existence of discrimination in the NHS. I had passed all my examinations at the first attempt, I had become a consultant in the early 1990s at the same average age (about 37 years) of any UK born white male doctor in orthopaedics at that time. It was only after I had blown the whistle while actually observing the horrendous treatment meted out to my colleague orthopaedic surgeons did I actually personally experience racial discrimination in the NHS in its ugliest form.

I have now come to recognize that the traditional attitude to recruiting and retaining BME doctors and nurses into the NHS is no different from the ‘Discard After Single Use Only’ policy of the slave trade. There is little security or safety and no fairness of treatment. The system of incentives and reward for hard work and competence simply do not seem to apply to BME staff. Unlike others, the course of life of a BME professional whether doctor or nurse seems to follow several distinct stages.

1. Stage of Denial: We work hard to keep the home and family together, crediting our limited successes to the support of others. Any perceived failures are almost always attributed to bad luck, never to the possibility of discrimination.

2. Stage of Panic: Naively believing that blowing the whistle is good for the sake of our patients, we publicly voice our concerns forgetting that those responsible for the cock-ups in the establishment will not thank a BME for exposing their incompetence. Such persons will not hesitate in recruiting others even less scrupulous than themselves to intimidate and harass you for the loss of their ‘private empire’ style of working. They usually have no difficulty colluding with your colleagues who are probably already dreading the loss of their private practice to others. The establishment leviathan is now ready to turn against you for stirring up a hornet’s nest when you were least expecting this response.

3. Stage of silence: We are made to feel guilty for creating a conflict in the department where none had supposedly existed previously. We become vulnerable to subtle emotional blackmail by promising to avoid future conflicts and agreeing to behave in a more ‘civil manner’, i.e. accept that we should next time bring up any issues ‘face to face’ for a ‘negotiated’ resolution of ‘confusions and misunderstandings’ rather than going through the employer. We are later reminded of this sword of Damocles hanging on our heads and we become too frightened to think rationally, instead we too begin to behave like any victim would. We invite others to quash us underfoot like a worm by tacitly acquiescing to the rules of their game. This not only bolsters the opposition but also puts our relationship with our employer in jeopardy. We now enter a state of limbo in our career progression to the extent of even questioning our own achievements and wondering whether we had truly deserved our CEA points, if we managed to get any. We convince ourselves that this was just a favour granted to us by our generous employer but only with the benevolent support of our well-meaning colleagues. We begin to lose our self-esteem and any frame of reference we may have for our sense of self-identity, our moral character is disabled and allows us to do peculiar things we would never normally do. We are soon at risk of losing our raison d’être.

4. Stage of Escalation: Unfortunately a number of us cannot or will not read the writing on the wall. We may injudiciously allow the situation to escalate out of control and pave the way leading to our own harassment and intimidation at the hands of the abusers in the establishment. If this does not succeed to cow us down we are then threatened with disciplinary action including the possibility of instant dismissal for supposedly ‘serious charges’ including criminal prosecutions for what are really minor infractions. The establishment will not hesitate to dispense summary retribution through Dismissal Orders under ‘MHPS’ for trumped-up charges and enforce redundancy despite any findings of  the Employment Tribunals. It is not uncommon for us to be referred to the GMC by this stage as the latter is hand in glove with the Medical Directors against the BME and feels obliged to take up investigating all such matters despite no evidence being submitted by the Establishment, a clear case of disproportionately handing out injustices to BME.   

5. Stage of ‘Resolution of Conflagration’: this usually means a ‘negotiated settlement for enforced retirement’ and it is most diabolical that this sometimes comes about because the innocent BME cannot bear the humiliation of a criminal trial or a GMC hearing and will most likely be on the verge of deciding to commit suicide.

Suggestions to avoid such a fate:

This is difficult because everyone reacts to crises in completely different and unpredictable ways. Following is just commonsense, not rocket-science:

1.    Maintain good medical practice (and relations with colleagues)

2.    Know the law (including the latest version of MHPS and PIDA)

3.    Take advice from a mentor (and follow every step correctly)

4.    Anticipate trouble (band up together, join BAPIO and MDS)

5.    Use local procedures fully (keep meticulous documentation)

6.    Involve regulatory bodies at an early stage (NCAS, GMC, CQC, CPS)

7.    Remain vigilant and focused, be discreet, stay calm and never say die

The elephant in the room is discrimination, name it, call it out, learn to effectively deal with it and work to reduce its harmful effects on yourself and others.

Prof Suresh Rao

Consultant Orthopaedic & Trauma Surgeon

North Cumbria University Hospitals NHS Trust

Hon. Professor, University of Cumbria

(The above is from the talk given by Suresh Rao at a meeting in Manchester on 26 March 2013. All the content are the personal views of Suresh Rao)

©M HEMADRI

Follow me M HEMADRI on Twitter @HemadriTweets

M Hemadri’s mini e-book 'Standardised Management Conversation' is available - click http://www.amazon.co.uk/Standardised-Management-Conversation-Hemadri-ebook/dp/B018AWBJTU 

QuizUp and the dangers of Unconscious Competence

I have recently been playing QuizUp. It is an online quiz which you can play real time against other people from all parts of the world. There are innumerable topics and categories with thousands of people playing it.

I chose a topic that was familiar and another one which was not familiar. What I learned was something many of us may already know. But are we applying what we already know? Are we harming people by not recognising and applying what we know in a proper manner?

When I start playing QuizUp even for very familiar topics such as medicine or healthcare I had to read the questions slowly because the style and format of the question is different for each question. Some are direct, some are linked with directly topic related pictures, some are related with general pictures from news and social media that relate to the topic, some have humour, others have pun and so on. Then comes the answers there are very technical answers from some questions, lay answers for some, humorous answers for others and so on. So even when I understood the question perfectly well and knew AN answer which was right, THE answer that was right for QuizUp took time to learn. Of course there is the issue of learning the answers that I did not know before. 

Now, once these were learned, the issue became one of speed, because even if I knew all the answers if I did not answer them fast enough I would lose. At this point, I began winning a number of matches/plays/games. But also loosing a number of them because the speed itself caused errors due to many reasons including the jumbling of answers and the pressure involved in a fast recall and response to a touch screen.

At this stage, there is enough knowledge, memory, recall and speed which then moves on to pattern recognition. Most often there was no need to read the questions or the answers the responses came automatically, fast and correctly. It was on auto-pilot and very successful.

My scores were soaring, the whole thing was getting a bit monotonous, repetitive and pointless. This is when QuizUp decided to update the questions so there were a number of new questions thrown in. Obviously I had to go through the sequence described above for these new questions. That is when I discovered that I not only had trouble with the new questions in terms of knowledge, speed etc. Because the new questions had been interspersed with the older/original ones I was struggling with the older ones as well.

I was struggling to answer questions that I used to answer automatically and correctly within a second. I was getting them either slow or wrong. I was UK top ten for a particular month in the topic and was getting stuff wrong. Interestingly, because I was already way up top ten it really did not matter, I did not drop too many ranks if at all. Mind you, I am talking about marginal differences here. The nature of the game and my overall rank meant I was still winning but not as efficiently as before.

The worrying thing was that the minute I stopped pattern matching my scores fell.

The last point I wish to draw your attention to is this. I was concerned about the efficiency of my wins and started reviewing my questions by reading the question and answer in detail after playing each game. I was surprised that I was neither fully aware of the wordings of the question nor the logic of the answers; I knew what the question was and what the answer was that is knowledge but while answering them repeatedly my knowledge formed the basis of pattern matching but as the pattern matching became dominant potential and/or real drops in awareness of knowledge and on some occasions of knowledge itself happened.

Pondering on the above gave rise to some worrying thoughts and certain concepts which may be negatively affecting some of us.

Many of you with some knowledge about education and learning methods will recognise the model where we are

Unconsciously incompetent

Consciously incompetent

Consciously competent

Unconsciously competent

These are called the four stages of learning or four stages of competence and linked with the concepts around the Johari window.

Is there a risk with Unconscious Competence?

You would have noticed from my above description that like any learning or skill my QuizUp journey moved from Unconsciously Incompetent to Unconsciously Comptent. Educationalists and trainers want us to be unconsciously competent, it is supposed to be the highest in the hierarchy of learning and competence.

Here is the worry or the risk.

Many senior experienced older doctors are unconsciously competent, i.e. where we actually want them to be. When we want them to incorporate something new into their routines we are pushing them back to conscious competence. We are aware for that for the new skill there is a learning curve, we accept that. I am not sure if whether while the new skill is being incorporated their performance with their established skills fall, even temporarily; and if it were to fall whether we even notice it as it is likely to be subsumed in the averages of their overall numbers/performance which had a good baseline to start with.

But, here is the more worrying aspect. Due to some unfortunate reason if any of the senior established busy doctors were referred for an assessment of their knowledge and competence (say to an agency such as NCAS) these doctors are tested for their conscious competence when their daily practice is in the domain of unconscious competence. Add the pressure and stress of going through the formal assessments that decide the fate of their careers, these doctors often unsurprisingly come out as lacking in knowledge and skills, i.e. incompetent.

I have no empirical research or data to show this. I can only hypothesise based on my observation of my play of QuizUp that I really enjoy and am good at to some extent. Also, this phenomenon of slipping back into conscious competence may be limited only to me and not the rest of the world (though I doubt it) and so this whole concept may be relevant only to me.

However, my concerns are two fold. First, in teaching new skills to the old dogs we may be negatively impacting on their overall competence at least temporarily (while their new skill competence gradually improves – learning curve) and while this may be happening we may not be able to recognise it. Secondly, once these doctors are in difficulty, we may be testing the skills of race car driving with a normal driving test template and failing them in both.

Whether this is purely theoretical or not, it is worth putting some research into this. It may be beneficial to both patients and doctors.

M. HEMADRI

Follow me on twitter @HemadriTweets