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We commend the authors on the first substantial work in assessing such an issue. However, we believe that important metrics have been overlooked.
This study’s supplementary dataset demonstrates that certain universities, namely Oxford, Cambridge, Imperial College London and University College London, have significantly higher number of graduates entering OST on their first attempt and passing the Fellow of the Royal College of Ophthalmologists (FRCOphth) Part 1 exam than other universities. These universities are known to accept a lower proportion of candidates in lower SEC and Participation Of Local Areas (POLAR) quintiles than average (1).
Those offered a place on OST had significantly higher educational performance measure (EPM) which comprises of points for examination ranking and additional degrees and publications (2) . For a variety of societal or financial reasons, lower SEC students may be less likely to intercalate or pursue medicine as a graduate, reducing their EPM(3).
Further, a potential financial barrier exists of up to £5,078 for additional opportunities to increase portfolio score when applying to OST (4).
Whilst no difference in this paper was found on first application, many gain OST after multiple attempts which bring with it a lack of job security, which could deter lower SEC applicants due to dependants, financial or geographical obligations.
International medical graduates...
International medical graduates (IMGs) comprise over 30% of UK registered doctors(5). Black and minority ethnic (BME) doctors, IMG or UK trained, are less likely than their white counterparts to progress in their careers (6). Differential attainment is shown in university applications, postgraduate examinations results and outcomes of annual review of competence progression. The 2022 RCOphth Differential Attainment paper (7) reported that 70 % of white UK graduates pass their FRCOphth Part 1 first time, compared to 60% of BME UK graduates, 45% white IMGs and 50% BME IMGs, and similarly for EEA graduates. Similar results are reflected by a British Medical Assiciation (BMA) report into ethnic minority doctor barriers across all medical postgraduate exams(8). The authors claim that ethnicity does not influence success in OST whilst omitting doctors with non-UK PMQs which total a significant 24% of candidates sitting the FRCOphth Part 1. This RCOphth report also noted that in 2021, the Black trainee doctor population vs OST applicants and offers holders were 6.4%, 6.2% and 4.5% respectively. Whereas, white offer holders compared to applicants were 35.4% and 25.6% respectively.
Whilst the authors state gender does not influence OST success, of 2021 applicants with recorded gender data, 55% were male and 39% female. However, of successful applicants, 74% were male and 16% female. The ratio of male to female doctors in training generally in the UK that year was 43.6% and 56.4% respectively. These findings demonstrate overrepresentation of men in OST year compared to females both in the application process and compared to the trainee population (7). Ophthalmology is second only to surgery as the speciality with the lowest proportion of female trainees(9).
Such work as done by the authors is important, but we feel the criteria and datasets used risk that creating a false reassurance that bias does not exist. We believe the subsequent publication of the RCOphth Differential Attainment Report does not support the authors’ claims regarding OST recruitment. Though not the methodology of their paper, to truly assess the impact of SEC, gender and ethnicity on career success, progress through the training programme itself, as well as subsequent consultant recruitment should also be investigated. Qualitative impact on trainee’s experiences would also buttress the quantitative data. We must remember that our ophthalmology workforce is much more than UK trained graduates who succeeded at their first attempt.
1. UCAS. 2021 ENTRY UCAS UNDERGRADUATE REPORTS BY SEX, AREA BACKGROUND, AND ETHNIC GROUP [Internet]. 2022 [cited 2023 Feb 24]. Available from: https://www.ucas.com/data-and-analysis/undergraduate-statistics-and-repo...
2. UKFP. Educational Performance Measure (EPM) Framework [Internet]. [cited 2023 Feb 24]. Available from: https://foundationprogramme.nhs.uk/faqs/educational-performance-measure-...
3. Kumwenda B, Cleland J, Prescott G, Walker K, Johnston P. Relationship between sociodemographic factors and specialty destination of UK trainee doctors: a national cohort study. Bmj Open. 2019;9(3):e026961.
4. Nairn J, Ferris J, Lockington D. The hidden financial hurdles of commitment to Ophthalmology in the current UK training system. Eye. 2020;34(5):984–5.
5. Rao M. Welcoming and Valuing International Medical Graduates – A guide to induction for IMGs recruited to the NHS [Internet]. London; 2022 Jun [cited 2023 Feb 26]. Available from: https://www.e-lfh.org.uk/wp-content/uploads/2022/06/Welcoming-and-Valuin...
6. Issar P. NHS workforce Race Equality Standard [Internet]. 2022 Feb [cited 2023 Feb 26]. Available from: https://www.england.nhs.uk/wp-content/uploads/2021/02/Workforce-Race-Equ...
7. RCOphth. Differential Attainment Report [Internet]. London; 2021 [cited 2023 Feb 27]. Available from: https://www.rcophth.ac.uk/wp-content/uploads/2023/01/Differential-Attain...
8. BMA. Summary of key evidence on barriers to and initiatives to support career progression for ethnic minority doctors [Internet]. London; 2022 Jun [cited 2023 Feb 26]. Available from: https://www.bma.org.uk/media/5747/bma-summary-of-key-evidence-report-15-...
9. GMC. The state of medical education and practice in the UK The workforce report 2022. 2022; Available from: https://www.gmc-uk.org/-/media/documents/workforce-report-2022---full-re...
Dear Aditi Das, Daniel Smith and Rashmi Mathew,
Thank you for your interesting and important article exploring predictors of career success in ophthalmology. It is vital that we examine the factors that both enable and hinder career progression in medicine and surgery, as these affect the wellbeing and retention of doctors, arguably two of the biggest issues currently afflicting our profession. In addition, tackling differential attainment in doctors' career success is a matter of ensuring our core values of equality, diversity and inclusion are upheld in healthcare. Resultantly, differential attainment has become a research priority for key stakeholders, including the national bodies of the General Medical Council (GMC), Health Education England, the British Medical Association and the Royal Colleges.
Your article stated that for your study's cohort, there was no association between ethnicity and passing the FRCOphth Part 1 on the first attempt. Conversely, the Royal College of Ophthalmologists (RCOphth) announced that GMC data found a statistically significant variation in the percentage of doctors passing FRCOphth examinations on their first attempt, depending on place of primary medical qualification and ethnicity. White UK graduates had a 72% pass rate, while BAME (Black, Asian or minority ethnic) UK graduates had a 60% pass rate, reducing to 50% for international BAME graduates.(1) These results display one way in which differential attainmen...
Your article stated that for your study's cohort, there was no association between ethnicity and passing the FRCOphth Part 1 on the first attempt. Conversely, the Royal College of Ophthalmologists (RCOphth) announced that GMC data found a statistically significant variation in the percentage of doctors passing FRCOphth examinations on their first attempt, depending on place of primary medical qualification and ethnicity. White UK graduates had a 72% pass rate, while BAME (Black, Asian or minority ethnic) UK graduates had a 60% pass rate, reducing to 50% for international BAME graduates.(1) These results display one way in which differential attainment affects doctors within ophthalmology.
Indeed, differential attainment has been known to exist for over two decades and the body of new evidence continues to grow.(2) There is now a collective agreement among the aforementioned key stakeholders that efforts must concentrate on constructing and executing action plans to effect change.(2-6) RCOphth have responded with the introduction of a reverse mentoring scheme to support both trainees and trainers, in order to reduce the inequalities faced by doctors in training.(1)
In conclusion, the GMC strategy for 2021-2025 includes focusing on doctors’ wellbeing; staff retention; and promoting a more supportive, fair and inclusive environment to improve our workforce and healthcare system.(7) Differential attainment is inextricably linked to all of these factors and is therefore a vital component to address. The focus should now be on piloting and evaluating interventions to tackle differential attainment, as well as sharing subsequent learning so that doctors may benefit across all branches of medicine and surgery.
1. Blizzard R and Arjunan M. RCOphth reverse mentoring scheme with a focus on differential attainment. https://www.rcophth.ac.uk/news-views/rcophth-reverse-mentoring-with-a-fo... [Accessed 23rd September 2022].
2. Chakravorty I, Dave S, Mehta R and Goddard A. Tackling differential attainment in summative assessments: Roundtable report and recommendations. Sushruta Journal of Health Policy & Opinion. 2020;13(3): 1-17. https://doi.org/10.38192/13.3.21 [Accessed 23rd September 2022].
3. BMA. Delivering racial equality in medicine. https://www.bma.org.uk/media/5745/bma-delivering-racial-equality-in-medi... [Accessed 23rd September 2022].
4. Royal College of Surgeons of England. Differential attainment in surgical and dental exams. https://www.rcseng.ac.uk/about-the-rcs/about-our-mission/diversity/diffe... [Accessed 23rd September 2022].
5. BMA. Differential attainment: Making medical training fair for all. https://www.bma.org.uk/media/2850/bma-differential-attainment-report-nov... [Accessed 23rd September 2022].
6. Regan de Bere S, Nunn S and Nasser M. Understanding differential attainment across medical training pathways: A rapid review of the literature. https://www.gmc-uk.org/-/media/documents/GMC_Understanding_Differential_... [Accessed 23rd September 2022].
7. GMC. Our Strategy 2021-2025. https://www.gmc-uk.org/-/media/gmc-site-images/about/how-we-work/corpora... [Accessed 23rd September 2022].