Workforce culture and diversity: Our questions answered at BOTA Congress

Oliver Adebayo, Thomas Key, Kathryn Dayananda and Ran Wei

Oliver Adebayo is a registrar on the Stanmore rotation in North East London and is the current President of the BOTA. As part of his mandate this year he is committed to supporting diversity, innovation, and sustainability amongst T&O trainees.

Thomas Key is an ST7 trainee in the Welsh Deanery and was the Welsh BOTA representative for 2019- 2021. He has specialist interests in shoulder surgery and medical education.

Kathryn Dayananda is a Specialty Trainee in Trauma and Orthopaedic Surgery in the Welsh Deanery. She is the outgoing BOTA Women in Surgery rep.

Ran Wei is currently a post-CCT knee fellow at the North Sydney Orthopaedic and Sports Medicine Centre. He is the immediate Past President of BOTA and led the Committee to deliver the virtual BOTA Congress 2021 and conception of the Culture and Diversity Rep role.

The Royal College of Surgeons of England’s unveiled its landmark review into the diversity of leadership of the surgical profession and of the College in April 2021. The report outlined a vision for the College and in turn set the surgical world talking about diversity, inclusion and equity.

Concurrently, throughout the world, there were great societal shifts and a spotlight had been shone onto diversity and inclusion through the George Floyd episode leading to Black Lives Matter and the differential COVID-19 death rates seen in ethnic minority communities across the Western World.

The Royal College – Our professional home: An independent review on diversity and inclusion

In September 2020 the new President of the Royal College of Surgeons England, Professor Neil Mortensen, commissioned an independent review into the College’s professional leadership. Led by Baroness Helena Kennedy QC, an assessment of diversity, inclusion and the sense of belonging among RCS college members was made in order to identify the barriers to fair representation and leadership within the College and the wider profession. 12 panellists across all seniority levels and surgical sub-specialties talked to a range of witnesses and engaged in focus groups, interviews and statements to produce the report.

The survey findings are stark; the most frequent barrier in achieving a senior role within the College life was the notion of the ‘old boys’ network’. Of those who felt this way, 3 in 5 members stated that the college did not represent people like themselves and 3 in 4 members believed the college did not do enough to foster an inclusive environment [1].

The report goes on to highlight the perception of surgeons and a career in surgery. Emphasis is placed on the importance of visibility and the accessibility of surgical role models across all career stages, including secondary-school, medical school, foundation and core / higher training years.

The report concluded with a 16-step action plan for the College to ensure reform in its processes and to create a more diverse and inclusive organisation demonstrating equality within its leadership. These recommendations include; reforms to the elections process, a clear SAS strategy and better Council representation at all levels.

Keynote session at BOTA Virtual Congress

In response to the Kennedy report and its implications for the future of surgical representation, the British Orthopaedic Trainees Association (BOTA) theme for this year’s congress was Workforce Culture, Diversity and Sustainability. BOTA invited Professor Neil Mortensen to give the key note speech at this year’s virtual BOTA Congress to discuss the findings of the report.

Professor Mortensen emphasised the purpose of the Kennedy report in his lecture. The College represents a surgical workforce of which 40% is from an ethnic minority background, yet this was not reflected in the proportion of surgical tutors and faculty. With regards to women, only 14% of surgical consultants are female with a third (35%) of surgical trainees being female1. Comparatively, just over half of all speciality trainees are female (57%) with the proportion of female consultants at 37% in 2020. Some specialities have a higher proportion of female doctors in training, such as paediatric surgery (53%) and plastic surgery (39%), however T&O has the lowest with 18%.

Professor Mortensen highlighted that the lack of diversity within RCS England demonstrated the need for change at the very top and that the report is a step in the right direction to create a more inclusive, diverse and representative College.

Following his talk, Professor Mortenson (NM) was joined by Professor Michael Griffin (MG), President of Royal College of Surgeons Edinburgh and Mr Bob Handley (BH), President of the British Orthopaedic Association for a panel discussion on Workforce Culture, Diversity and Sustainability in Surgery. Their enthusiasm to take part in the session highlights the desire at the very top of the profession for change. The guest speakers were invited to answer the following questions:

Question: How do we make surgery, in particular T&O more attractive to a diverse cohort of applicants?

BH: Unfortunately, the stereotype of T&O surgeons still persists in medical school today with the presumption that you have to be a white rugby playing male to get in and progress.

This puts off a lot of applicants at the medical school level. We need to show that we are just normal people, trying to live our lives and have a good work life balance, not putting ourselves on a pedestal. There are now more role models within T&O and those people need to be in a position where they are seen by medical students and people at school.

MG: ‘People can’t be what they can’t see’ – it’s essential that roles models exist within the College and that we work with medical schools to widen participation. Over 50% of state schools have never even had a pupil apply to study medicine. We need to look at the barriers to surgery, which includes how professional development is delivered and the appalling level of bullying and undermining. Through the RCS Edinburgh ‘Lets Remove it Campaign’, T&O surgery was found to have a high incidence of bullying and undermining behaviour. It’s important for people to understand it should be an inclusive environment.

Question: How do you feel the College will address the issues of differential attainment?

NM: We have been looking at the data around differential attainment within our exam results and will be reporting that. The College will be formally studying this as part of Kennedy Report. We need to do much more to help people be more prepared.

MG: There was an issue with ethnic minorities and differential attainment in the exam. Within the examination process, the issue of differential attainment is not so much an ethnic one but it was an issue of those not in training compared to being in training. The issue was with those not in training who were more likely to be from an ethnic background. There is actually improved attainment in Asian trainees compared to white British trainees.

JCIE has been aware of these issues and in the last few years, examiners have had training in unconscious bias to try to make sure the exam is a fair process. The Kennedy report has highlighted that differential attainment is not just about exams however that it is hard for ethnic minorities and women to progress at all stages of their career.

BH: With regards to T&O SpR recruitment – women are more likely to be selected and more likely to do well at the FRCS. However they don’t seem to do as well at ARCP – this is being investigated.

When looking at ethnic minorities and how they perform in exams, there is a difference in attainment however the difference is the same in section one and two, indicating that the bias is not due to examiners. There is no doubt that UK graduates fair better, with the reasons not clear.

Question: What has been done to improve retention within T&O and within surgery particular for parents?

NM: Surgery is no longer something which you have to be in day in and day out there all the time to have continuity of care. I think we can work collaboratively in teams to make less than full time working happen to allow more flexibility within training and beyond. If our medical students and pre-medical students, saw a world where surgery was much more open and flexible it would be much more open and attractive.

MG: Working practices have changed and the extended surgical team are important. We are no longer a one man band. It is a different, better and safer way of working now.

50% of women go into surgical training and only 15-18% are coming out at the end. We are losing a lot of women within the course of their surgical training. We are starting to get better with less than full time training options, however some trusts are very good at administering that, others put obstacles in the way. This has to change.

Question: How the BOA will ensure individual surgeons wellbeing will be protected in the post COVID recovery?

BH: We had a number of discussions with the BOA. It is important that we all help to look each other. We need to look at our own colleagues and peers on a personal and professional level. This is difficult to influence centrally but we can treat each other with respect in order to be able to look out for ourselves.

BOTA Culture and Diversity agenda

This year’s keynote session was the perfect springboard for BOTA to launch our Culture and Diversity agenda for the upcoming year. A new Culture and Diversity representative was voted in at this year’s AGM during virtual Congress and a new Committee working group focused on culture and diversity has been formed.

In the upcoming year, together with the BOA, BOTA will be looking for passionate, driven individuals to become Culture and Diversity champions within T&O departments across the UK. We want to encourage people from all levels of the career ladder to apply for these regional roles and support initiatives in culture change and equal opportunities for all. T&O surgery has always been a trailblazing specialty and this is an opportunity for us all to change our narrative and lead on positive change.

References

1. The Royal College of Surgeons of England (2021). An independent review on diversity and inclusion for the Royal College of Surgeons of England. Available at: www.rcseng.ac.uk/about-the-rcs/ about-our-mission/diversity-review-2021.