ABSTRACT
Gender bias and sexism in the health profession in the UK has been highlighted as a major problem. Efforts to reduce this must include medical training and examinations. The Situational Judgment Test (SJT) is an examination that must be passed to work as a foundation doctor in the UK; and is taken by all UK medical students. We analysed gender balance in all 215 scenarios included in the official practice papers for the SJT. We found that senior doctors were more than twice as likely to be men than women, while there was no significant gender difference in representation of foundation year-1 doctors, other health professionals or patients/relatives. This inequality has the potential to reinforce gender biases in healthcare. Medical examinations can, instead, represent an opportunity for prejudices to be challenged.
Introduction
Sexism remains prevalent across the medical profession.1 This is despite female UK medical students outnumbering their male counterparts since 1997 and women now making up almost half of the UK medical workforce.2,3
As foundation doctors, we regularly witness sexist behaviour and attitudes at work.
The British Medical Association (BMA) Sexism in medicine report in 2021 highlights that positions of seniority are associated with male figures and, furthermore, that ‘Sexism [and gender bias are] impacting women's long-term career progression’.1 The report highlights the need for the medical profession to identify where gender bias is introduced or re-enforced, and opportunities for these biases to be challenged.
The Situational Judgment Test (SJT) is an exam sat each year by all final-year medical students hoping to join the UK Foundation Programme (UKFP) as a junior doctor. The UKFP describes the SJT as assessing the ‘key attributes’ needed to work as junior doctors by posing ‘a series of work-related’ scenarios.4
The SJT is used to rank medical students nationally, helping to determine where they will live and work for the 2 years as a foundation doctor. There are three official practice papers available and we, like thousands of final-year medical students across the country, spent significant time looking over these papers as we prepared for our exam. During our preparation, we began to notice what felt like a disproportionate number of scenarios where the senior doctors were identified as being men. We, therefore, set out to ask: is there inequality in gender representation within the official SJT practice papers?
Methodology and results
We analysed the 215 scenarios given across all three official SJT practice papers available.5 We assessed explicit or implied gender of the 574 individuals described using pronouns, prefixes or names commonly associated with a particular gender. An illustrative example is where a patient is suspected of having an acute coronary syndrome and the question offers the option ‘Contact the cardiology consultant, asking him to review...’, implying the consultant is a man (question 29, practice paper 2). Individuals were categorised into first-year doctors (FY1), senior doctors (more senior than FY1), other (non-doctor) healthcare professionals (nurses, allied health professionals and other staff) and patients/relatives. The one-proportion Z-test was used to analyse gender balance in each category.
Senior doctors were twice as likely to be represented as men (men:women = 50:23; p=0.002; Fig 1).5 Conversely there were no significant gender differences in FY1 doctors (men:women = 28:27; p=0.89), in other health professionals (men:women = 15:24; p=0.15) or in patients/relatives (men:women = 58:66; p=0.48).
Genders of the roles from all scenarios described in the three official Situational Judgment Test practice papers compared with UK final-year medical students’ genders taking the Situational Judgment Test.3,5
Where no gender was initially explicitly ascribed, but subsequently implied, senior doctors were also more likely to be men (men:women = 39:15; p=0.001); other health professionals were more likely to be women (men:women = 6:18; p=0.01). Again, there was no significant difference among FY1 doctors (men:women = 5:11; p=0.13) or among patients/relatives (men:women = 23;16; p=0.26).
Discussion
Across the SJT practice papers, senior doctors were twice as likely to be ascribed a male gender than a female gender. This was in stark contrast to FY1 doctors, other healthcare professionals and patients/family members where there was no significant difference in gender ascribed.
This inequality has the potential to reinforce and perpetuate the association of senior doctors with male figures, which could encourage candidates and, therefore, future doctors to assume that senior doctors would be men. The tendency to make these assumptions is further reinforced by the subset of scenarios in which gender was implied after an individual is introduced to the scenario, where an even greater proportion of senior doctors were depicted as men.
Our analysis was limited in only analysing individuals whose gender was ascribed and did not include identities outside the gender binary. We also only analysed the practice papers for one examination, albeit one that is taken by all future UK foundation doctors, and so cannot comment on gender bias in other examinations.
These results, however, should encourage the profession to reflect on where biases, including other biases (such as racial bias) may be present in undergraduate and postgraduate examinations, and medical education more broadly. Much is learnt in medicine through example and practice, including the attitudes that shape our clinical practice.
Conclusion
Junior doctors work across a range of teams and settings, but sitting and revising for examinations is an experience we all have in common. Examinations represent an opportunity for prejudices to be challenged or, on the other hand, reinforced. Tackling gender inequality within the healthcare system requires a range of collaborative approaches, but a good place to start is within our medical examinations.
- © Royal College of Physicians 2022. All rights reserved.
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