Dr Nina Su: "It's really hard to know whether racial bias is an issue or not."
Claims that a medical exam discriminates against candidates who aren’t white must be properly investigated, says a doctor who recently completed the assessment.
Dr Nina Su is a locum paediatric doctor in Auckland, and this year sat and passed a clinical examination now under review after more than 30 doctors alleged racial bias.
“I was worried I was going in with a different likelihood of passing compared to some of my peers,” said Su, host of the Revolving Door Syndrome podcast, in which she interviews people at the frontlines of the health, social and justice systems.
“It’s really hard to know whether racial bias is an issue or not. It’s an entirely subjective examination in terms of how it’s marked, and there’s not a robust form of moderation or appeal process to get your performance re-evaluated if you feel the exam was unfair, because it’s not videoed.”
Paediatrics exams include a written and an in-person, clinical format, and are sat by doctors - generally with about 4-5 years experience - before advanced training.
Yesterday, the Weekend Herald revealed a letter of protest from a group of doctors was sent to the Royal Australasian College of Physicians (RACP), outlining serious concern about the clinical examinations.
“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 per cent. This increased to 93 per cent for a caucasian candidate,” stated the letter, sent in February.
“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 college has started a board-led review of the exam, and a separate inquiry “by an external third party”. It won’t provide more detail, but says “we note the issues raised in the letter, and they are viewed with concern by the college”.
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 letter, the doctors noted that examiners are more than 90 per cent 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.
Su, 29, wasn’t part of the group behind the letter. However, she too wants the “incredible” discrepancy in first-pass rates properly investigated and addressed, “whether it’s a problem of the exam process or training itself”.
In her view, the examinations need to be reformed, even if the possibility of racial bias is set aside. One issue: the time a candidate spends with a young person and their family not being observed by the examiners, only the “performative” presentation.
The high overall fail rate indicates a problem with the exam and/or medical training, she said.
“Everyone’s really burned out at the moment. I myself had poor mental health in the lead-up to the exam, to the point where it didn’t feel like it was worth it.
“The exam is a massive hurdle that comes only once a year, that severely impacts doctors’ wellbeing and life plans, such as settling down and starting a family.”
Every doctor brings with them their own life experience, views and implicit biases, Su said, and research shows workforce diversity can help address inequities that mean groups including Māori and Pasifika can suffer worse treatment and health.
“If you look at the paediatric doctors who are coming through, there’s very few Māori and Pasifika, even though we all know that Māori and Pasifika kids are overrepresented in our paediatric hospitals, in terms of patient load.
“We can’t just have one sort of person becoming a paediatrician.”
Nicholas Jones is an investigative reporter at the New Zealand Herald. He won the best individual investigation and best social issues reporter categories at the 2023 Voyager Media Awards.