Exploring the underperformance of male and minority ethnic medical students in first year clinical examinations

Non-native English-speaking applicants and the likelihood of physician assistant program matriculation

PURPOSE

Effective communication is critical in patient care. Multilingual medical providers, including Physician Assistants (PAs) can contribute to improved health care among patients with limited English proficiency; however, this is contingent upon matriculating multilingual providers. In this study, the association between prospective applicants' self-reported English as second language (ESL) status and their likelihood of matriculation into a PA program was investigated.

METHODS

Participants included applicants to five admission cycles of the Centralized Application Service for Physician Assistant from 2012 to 2020. Logistic regression was utilized to investigate association between applicant ESL status and odds of program matriculation in both bivariate and multivariable regression models. Models were adjusted for citizenship status, undergraduate grade point average, gender, age, race/ethnicity, number of programs applied to, and patient care hours.

RESULTS

In unadjusted and adjusted models, ESL status was associated with a significantly lower odds of matriculation to a PA program across all study years. In adjusted multivariable models, associations were strongest for 2014-2015 where ESL status was associated with a 35% lower odds of matriculation (odds ratio 0.65, 95% confidence interval 0.56, 0.76) when controlling for demographics, citizenship status, patient care experience, and academic achievement. In sensitivity analyses restricting to (a) those with TOEFL scores ≥ 100, and (b) restricting to those ESL applicants without TOEFL scores, we did not observe important changes in our results.

CONCLUSIONS

Results indicated that non-native English-speaking applicants have lower odds of PA program matriculation. Decrements in matriculation odds were large magnitude, minimally impacted by adjustment for confounders and persistent across the years. These findings suggest that PA program admission processes may disadvantage non-native English-speaking applicants. While there are potential explanations for the observed findings, they are cause for concern. Matriculating and training PAs who have language concordance with underserved populations are important means of improving patient outcomes.

Attitude and communication skills of German medical students

Objective

While the development of communication competencies in medical schools plays a pivotal role in the curriculum, studies show that students’ communication skills and patient-centred attitudes may vary based on gender and ethnicity. The goal of this study was to investigate the socio-demographic factors that influence medical students’ communication abilities and, more specifically, to what extent their attitude toward communication skills learning and patient orientation associate with communication abilities. Our population included medical students admitted in 2017. Used tools included a communication score, the patient-provider orientation and communication skills attitudes scales.

Results

Three hundred and sixty-five students participated in the study (56.4% female, 85.2% German native speakers, mean age 24.2 ± 3.5 years). Female and German native speaking students had a better communication skills OSCE performance, were more patient-oriented and had more positive attitudes toward communication skills learning than male and non-native speaking students. There was a significant association between gender, native tongue, attitudes towards communication skills learning and communication skills OSCE performance. In conclusion, to support medical students to improve their communication proficiency and attitudes towards the importance of clear communication and patient-oriented care, medical educators should consider teaching and assessment strategies that address socio-cultural aspects of communication.

Gender and ethnic differences in publication of BMJ letters to the editor: an observational study using machine learning

OBJECTIVES

To analyse the relationship between first author's gender and ethnicity (estimated from first name and surname), and chance of publication of rapid responses in the British Medical Journal (BMJ). To analyse whether other features of the rapid response account for any gender or ethnic differences, including the presence of multiple authors, declaration of conflicts of interests, the presence of Twitter handle, word count, reading ease, spelling and grammatical mistakes, and the presence of references.

DESIGN

A retrospective observational study.

SETTING

Website of the BMJ (BMJ.com).

PARTICIPANTS

Publicly available rapid responses submitted to BMJ.com between 1998 and 2018.

MAIN OUTCOME MEASURES

Publication of a rapid response as a letter to the editor in the BMJ.

RESULTS

We analysed 113 265 rapid responses, of which 8415 were published as letters to the editor (7.4%). Statistically significant univariate correlations were found between odds of publication and first author estimated gender and ethnicity, multiple authors, declaration of conflicts of interest, the presence of Twitter handle, word count, reading ease, spelling and grammatical mistakes, and the presence of references. Multivariate analysis showed that first author estimated gender and ethnicity predicted publication after taking into account the other factors. Compared to white authors, black authors were 26% less likely to be published (OR: 0.74, CI: 0.57-0.96), Asian and Pacific Islander authors were 46% less likely to be published (OR: 0.54, CI: 0.49-0.59) and Hispanic authors were 49% less likely to be published (OR: 0.51, CI: 0.41-0.64). Female authors were 10% less likely to be published (OR: 0.90, CI: 0.85-0.96) than male authors.

CONCLUSION

Ethnic and gender differences in rapid response publication remained after accounting for a broad range of features, themselves all predictive of publication. This suggests that the reasons for the differences of these groups lies elsewhere.

Multiple Speed Assessments

Abstract. This paper presents Multiple Speed Assessments as an umbrella term to encompass a variety of approaches that include multiple (e.g., 20), short (e.g., 3 min), and often integrated interpersonal simulations to elicit overt behavior in a standardized way across participants. Multiple Speed Assessments can be used to get insight into the behavioral repertoire of a target person in situations sampled from a predefined target domain and their intraindividual variability across these situations. This paper outlines the characteristics and theoretical basis of Multiple Speed Assessments. We also discuss various already existing examples of Multiple Speed Assessments (Objective Structured Clinical Examinations, Multiple Mini-Interviews, and constructed response multimedia tests) and provide an overview of design variations. Finally, we present current research evidence and future research directions related to Multiple Speed Assessments. Although we present Multiple Speed Assessments in the context of personnel selection, it can also be used for assessment in the educational, personality, or clinical psychology field.

Working hard to belong: a qualitative study exploring students from black, Asian and minority ethnic backgrounds experiences of pre-registration physiotherapy education

BACKGROUND

Previous research has demonstrated that attainment inequalities exist for students from Black Asian and Minority Ethnic (BAME) groups in pre-registration physiotherapy education. While previous research has explored students from BAME backgrounds experience of university, the context of physiotherapy is unique and is under researched. Therefore the purpose of this study was to explore BAME student experiences during their physiotherapy training.

METHODS

Using a phenomenological approach pre-registration BSc and MSc students from BAME backgrounds from two universities who had completed both academic and clinical modules were invited to participate. Focus groups followed a topic guide developed from the literature and were facilitated by physiotherapy educators from outside the host institution. They were digitally recorded, transcribed verbatim and analysed thematically. Analytical triangulation was adopted throughout the research process as a mechanism to enhance rigour.

RESULTS

Seventeen students participated from a range of self-identified BAME backgrounds that were also representative of age, gender and course. Themes derived from the data included: feeling an outsider in reflections of belonging, behaviours by others that marginalise BAME and personal strategies to integrate in physiotherapy despite the lack of power and influence. Collectively these themes demonstrate a range of challenges which students from BAME backgrounds face within both an academic and practice learning environment.

CONCLUSIONS

While this may not be surprising based on other disciplines, this study demonstrates that studying physiotherapy as a student from BAME background requires persistence to overcome a series of many implicit challenges. Understanding the experiences of students from BAME backgrounds presents unique opportunities to educate the profession and co-create opportunities for a more diverse profession with practitioners and educators as role models. There is a need for greater training for educators to listen to these students' voices and their stories, and understand where institutional structures and practices could be modified to enable BAME student inclusion in physiotherapy education and practice.

Sex differences in fitness to practise test scores: a cohort study of GPs

BACKGROUND

Tests of competence are written and clinical assessments taken by doctors under investigation by the General Medical Council (GMC) who have significant performance concerns. Male doctors on average perform more poorly in clinical assessments than female doctors, and are more likely to be sanctioned. It is unclear why.

AIM

To examine sex differences in the tests of competence assessment scores of GPs under investigation by the GMC, compared with GPs not under investigation, and whether scores mediate any relationship between sex and sanction likelihood.

DESIGN AND SETTING

Retrospective cohort study of GPs' administrative tests of competence data.

METHOD

Analysis of variance was undertaken to compare written and clinical tests of competence performance by sex and GP group (under investigation versus volunteers). Path analysis was conducted to explore the relationship between sex, written and clinical tests of competence performance, and investigation outcome.

RESULTS

On the written test, female GPs under investigation outperformed male GPs under investigation (Cohen's d = 0.28, P = 0.01); there was no sex difference in the volunteer group (Cohen's d = 0.02, P = 0.93). On the clinical assessment, female GPs outperformed male GPs in both groups (Cohen's d = 0.61, P<0.0001). A higher clinical score predicted remaining on the UK medical register without a warning or sanction, with no independent effect of sex controlling for assessment performance.

CONCLUSION

Female GPs outperform male GPs on clinical assessments, even among GPs with generally very poor performance. Male GPs under investigation may have particularly poor knowledge. Further research is required to understand potential sex differences in doctors who take tests of competence and how these impact on sex differences in investigation outcomes.

A Comparison of Stress Perception in International and Local First Semester Medical Students Using Psychometric, Psychophysiological, and Humoral Methods

(1) Medical doctors and medical students show increased psychological stress levels. International medical students seem to be particularly vulnerable. (2) We compared different methods of assessing stress levels in international and local first year medical students. First, study participants completed questionnaires related to stress, depression, empathy, and self-efficacy (MBI, PSQ, PHQ-9, JSPE-S, and GSE) at three separate points in time (T1 to T3). Second, their heart rate variabilities (HRVs) were recorded in an oral examination, a seminar, and in a relaxing situation. Third, hair samples were collected at the beginning and at the end of the semester to assess the cortisol concentration. (3) Included were 20 international and 20 local first semester medical students. At T1, we found considerable differences between international and local students in the JSPE-S; at T2 in the MBI factor "professional efficacy", the PHQ-9, and in the JSPE-S; and at T3 in the MBI factors "cynicism" and "professional efficacy", the PHQ-9, and in the JSPE-S. International and local students also differed concerning their HRVs during relaxation. Over the course of the semester, international students showed changes in the MBI factors "emotional exhaustion" and "professional efficacy", the PHQ-9, and the GSE. Local students showed changes in the GSE. No effects were found for students' hair cortisol concentrations. (4) All participants showed low levels of stress. However, while international students experienced their stress levels to decrease over the course of the semester, local students found their stress levels to increase.

Welcome, Orientation, Language Training: a project at the Charité for new international medical students

Objective: A comprehensive, integrated support programme for new international students of medicine has been developed, implemented and evaluated at the Charité. The objectives of the programme were improved social integration, orientation on the study program and Charité campus, as well as qualification in medical specialist language. Project outline: The "Charité Orientation Module for International Students" (ChOIS) was designed by a working group with a variety of expertise in the field of international students. The programme has three stages: Recruitment (specific invitation on matriculation); Orientation week before semester start; and Parallel events during the first semester. ChoOIS was piloted in the Winter Semester 2015/16 and, following evaluation, continued in a modified form in the Summer Semester 2016. Key features were: Welcome and social integration by faculty welcome-events and student group activities; Orientation on the study program, on teaching infrastructures at the Charité and on student life in Berlin by senior medical students; and Training in language for medical communication and bedside teaching by professional lecturers. Results: Results of evaluations conducted after the orientation weeks, at the end of the semester and retrospectively in the 3rd semester produced high approval ratings of the individual features of the ChOIS-programme and of the programme as a whole by participating students. Discussion: A comprehensive, integrated support programme for new international students of medicine has been developed and implemented. The ChOIS-programme can serve as a practice model to guide other medical faculties. In future, a programme that goes beyond the start of the course and includes more involvement by senior students would be desirable.

Borderline grades in high stakes clinical examinations: resolving examiner uncertainty

BACKGROUND

Objective Structured Clinical Exams are used to increase reliability and validity, yet they only achieve a modest level of reliability. This low reliability is due in part to examiner variance which is greater than the variance of students. This variance often represents indecisiveness at the cut score with apparent confusion over terms such as "borderline pass". It is amplified by a well reported failure to fail.

METHODS

A borderline grade (meaning performance is neither a clear pass nor a clear fail) was introduced in a high stakes undergraduate medical clinical skills exam to replace a borderline pass grade (which was historically resolved as 50%) in a 4 point scale (distinction, pass, borderline, fail). Each Borderline grade was then resolved into a Pass or Fail grade by a formula referencing the difficulty of the station and the performance in the same domain by the student in other stations. Raw pass or fail grades were unaltered. Mean scores and 95%CI were calculated per station and per domain for the unmodified and the modified scores/grades (results are presented on error bars). To estimate the defensibility of these modifications, similar analysis took place for the P and the F grades which resulted from the modification of the B grades.

RESULTS

Of 14,634 observations 4.69% were Borderline. Application of the formula did not impact the mean scores in each domain but the failure rate for the exam increased from 0.7 to 4.1%. Examiners and students expressed satisfaction with the Borderline grade, resolution formula and outcomes. Mean scores (by stations and by domains respectively) of students whose B grades were modified to P were significantly higher than their counterparts whose B grades were modified to F.

CONCLUSIONS

This study provides a feasible and defensible resolution to situations where the examinee's performance is neither a clear pass nor a clear fail, demonstrating the application of the resolution of borderline formula in a high stakes exam. It does not create a new performance standard but utilises real data to make judgements about these small number of candidates. This is perceived as a fair approach to Pass/Fail decisions.

Passing MRCP (UK) PACES: a cross-sectional study examining the performance of doctors by sex and country

BACKGROUND

There is much discussion about the sex differences that exist in medical education. Research from the United Kingdom (UK) and United States has found female doctors earn less, and are less likely to be senior authors on academic papers, but female doctors are also less likely to be sanctioned, and have been found to perform better academically and clinically. It is also known that international medical graduates tend to perform more poorly academically compared to home-trained graduates in the UK, US, and Canada. It is uncertain whether the magnitude and direction of sex differences in doctors' performance is variable by country. We explored the association between doctors' sex and their performance at a large international high-stakes clinical examination: the Membership of the Royal Colleges of Physicians (UK) Practical Assessment of Clinical Examination Skills (PACES). We examined how sex differences varied by the country in which the doctor received their primary medical qualification, the country in which they took the PACES examination, and by the country in which they are registered to practise.

METHODS

Seven thousand six hundred seventy-one doctors attempted PACES between October 2010 and May 2013. We analysed sex differences in first time pass rates, controlling for ethnicity, in three groups: (i) UK medical graduates (N = 3574); (ii) non-UK medical graduates registered with the UK medical regulator, the General Medical Council (GMC), and thus likely to be working in the UK (N = 1067); and (iii) non-UK medical graduates without GMC registration and so legally unable to work or train in the UK (N = 2179).

RESULTS

Female doctors were statistically significantly more likely to pass at their first attempt in all three groups, with the greatest sex effect seen in non-UK medical graduates without GMC registration (OR = 1.99; 95% CI = 1.65-2.39; P < 0.0001) and the smallest in the UK graduates (OR = 1.18; 95% CI = 1.03-1.35; P = 0.02).

CONCLUSIONS

As found in a previous format of this examination and in other clinical examinations, female doctors outperformed male doctors. Further work is required to explore why sex differences were greater in non-UK graduates, especially those without GMC registration, and to consider how examination performance may relate to performance in practice.

Enhancing the defensibility of examiners' marks in high stake OSCEs

BACKGROUND

Most assessments in health professions education consist of knowledge-based examinations as well as practical and clinical examinations. Among the most challenging aspects of clinical assessments is decision making related to borderline grades assigned by examiners. Borderline grades are commonly used by examiners when they do not have sufficient information to make clear pass/fail decisions. The interpretation of these borderline grades is rarely discussed in the literature. This study reports the application of the Objective Borderline Method (version 2, henceforth: OBM2) to a high stakes Objective Structured Clinical Examination undertaken at the end of the final year of a Medicine program in Australia.

METHODS

The OBM2 uses all examination data to reclassify borderline grades as either pass or fail. Factor analysis was used to estimate the suitability of data for application of OBM2. Student's t-tests, utilising bootstrapping, were used to compare the OBM2 with 'traditional' results. Interclass correlations were used to estimate the association between the grade reclassification and all other grades in this examination.

RESULTS

The correlations between scores for each station and pass/fail outcomes increased significantly after the mark reclassification, yet the reclassification did not significantly impact on students' total scores. Examiners, students and program leaders expressed high levels of satisfaction and the Faculty's Curriculum Development Committee has decided that the OBM2 will be used for all future clinical examinations. Implications of the OBM2 are discussed.

CONCLUSIONS

The OBM2 provides a feasible, defensible and acceptable solution for classification of borderline grades as either pass or fail.

Interactive peer-guided examination preparation course for second-year international full-time medical students: quantitative and qualitative evaluation

Background: It has been documented that international students face diverse challenges due to language and cultural barriers. International medical students suffer from personal distress, a lack of support and perform poorer than local fellow-students in clinical examinations. It has been documented that international medical students benefit from peer-led tutorials in their first year. We investigated the effectiveness of a tutorial offered for international medical students in their second year. Methods: A peer-guided examination preparation course with interactive elements for second year international medical students was designed, learning objectives were defined. Two evaluations were undertaken: In a quantitative assessment, students were asked to fill out five multiple-choice-questions at the beginning of every session of the tutorial (pre-test) as well as to participate in a post-test at the end of the semester in which all former multiple-choice-questions were re-used. Using a qualitative approach, participants were asked for their thoughts and comments in a semi-structured interview at the end of the semester. Results: International students (N=12) showed significantly better results in the post- than in the pre-test (t(11)=-8.48, p<.001, d=1.95). Within the interviews, international students (N=10) reported to have benefited from technical and didactic, as well as social learning experiences. The individual lectures students were asked to contribute were discussed controversially. Conclusion: Our peer-guided tutorial for second year international medical students is an effective and well accepted possibility to prepare these students for examinations.

Individual student characteristics and attainment in pre registration physiotherapy: a retrospective multi site cohort study

INTRODUCTION

Worldwide there is a desire to diversify the physiotherapy workforce. However, limited research indicates that some student characteristics linked to under-representation in pre registration physiotherapy education have lower attainment and greater attrition. This study explored the relationship between individual characteristics and success of students in pre registration physiotherapy education within South East England.

DESIGN

A retrospective multi site cohort study including pre registration physiotherapy programmes in the South East of England. Anonymised data included background information (age, gender, ethnicity, socio-economic status) and outcomes (assessment marks, type of award and classification of degree). Analysis involved Bayesian regression models and ordinal logistic regression to examine the association of student characteristics on outcomes.

RESULTS

Data from 1851 student records were collected from four institutions. There were significantly lower assessment scores for Asian (-11% 95% CI: -13.1 to -9.2), Black (-7%, 95% CI: -9.7 to -4.5) and Other/Mixed ethnicity groups (-5%, 95% CI: -7.1 to -2.4), most notable in clinical and observed assessments, compared to their White British colleagues. All BME groups also demonstrated worse odds for a one step lower overall award or no award (Black OR: 3.35, Asian OR: 3.97, Other OR: 2.03). Associations of learning disability, age and non-traditional entry routes with assessment scores and/or degree classification were also noted.

CONCLUSION

These findings suggest significant attainment gaps in pre registration physiotherapy education in this specific geographical region, particularly for non-White ethnic and disability groups. The association with assessment type challenges educators to look beyond a purely student deficit model to explore all factors that may lead to inequality.

A randomised trial of the influence of racial stereotype bias on examiners' scores, feedback and recollections in undergraduate clinical exams

BACKGROUND

Asian medical students and doctors receive lower scores on average than their white counterparts in examinations in the UK and internationally (a phenomenon known as "differential attainment"). This could be due to examiner bias or to social, psychological or cultural influences on learning or performance. We investigated whether students' scores or feedback show influence of ethnicity-related bias; whether examiners unconsciously bring to mind (activate) stereotypes when judging Asian students' performance; whether activation depends on the stereotypicality of students' performances; and whether stereotypes influence examiner memories of performances.

METHODS

This is a randomised, double-blinded, controlled, Internet-based trial. We created near-identical videos of medical student performances on a simulated Objective Structured Clinical Exam using British Asian and white British actors. Examiners were randomly assigned to watch performances from white and Asian students that were either consistent or inconsistent with a previously described stereotype of Asian students' performance. We compared the two examiner groups in terms of the following: the scores and feedback they gave white and Asian students; how much the Asian stereotype was activated in their minds (response times to Asian-stereotypical vs neutral words in a lexical decision task); and whether the stereotype influenced memories of student performances (recognition rates for real vs invented stereotype-consistent vs stereotype-inconsistent phrases from one of the videos).

RESULTS

Examiners responded to Asian-stereotypical words (716 ms, 95% confidence interval (CI) 702-731 ms) faster than neutral words (769 ms, 95% CI 753-786 ms, p < 0.001), suggesting Asian stereotypes were activated (or at least active) in examiners' minds. This occurred regardless of whether examiners observed stereotype-consistent or stereotype-inconsistent performances. Despite this stereotype activation, student ethnicity had no influence on examiners' scores; on the feedback examiners gave; or on examiners' memories for one performance.

CONCLUSIONS

Examiner bias does not appear to explain the differential attainment of Asian students in UK medical schools. Efforts to ensure equality should focus on social, psychological and cultural factors that may disadvantage learning or performance in Asian and other minority ethnic students.

Communication skills of medical students during the OSCE: Gender-specific differences in a longitudinal trend study

BACKGROUND

Communication skills are essential in a patient-centred health service and therefore in medical teaching. Although significant differences in communication behaviour of male and female students are known, gender differences in the performance of students are still under-reported. The aim of this study was to analyse gender differences in communication skills of medical students in the context of an OSCE exam (OSCE = Objective Structured Clinical Examination).

METHODS

In a longitudinal trend study based on seven semester-cohorts, it was analysed if there are gender differences in medical students' communication skills. The students (self-perception) and standardized patients (SP) (external perception) were asked to rate the communication skills using uniform questionnaires. Statistical analysis was performed by using frequency analyses and t-tests in SPSS 21.

RESULTS

Across all ratings in the self- and the external perception, there was a significant gender difference in favour of female students performing better in the dimensions of empathy, structure, verbal expression and non-verbal expression. The results of male students deteriorated across all dimensions in the external perception between 2011 and 2014.

DISCUSSION & CONCLUSION

It is important to consider if gender-specific teaching should be developed, considering the reported differences between female and male students.

Ethnic and social disparities in different types of examinations in undergraduate pre-clinical training

Medical schools are increasingly faced with a more diverse student population. Generally, ethnic minority students are reported to underperform compared with those from the ethnic majority. However, there are inconsistencies in findings in different types of examinations. Additionally, little is known about the performance of first-generation university students and about performance differences across ethnic minority groups. This study aimed to investigate underperformance across ethnic minority groups and by first-generation university students in different types of written tests and clinical skills examinations during pre-clinical training. A longitudinal prospective cohort study of progress on a 3-year Dutch Bachelor of Medicine course was conducted. Participants included 2432 students who entered the course over a consecutive 6-year period (2008-2013). Compared with Dutch students, the three non-Western ethnic minority groups (Turkish/Moroccan/African, Surinamese/Antillean and Asian) underperformed in the clinical problem solving tests, the language test and the OSCEs. Findings on the theoretical end-of-block tests and writing skills tests, and results for Western minority students were less consistent. Age, gender, pre-university grade point average and additional socio-demographic variables (including first-generation university student, first language, and medical doctor parent) could explain the ethnicity-related differences in theoretical examinations, but not in language, clinical and writing skills examinations. First-generation university students only underperformed in the language test. Apparently, underperformance differs both across ethnic subgroups and between different types of written and clinical examinations. Medical schools should ensure their assessment strategies create a level playing field for all students and explore reasons for underperformance in the clinical and writing skills examinations.

Voluntary peer-led exam preparation course for international first year students: Tutees' perceptions

BACKGROUND

While the number of international students has increased over the last decade, such students face diverse challenges due to language and cultural barriers. International medical students suffer from personal distress and a lack of support. Their performance is significantly lower than non-international peers in clinical examinations. We investigated whether international students benefit from a peer-led exam preparation course.

METHODS

An exam preparation course was designed, and relevant learning objectives were defined. Two evaluations were undertaken: Using a qualitative approach, tutees (N = 10) were asked for their thoughts and comments in a semi-structured interview at the end of the semester. From a quantitative perspective, all participants (N = 22) were asked to complete questionnaires at the end of each course session.

RESULTS

International students reported a range of significant benefits from the course as they prepared for upcoming exams. They benefited from technical and didactic, as well as social learning experiences. They also considered aspects of the tutorial's framework helpful.

CONCLUSION

Social and cognitive congruence seem to be the key factors to success within international medical students' education. If tutors have a migration background, they can operate as authentic role models. Furthermore, because they are still students themselves, they can offer support using relevant and understandable language.

The effect of English proficiency and ethnicity on academic performance and progress

Non-local ethnicity or nationality and lower English proficiency have been linked with poor performance in health professional education. This study sought to compare the relative contributions of ethnicity and English proficiency, and to do so in a context where students had not been selected via interviews or some other proxy for language proficiency. Ethnicity, citizenship, and demographic data, as well as academic performance and progress were obtained for three successive cohorts (entering in 2007, 2008 and 2009) into a three-year pharmacy programme, following a common first-year. Complete data was available for all 297 students entering via this path. By the end of the programme, controlling for grades at entry, students from some non-local ethnic backgrounds (p < .001) underperformed local students, as did males (p < .001) and those who had been identified as having low English proficiency in year 1 (p < .01). Males (p < .01) and one non-local ethnic group (p < .01) were also more likely to have to repeat a year of study. Ethnicity was a stronger predictor than English proficiency or acculturation, but English proficiency was still independently and additively predictive. This suggests that targeted support strategies for students with lower English language proficiency are still important, but that cultural differences should not be underestimated.

International medical students--a survey of perceived challenges and established support services at medical faculties

INTRODUCTION

Medical students with a non-German background face several challenges during their studies. Besides support given by foreign student offices further specific projects for international students have been developed and are offered by medical faculties. However, so far, neither a systematic survey of the faculties' perceived problems nor of the offered support exists.

METHOD

All study deaneries of medical faculties in Germany were contacted between April and October 2013 and asked for their participation in a telephone interview. Interview partners were asked about 1.) The percentage of non-German students at the medical faculty; 2.) The perceived difficulties and problems of foreign students; 3.) The offers for non-German students; and 4.) The specification of further possibilities of support. Given information was noted, frequencies counted and results interpreted via frequency analysis.

RESULTS

Only 39% of the medical faculties could give detailed information about the percentage of non-German students. They reported an average share of 3.9% of students with an EU migration background and 4.9% with a non-EU background. Most frequently cited offers are student conducted tutorials, language courses and tandem-programs. The most frequently reported problem by far is the perceived lack of language skills of foreign students at the beginning of their studies. Suggested solutions are mainly the development of tutorials and the improvement of German medical terminology.

DISCUSSION

Offers of support provided by medical faculties for foreign students vary greatly in type and extent. Support offered is seen to be insufficient in coping with the needs of the international students in many cases. Hence, a better coverage of international students as well as further research efforts to the specific needs and the effectiveness of applied interventions seem to be essential.

Examination performances of German and international medical students in the preclinical studying-term--a descriptive study

INTRODUCTION

Medical students with a migration background face several specific problems during their studies. International surveys show first indications that this group of students performs worse in written, oral or practical exams. However, so far, nothing is known about the performance of international students in written pre-clinical tests as well as in pre-clinical State Examinations for German-speaking countries.

METHOD

A descriptive, retrospective analysis of the exam performances of medical students in the pre-clinical part of their studies was conducted at the Faculty of Medicine of Heidelberg in for the year 2012. Performance in written tests of the final exams in the second (N=276), third (N=292) and fourth semester (N=285) were compared between German students, students from EU countries and students from non-EU countries. Same comparison was drawn for the performance in the oral exam of the First State Examination in the period from 2009 - 2012 (N=1137).

RESULTS

German students performed significantly better than students with a non-EU migration background both in all written exams and in the oral State Examination (all p<.05). The performance of students with an EU migration background was significantly better than that of students with a non-EU background in the written exam at the end of the third and fourth semester (p<.05). Furthermore, German students completed the oral exam of the First State Examination significantly earlier than students with a non-EU migration background (<.01).

DISCUSSION

Due to its poorer performance in written and oral examinations and its simultaneously longer duration of study, the group of non-German medical students with a country of origin outside of the European Union has to be seen as a high-risk group among students with a migration background. For this group, there is an urgent need for early support to prepare for written and oral examinations.

The Academic Backbone: longitudinal continuities in educational achievement from secondary school and medical school to MRCP(UK) and the specialist register in UK medical students and doctors

BACKGROUND

Selection of medical students in the UK is still largely based on prior academic achievement, although doubts have been expressed as to whether performance in earlier life is predictive of outcomes later in medical school or post-graduate education. This study analyses data from five longitudinal studies of UK medical students and doctors from the early 1970s until the early 2000s. Two of the studies used the AH5, a group test of general intelligence (that is, intellectual aptitude). Sex and ethnic differences were also analyzed in light of the changing demographics of medical students over the past decades.

METHODS

Data from five cohort studies were available: the Westminster Study (began clinical studies from 1975 to 1982), the 1980, 1985, and 1990 cohort studies (entered medical school in 1981, 1986, and 1991), and the University College London Medical School (UCLMS) Cohort Study (entered clinical studies in 2005 and 2006). Different studies had different outcome measures, but most had performance on basic medical sciences and clinical examinations at medical school, performance in Membership of the Royal Colleges of Physicians (MRCP(UK)) examinations, and being on the General Medical Council Specialist Register.

RESULTS

Correlation matrices and path analyses are presented. There were robust correlations across different years at medical school, and medical school performance also predicted MRCP(UK) performance and being on the GMC Specialist Register. A-levels correlated somewhat less with undergraduate and post-graduate performance, but there was restriction of range in entrants. General Certificate of Secondary Education (GCSE)/O-level results also predicted undergraduate and post-graduate outcomes, but less so than did A-level results, but there may be incremental validity for clinical and post-graduate performance. The AH5 had some significant correlations with outcome, but they were inconsistent. Sex and ethnicity also had predictive effects on measures of educational attainment, undergraduate, and post-graduate performance. Women performed better in assessments but were less likely to be on the Specialist Register. Non-white participants generally underperformed in undergraduate and post-graduate assessments, but were equally likely to be on the Specialist Register. There was a suggestion of smaller ethnicity effects in earlier studies.

CONCLUSIONS

The existence of the Academic Backbone concept is strongly supported, with attainment at secondary school predicting performance in undergraduate and post-graduate medical assessments, and the effects spanning many years. The Academic Backbone is conceptualized in terms of the development of more sophisticated underlying structures of knowledge ('cognitive capital' and 'medical capital'). The Academic Backbone provides strong support for using measures of educational attainment, particularly A-levels, in student selection.

Gender, ethnicity and graduate status, and junior doctors' self-reported preparedness for clinical practice: national questionnaire surveys

OBJECTIVES

Medical schools need to ensure that graduates feel well prepared for their first medical job. Our objective was to report on differences in junior doctors' self-reported preparedness for work according to gender, ethnicity and graduate status.

DESIGN

Postal and electronic questionnaires.

SETTING

UK.

PARTICIPANTS

Medical graduates of 2008 and 2009, from all UK medical schools, one year after graduation.

MAIN OUTCOME MEASURES

The main outcome measure was the doctors' level of agreement with the statement that 'My experience at medical school prepared me well for the jobs I have undertaken so far', to which respondents were asked to reply on a scale from 'strongly agree' to 'strongly disagree'.

RESULTS

Women were slightly less likely than men to agree that they felt well prepared for work (50% of women agreed or strongly agreed vs. 54% of men), independently of medical school, ethnicity, graduate entry status and intercalated degree status, although they were no more likely than men to regard lack of preparedness as having been a problem for them. Adjusting for the other subgroup differences, non-white respondents were less likely to report feeling well prepared than white (44% vs. 54%), and were more likely to indicate that lack of preparedness was a problem (30% non-white vs. 24% white). There were also some gender and ethnic differences in preparedness for specific areas of work.

CONCLUSIONS

The identified gender and ethnic differences need to be further explored to determine whether they are due to differences in self-confidence or in actual preparedness.

'You're certainly relatively competent': assessor bias due to recent experiences

CONTEXT

A recent study has suggested that assessors judge performance comparatively rather than against fixed standards. Ratings assigned to borderline trainees were found to be biased by previously seen candidates' performances. We extended that programme of investigation by examining these effects across a range of performance levels. Furthermore, we investigated whether confidence in the rating assigned predicts susceptibility to manipulation and whether prompting consideration of typical performance lessens the influence of recent experience.

METHODS

Consultant doctors were randomised to groups within an internet experiment. The descending performance group judged videos of Foundation Year 1 (F1; postgraduate Year 1) doctors in descending order of proficiency; the ascending performance group judged the same videos in ascending order. For all videos, participants rated: (i) trainee competence; (ii) rater confidence and (iii) percentage better (the percentage of other F1 doctors who would perform better on the same task).

RESULTS

Overall, the descending performance group assigned lower scores than the ascending performance group (2.97 [95% confidence interval 2.73-3.20] versus 3.50 [95% confidence interval 3.25-3.74]; F(1,47) = 9.80, p = 0.003, d = 0.52). Pairwise comparisons showed differences were significant for good and borderline performances. The percentage better ratings showed a similar pattern (descending performance mean = 57.4 [95% confidence interval 52.5-62.3], ascending performance mean = 43.4 [95% confidence interval 38.4-48.5]; F(1, 46) = 16.0, p < 0.001, d = 0.67). Confidence ratings did not vary by level of performance and showed no relationship with the effect of group.

DISCUSSION

Assessors' judgements showed contrast effects at both good and borderline performance levels. Findings suggest that assessors use normative rather than criterion-referenced decision making while judging, and that the norms referenced are weakly represented in memory and easily influenced. Confidence ratings suggested a lack of insight into this phenomenon. Raters' judgements could be importantly influenced in ways that are unfair to candidates.

Seeing the same thing differently: mechanisms that contribute to assessor differences in directly-observed performance assessments

Assessors' scores in performance assessments are known to be highly variable. Attempted improvements through training or rating format have achieved minimal gains. The mechanisms that contribute to variability in assessors' scoring remain unclear. This study investigated these mechanisms. We used a qualitative approach to study assessors' judgements whilst they observed common simulated videoed performances of junior doctors obtaining clinical histories. Assessors commented concurrently and retrospectively on performances, provided scores and follow-up interviews. Data were analysed using principles of grounded theory. We developed three themes that help to explain how variability arises: Differential Salience-assessors paid attention to (or valued) different aspects of the performances to different degrees; Criterion Uncertainty-assessors' criteria were differently constructed, uncertain, and were influenced by recent exemplars; Information Integration-assessors described the valence of their comments in their own unique narrative terms, usually forming global impressions. Our results (whilst not precluding the operation of established biases) describe mechanisms by which assessors' judgements become meaningfully-different or unique. Our results have theoretical relevance to understanding the formative educational messages that performance assessments provide. They give insight relevant to assessor training, assessors' ability to be observationally "objective" and to the educational value of narrative comments (in contrast to numerical ratings).

Poorer verbal working memory for a second language selectively impacts academic achievement in university medical students

Working memory (WM) is often poorer for a second language (L2). In low noise conditions, people listening to a language other than their first language (L1) may have similar auditory perception skills for that L2 as native listeners, but do worse in high noise conditions, and this has been attributed to the poorer WM for L2. Given that WM is critical for academic success in children and young adults, these speech in noise effects have implications for academic performance where the language of instruction is L2 for a student. We used a well-established Speech-in-Noise task as a verbal WM (vWM) test, and developed a model correlating vWM and measures of English proficiency and/or usage to scholastic outcomes in a multi-faceted assessment medical education program. Significant differences in Speech-Noise Ratio (SNR₅₀) values were observed between medical undergraduates who had learned English before or after five years of age, with the latter group doing worse in the ability to extract whole connected speech in the presence of background multi-talker babble (Student-t tests, p < 0.001). Significant negative correlations were observed between the SNR₅₀ and seven of the nine variables of English usage, learning styles, stress, and musical abilities in a questionnaire administered to the students previously. The remaining two variables, Perceived Stress Scale (PSS) and the Age of Acquisition of English (AoAoE) were significantly positively correlated with the SNR₅₀, showing that those with a poorer capacity to discriminate simple English sentences from noise had learnt English later in life and had higher levels of stress – all characteristics of the international students. Local students exhibited significantly lower SNR₅₀ scores and were significantly younger when they first learnt English. No significant correlation was detected between the SNR₅₀ and the students’ Visual/Verbal Learning Style (r = −0.023). Standard multiple regression was carried out to assess the relationship between language proficiency and verbal working memory (SNR₅₀) using 5 variables of L2 proficiency, with the results showing that the variance in SNR₅₀ was significantly predicted by this model (r² = 0.335). Hierarchical multiple regression was then used to test the ability of three independent variable measures (SNR₅₀, age of acquisition of English and English proficiency) to predict academic performance as the dependent variable in a factor analysis model which predicted significant performance differences in an assessment requiring communications skills (p = 0.008), but not on a companion assessment requiring knowledge of procedural skills, or other assessments requiring factual knowledge. Thus, impaired vWM for an L2 appears to affect specific communications-based assessments in university medical students.

Ethnic disparities in undergraduate pre-clinical and clinical performance

CONTEXT

Research from numerous medical schools has shown that students from ethnic minorities underperform compared with those from the ethnic majority. However, little is known about why this underperformance occurs and whether there are performance differences among ethnic minority groups.

OBJECTIVES

This study aimed to investigate underperformance across ethnic minority groups in undergraduate pre-clinical and clinical training.

METHODS

A longitudinal prospective cohort study of progress on a 6-year undergraduate medical course was conducted in a Dutch medical school. Participants included 1661 Dutch and 696 non-Dutch students who entered the course over a consecutive 6-year period (2002-2007). Main outcome measures were performance in Year 1 and in the pre-clinical and clinical courses. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated by logistic regression analysis for ethnic subgroups (Surinamese/Antillean, Turkish/Moroccan/African, Asian, Western) compared with Dutch students, adjusted for age, gender, pre-university grade point average (pu-GPA), additional socio-demographic variables (first-generation immigrant, urban background, first-generation university student, first language, medical doctor as parent) and previous performance at medical school.

RESULTS

Compared with Dutch students, Surinamese and Antillean students specifically underperformed in the Year 1 course (pass rate: 37% versus 64%; adjusted OR 0.40, 95% CI 0.27-0.60) and the pre-clinical course (pass rate: 19% versus 41%; adjusted OR 0.57, 95% CI 0.35-0.93). On the clinical course all non-Dutch subgroups were less likely than Dutch students to receive a grade of ≥ 8.0 (at least three of five grades: 54-77% versus 88%; adjusted ORs: 0.17-0.45).

CONCLUSIONS

Strong ethnic disparities exist in medical school performance even after adjusting for age, gender, pu-GPA and socio-demographic variables. More subjective grading cannot be ruled out as a cause of lower grades in clinical training, but other possible explanations should be studied further to mitigate the disparities.

Clinical assessment performance of graduate- and undergraduate-entry medical students

BACKGROUND

Recent evidence suggests that graduate-entry medical students may have a marginal academic performance advantage over undergraduate entrants in a pre-clinical curriculum in both bioscience knowledge and clinical skills assessments. It is unclear whether this advantage is maintained in the clinical phase of medical training.

AIM

The study aimed to compare graduate and undergraduate entrants undertaking an identical clinical curriculum on assessments undertaken during clinical training in the medical course.

METHODS

Clinical assessment results for four cohorts of medical students (n = 713) were compared at the beginning and at the end of clinical training for graduate and undergraduate entrants.

RESULTS

Results showed that graduate- and undergraduate-entry medical students performed similarly on clinical assessments. Female students performed consistently better than male students.

CONCLUSION

The findings of this study suggest that any academic performance advantage held by graduate-entry medical students is limited to the early years of the medical course, and is not evident during clinical training in the later years of the course.

Ethnicity and academic performance in UK trained doctors and medical students: systematic review and meta-analysis

OBJECTIVE

To determine whether the ethnicity of UK trained doctors and medical students is related to their academic performance.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Online databases PubMed, Scopus, and ERIC; Google and Google Scholar; personal knowledge; backwards and forwards citations; specific searches of medical education journals and medical education conference abstracts.

STUDY SELECTION

The included quantitative reports measured the performance of medical students or UK trained doctors from different ethnic groups in undergraduate or postgraduate assessments. Exclusions were non-UK assessments, only non-UK trained candidates, only self reported assessment data, only dropouts or another non-academic variable, obvious sampling bias, or insufficient details of ethnicity or outcomes. Results 23 reports comparing the academic performance of medical students and doctors from different ethnic groups were included. Meta-analyses of effects from 22 reports (n = 23,742) indicated candidates of "non-white" ethnicity underperformed compared with white candidates (Cohen's d = -0.42, 95% confidence interval -0.50 to -0.34; P<0.001). Effects in the same direction and of similar magnitude were found in meta-analyses of undergraduate assessments only, postgraduate assessments only, machine marked written assessments only, practical clinical assessments only, assessments with pass/fail outcomes only, assessments with continuous outcomes only, and in a meta-analysis of white v Asian candidates only. Heterogeneity was present in all meta-analyses.

CONCLUSION

Ethnic differences in academic performance are widespread across different medical schools, different types of exam, and in undergraduates and postgraduates. They have persisted for many years and cannot be dismissed as atypical or local problems. We need to recognise this as an issue that probably affects all of UK medical and higher education. More detailed information to track the problem as well as further research into its causes is required. Such actions are necessary to ensure a fair and just method of training and of assessing current and future doctors.

Evidence for increasing diversity in graduate medical education: the competence of underrepresented minority residents measured by an intern objective structured clinical examination

OBJECTIVE

Some have commented that the limited number of underrepresented minorities (URMs) in United States' residency programs is due to a lack of qualified candidates. At the University of Michigan, an objective structured clinical examination is administered to incoming residents at the beginning of training to determine baseline competence. In this study we wanted to determine if competence differed for underrepresented minorities when compared to non-URM residents.

METHOD

The postgraduate orientation assessment, a 10-station examination, was developed that focused specifically on the knowledge and skills needed in the first 6 to 18 weeks of training. Stations assessed competence in informed consent, aseptic technique, evidence-based medicine, diagnostic images, critical laboratory values, cross-cultural communication, and Joint Commission requirements such as surgical fire safety, pain assessment, and management. We used various assessment measures including standardized patients, computer-based testing, and multiple-choice questions.

RESULTS

Our study found no significant differences in overall mean scores between URM residents and all other residents for the 5 years during which we administered the examination, except for 2002. This stands in contrast to the consistently worse performances of URM students on USMLE Step 1 and Step 2 Clinical Knowledge. Also, URM residents did not perform better or worse than their non-URM colleagues on standardized patient stations during the course of 5 years during which the examination was administered.

CONCLUSIONS

The postgraduate orientation assessment provides residency program directors with a standard format to measure initial clinical skills. When compared to incoming non-URM residents from a variety of medical schools, URM residents perform as well as other trainees. Our results may aid in the recruitment efforts of URM medical students into academic residency programs such as those at the University of Michigan.

The influence of language family on academic performance in Year 1 and 2 MBBS students

OBJECTIVES

Generally, in most countries around the world, local medical students outperform, in an academic sense, international students. In an endeavour to understand if this effect is caused by language proficiency skills, we investigated academic differences between local and international MBBS students categorised by native language families.

METHODS

Data were available and obtained for medical students in their first and second years of study in 2002, 2003, 2005 and 2006. Information on social demographics, personal history and language(s) spoken at home was collected, as well as academic assessment results for each student. Statistical analysis was carried out with a dataset pertaining to a total of 872 students.

RESULTS

Local students performed better than international students in first- (p < 0.001) as well as second-year (p < 0.001) assessments. In addition, there was a main interaction effect between language family and origin in the first year (p < 0.05). For international students only, there was a main effect for language in the second year (p < 0.05), with students from Sino-Tibetan language family backgrounds obtaining higher mean scores than students from English or Indo-European language family backgrounds.

CONCLUSIONS

Our results confirmed that, overall, local students perform better academically than international students. However, given that language family differences exist, this may reflect acculturation rather than simply English language skills.

Stereotype threat and health disparities: what medical educators and future physicians need to know

Patients' experience of stereotype threat in clinical settings and encounters may be one contributor to health care disparities. Stereotype threat occurs when cues in the environment make negative stereotypes associated with an individual's group status salient, triggering physiological and psychological processes that have detrimental consequences for behavior. By recognizing and understanding the factors that can trigger stereotype threat and understanding its consequences in medical settings, providers can prevent it from occurring or ameliorate its consequences for patient behavior and outcomes. In this paper, we discuss the implications of stereotype threat for medical education and trainee performance and offer practical suggestions for how future providers might reduce stereotype threat in their exam rooms and clinics.

Are multiple choice tests fair to medical students with specific learning disabilities?

The purpose of multiple choice tests of medical knowledge is to estimate as accurately as possible a candidate's level of knowledge. However, concern is sometimes expressed that multiple choice tests may also discriminate in undesirable and irrelevant ways, such as between minority ethnic groups or by sex of candidates. There is little literature to establish whether multiple choice tests may also discriminate against students with specific learning disabilities (SLDs), in particular those with a diagnosis of dyslexia, and whether the commonly-used accommodations allow such students to perform up to their capability. We looked for evidence to help us determine whether multiple choice tests could be relied upon to test all medical students fairly, regardless of disability. We analyzed the mean scores of over 900 undergraduate medical students on eight multiple-choice progress tests containing 1,000 items using a repeated-measures analysis of variance. We included disability, gender and ethnicity as possible explanatory factors, as well as year group. There was no significant difference between mean scores of students with an SLD who had test accommodations and students with no SLD and no test accommodation. Virtually all students were able to complete the tests within the allowed time. There were no significant differences between the mean scores of known minority ethnic groups or between the genders. We conclude that properly-designed multiple-choice tests of medical knowledge do not systematically discriminate against medical students with specific learning disabilities.

The effect of a brief social intervention on the examination results of UK medical students: a cluster randomised controlled trial

BACKGROUND

Ethnic minority (EM) medical students and doctors underperform academically, but little evidence exists on how to ameliorate the problem. Psychologists Cohen et al. recently demonstrated that a written self-affirmation intervention substantially improved EM adolescents' school grades several months later. Cohen et al.'s methods were replicated in the different setting of UK undergraduate medical education.

METHODS

All 348 Year 3 white (W) and EM students at one UK medical school were randomly allocated to an intervention condition (writing about one's own values) or a control condition (writing about another's values), via their tutor group. Students and assessors were blind to the existence of the study. Group comparisons on post-intervention written and OSCE (clinical) assessment scores adjusted for baseline written assessment scores were made using two-way analysis of covariance. All assessment scores were transformed to z-scores (mean = 0 standard deviation = 1) for ease of comparison. Comparisons between types of words used in essays were calculated using t-tests. The study was covered by University Ethics Committee guidelines.

RESULTS

Groups were statistically identical at baseline on demographic and psychological factors, and analysis was by intention to treat [intervention group EM n = 95, W n = 79; control group EM n = 77; W n = 84]. As predicted, there was a significant ethnicity by intervention interaction [F(4,334) = 5.74; p = 0.017] on the written assessment. Unexpectedly, this was due to decreased scores in the W intervention group [mean difference = 0.283; (95% CI = 0.093 to 0.474] not improved EM intervention group scores [mean difference = -0.060 (95% CI = -0.268 to 0.148)]. On the OSCE, both W and EM intervention groups outperformed controls [mean difference = 0.261; (95%CI = -0.047 to -0.476; p = 0.013)]. The intervention group used more optimistic words (p < 0.001) and more "I" and "self" pronouns in their essays (p < 0.001), whereas the control group used more "other" pronouns (p < 0.001) and more negations (p < 0.001).

DISCUSSION

Cohen et al.'s finding that a brief self-affirmation task narrowed the ethnic academic achievement gap was replicated on the written assessment but against expectations, this was due to reduced performance in the W group. On the OSCE, the intervention improved performance in both W and EM groups. In the intervention condition, participants tended to write about themselves and used more optimistic words than in the control group, indicating the task was completed as requested. The study shows that minimal interventions can have substantial educational outcomes several months later, which has implications for the multitude of seemingly trivial changes in teaching that are made on an everyday basis, whose consequences are never formally assessed.

Ethnic stereotypes and the underachievement of UK medical students from ethnic minorities: qualitative study

OBJECTIVE

To explore ethnic stereotypes of UK medical students in the context of academic underachievement of medical students from ethnic minorities.

DESIGN

Qualitative study using semistructured one to one interviews and focus groups.

SETTING

A London medical school.

PARTICIPANTS

27 year 3 medical students and 25 clinical teachers, purposively sampled for ethnicity and sex.

METHODS

Data were analysed using the theory of stereotype threat (a psychological phenomenon thought to negatively affect the performance of people from ethnic minorities in educational contexts) and the constant comparative method.

RESULTS

Participants believed the student-teacher relationship was vital for clinical learning. Teachers had strong perceptions about "good" clinical students (interactive, keen, respectful), and some described being aggressive towards students whom they perceived as quiet, unmotivated, and unwilling. Students had equally strong perceptions about "good" clinical teachers (encouraging, interested, interactive, non-aggressive). Students and teachers had concordant and well developed perceptions of the "typical" Asian clinical medical student who was considered over-reliant on books, poor at communicating with patients, too quiet during clinical teaching sessions, and unmotivated owing to being pushed into studying medicine by ambitious parents. Stereotypes of the "typical" white student were less well developed: autonomous, confident, and outgoing team player. Direct discrimination was not reported.

CONCLUSIONS

Asian clinical medical students may be more likely than white students to be perceived stereotypically and negatively, which may reduce their learning by jeopardising their relationships with teachers. The existence of a negative stereotype about their group also raises the possibility that underperformance of medical students from ethnic minorities may be partly due to stereotype threat. It is recommended that clinical teachers be given opportunities and training to encourage them to get to know their students as individuals and thus foster positive educational relationships with them.