“The key findings in the report highlight the need for the RACP to do better to address the structure, design and delivery of the clinical exam, to address issues of unconscious bias and cultural awareness training, transparency, and support within the examination processes to ensure fairness and equity for all candidates.
“We thank you for the time and courage it took to bring these concerns to the RACP. Once again, we apologise unreservedly for any harm this may have caused you and for the college’s unacceptable delay in responding appropriately to your concerns.”
RACP Aotearoa New Zealand President Dr Hamish McCay said the matters identified were being treated “with the utmost seriousness”.
“We are committed to creating an inclusive and culturally safe environment for our trainees and we will be making the necessary changes to ensure that is the case.”
The findings come after a letter of protest from a group of more than 30 New Zealand doctors - who remained anonymous for fear of professional repercussions - was in February 2023 sent to the College of Physicians, outlining serious concern about the clinical examinations.
Prior to this, 10 anonymous complaints had been made to the college through its web portal.
The Herald revealed the extraordinary claims in July 2023.
The exam in question
Paediatrics exams include a written and an in-person, clinical format, and are sat by doctors - generally with about four to five years of experience - before advanced training.
“Within the Auckland clinical examination candidates, having reviewed the data for the last five years, the overall chance of passing the examination on the first attempt for a non-Caucasian candidate is 40%. This increased to 93% for a Caucasian candidate,” stated the letter.
“We believe the vast discrepancy of pass rates reflects the existing racial bias and discrimination, and that this is in breach of the NZ Human Rights Act.”
The paediatrics clinical exam involves doctors travelling to another hospital, where they assess real patients and talk to their families.
In the longer cases, the doctor spends about an hour with a patient and their family; this isn’t observed or marked directly. They then spend up to 25 minutes presenting to two senior specialists, who act as examiners.
The trainee describes the patient, their medical history and active problems, and identifies the key issues to focus on.
In their complaint letter, the doctors noted that examiners were more than 90% white, and overseas studies had shown greater diversity is essential “to ensure a fair and unbiased process”.
“Pass/fail standards for each case are set by the pair of examiners allocated to the specific case. This means that the examiner’s own professional and clinical experiences as well as personal views and beliefs have significant influence in identifying key issues and management priorities,” the letter, which was sent anonymously, stated.
What the review found
After little initial response, the doctors turned to the Resident Doctors’ Association (RDA) union, which confirmed the concerns were widely held among members, and followed up.
In May 2023, RACP ordered the review. A report was delivered in November 2024, and has been released today.
The review found discontent had existed over a three-year period. The college had not undertaken any analyses of pass rates of trainees from indigenous or other ethnic backgrounds, and did not have statistics on pass rates broken down by ethnicity.
The advisory group was unable to assess individual candidates’ complaints of racism, because they declined to come forward.
“However, based on the evidence presented from participants and the acceptance of structural bias in the health sector more generally, we are satisfied that unconscious bias including racism, did likely exist in the clinical examination processes in both NZ and Australia in 2021 and other years,” the report states.
“The advisory group accepts the evidence of the chair of the Māori Health Committee and the chairs of the trainee committees, that unconscious bias including structural and unconscious racism has existed in the clinical examinations in 2021 and in other years.”
The chairman of the Māori Health Committee had told the advisory group that as a senior Māori physician he’d advised Māori trainees to adopt a “talk like them, walk like them” approach in relation to examiners. “It would be nice not to have to feel that we need to behave in a different way to not be negatively biased against,” he said.
The group’s report said it was notable that the college didn’t collect any data on the ethnicity or disability status of candidates.
“This is preventing the college from being able to evaluate its performance on equity goals or any assessment of bias …the absence of this focus on gathering and assessing such data is itself a key indicator of structural bias towards the concerns of the majority.”
The RACP board has endorsed the group’s 18 recommendations and has created a working group to make needed changes.
Dr Deborah Powell, national secretary of the RDA union, said it was pleasing the college had owned the findings of the report, and released it.
“This is the first step in getting things right. We also want to commend and acknowledge those trainees who raised concerns, especially given the power imbalance that exists between trainees and those who assess whether they will become specialists.
“NZRDA will continue to work with the college to ensure the recommendations are effected in a timely manner. NZRDA is acutely aware the next exam will be sat in May 2025, leaving a narrow window to get it right.”
Nicholas Jones is an investigative reporter at the Herald. He was a finalist for Reporter of the Year at the 2024 Voyager Media Awards, and has won numerous national media awards for his reporting and feature writing.
