Vol. 14 No. 1 (2021): Year of the Nurse

Does a Narrow Definition of Medical Professionalism lead to Systemic Bias and Differential Outcomes? : A Narrative Commentary

Ananta Dave MD FRCPsych
Lincolnshire Partnership NHS Foundation Trust, Lincoln, UK
Naureen Bhatti FRCGP
Health Education England, London, UK
Joydeep Grover MBBS FRCEM
Southmead Hospital, Bristol, UK
Rosanna Geddes
Medical Defence Shield, UK
Triya A Chakravorty BA(Oxon)
University of Oxford, UK
Satheesh Mathew MD FRCPCH
British Association of Physicians of Indian Origin, Bedford, UK
Shivani Sharma, MBPsS, PGCert, FHEA, CPsychol 
University of Hertfordshire, UK
Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
Indranil Chakravorty MBBS PhD FRCP
St Georges University Hospitals Foundation Trust, London, UK
capt Tom Moore by Aria

Published 2021-02-23


  • differential attainment,
  • Regulator,
  • Medical Professionalism,
  • General Medical Council

How to Cite

Dave, A., Bhatti, N., Grover, J., Geddes, R., Chakravorty, T., Mathew, S. ., Sharma, S., Bamrah, J., & Chakravorty, I. (2021). Does a Narrow Definition of Medical Professionalism lead to Systemic Bias and Differential Outcomes? : A Narrative Commentary. Sushruta Journal of Health Policy & Opinion, 14(1), 1–12. https://doi.org/10.38192/14.1.13


The concept of medical professionalism is enshrined in the principles of Good Medical Practice (GMP), upheld by the General Medical Council (GMC), and is applicable to all doctors as well as undergraduate students in the United Kingdom. The principles were conceived, developed and implemented to ensure that the highest standards of medical practice are adhered to for the safety of the public and to retain trust in the medical profession. The GMC has a statutory duty to ensure that professional standards are maintained. Approximately 1% of doctors on the medical register are subject to investigation by the GMC, based on referrals made by employing organisations or the public.

While appropriate GMC investigation is essential to maintain standards, patient safety and public confidence, there are inherent inequalities in the process resulting in widely different outcomes for certain groups of students or doctors based on Black and minority ethnicity, male gender and non-UK primary medical qualification often leading to devastating consequences.

This narrative review considers the contributors to differential attainment (DA) and the impact on the health service, patients and individual wellbeing. It explores the tenets of a current narrow definition of professionalism which, while representing the unidimensional White majority view, ignores the huge diversity of the workforce and the public, thus exposing significant tensions for groups of professionals.  The Covid-19 pandemic has exposed the inherent systemic bias in the health service for both professionals and the public. This review recommends root and branch reform of the definition of professionalism, by engagement with the public and the workforce, to incorporate principles of equality, diversity and inclusion, which the authors believe will create the environment for a just and equitable professional experience. 1 


  1. NHS England » Action required to tackle health inequalities in latest phase of COVID-19 response and recovery https://www.england.nhs.uk/about/equality/equality-hub/action-required-to-tackle-health-inequalities-in-latest-phase-of-covid-19-response-and-recovery/
  2. Chakravorty, I., Daga, S., Chakravorty, S., Bamrah, J., & Mehta, R. (2020). Protocol for Thematic Synthesis of Differential Attainment in the Medical Profession - ‘Bridging the Gap’ Series: Alliance for Equality in Health Professions. Sushruta Journal of Health Policy & Opinion, 13(3). https://doi.org/10.38192/13.3.17
  3. Nunn, S. Understanding differential attainment across medical training pathways: A rapid review of the literature. 89. https://www.gmc-uk.org/-/media/documents/gmc-understanding-differential-attainment_pdf-63533431.pdf
  4. Woolf, K., Potts, H. W. W. & McManus, I. C. Ethnicity and academic performance in UK trained doctors and medical students: systematic review and meta-analysis. BMJ 342, d901 (2011). doi: https://doi.org/10.1136/bmj.d901
  5. New data on gender pay gap in medicine. GOV.UK https://www.gov.uk/government/news/new-data-on-gender-pay-gap-in-medicine.
  6. 1975 - Report of G.M.C. inquiry.pdf. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1675971/
  7. Good medical practice. https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice.
  8. Dyer, C. Bristol inquiry: Bristol inquiry condemns hospital’s “club culture”. BMJ 323, 181 (2001). doi: https://doi.org/10.1136/bmj.323.7306.181
  9. The Shipman Inquiry. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/273227/5854.pdf
  10. Our history. https://www.gmc-uk.org/about/who-we-are/our-history.
  11. Regulatory_Reform_Consultation_Document.pdf. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/655794/Regulatory_Reform_Consultation_Document.pdf
  12. Health Equity in England: The Marmot Review 10 Years On. The Health Foundation https://www.health.org.uk/publications/reports/the-marmot-review-10-years-on.
  13. Black Lives Matter. Wikipedia (2020). https://en.wikipedia.org/w/index.php?title=Black_Lives_Matter&oldid=971334380
  14. Chakravorty, I., Bamrah, J. S. & Mehta, R. A Rainbow Paper - Tackling inequalities, a neo-liberal order in a world after Corona. Sushruta J. Health Policy Opin. 13, (2020). https://doi.org/10.38192/13.3.14
  15. NHS Race and Health Observatory. http://www.nhsconfed.org/networks/nhs race and health observatory.
  16. Aims of the Observatory. http://www.nhsconfed.org/networks/nhs race and health observatory/aims of the observatory.
  17. Horsfall, S. Doctors who commit suicide while under GMC fitness to practise investigation. 83. https://www.gmc-uk.org/-/media/documents/Internal_review_into_suicide_in_FTP_processes.pdf_59088696.pdf
  18. Walshe, K. & Offen, N. A very public failure: lessons for quality improvement in healthcare organisations from the Bristol Royal Infirmary. BMJ Qual. Saf. 10, 250–256 (2001). https://doi.org/10.1136/qhc.0100250
  19. An update on the GMC’s work to address the Francis Recommendations. 11. https://www.gmc-uk.org/-/media/documents/gmc-update-on-francis-recommendations---final_pdf-53738187.pdf
  20. Ham, C. R. Klein, The Politics of the National Health Service, Longman, London, 1983 J. Soc. Policy 13, 359–360 (1984).
  21. Archives, T. N. The National Health Service. https://www.nationalarchives.gov.uk/cabinetpapers/alevelstudies/nhs.htm?WT.ac=The%20National%20Health%20Service.
  22. CanMEDS Role: Professional : The Royal College of Physicians and Surgeons of Canada. https://www.royalcollege.ca/rcsite/canmeds/framework/canmeds-role-professional-e
  23. Donaldson, L. J. Professional accountability in a changing world. Postgrad. Med. J. 77, 65–67 (2001). https://doi.org/10.1136/pmj.77.904.65
  24. Baillie, L. & Matiti, M. Dignity, equality and diversity: an exploration of how discriminatory behaviour of healthcare workers affects patient dignity. Divers. Equal. Health Care 10, (2013). https://diversityhealthcare.imedpub.com/abstract/dignity-equality-and-diversity-an-exploration-of-how-discriminatory-behaviour-of-healthcare-workers-affects-patient-dignity-1724.html
  25. The Bias of ‘Professionalism’ Standards (SSIR). https://ssir.org/articles/entry/the_bias_of_professionalism_standards.
  26. Powers, B. W., White, A. A., Oriol, N. E. & Jain, S. H. Race-Conscious Professionalism and African American Representation in Academic Medicine. Acad. Med. 91, 913–915 (2016). https://doi.org/10.1097/ACM.0000000000001074
  27. Weaver, M. What you need to know about the junior doctors’ strike. The Guardian (2016). https://www.theguardian.com/society/2016/sep/01/what-you-need-to-know-about-the-junior-doctors-strike
  28. The Bawa-Garba case | The BMJ. https://www.bmj.com/bawa-garba.
  29. Bamrah, J. S. & Mehta, R. Back to Blame: Sushruta J. Health Policy Opin. 11, 9–12 (2018). https://doi.org/10.38192/11.1.3
  30. Patel F, Chakravorty I. Millennials - The missing piece in the NHS Workforce puzzle? Sushruta 13, (2020). https://doi.org/10.38192/13.1.7
  31. Disparities in the risk and outcomes of COVID-19. 92 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/908434/Disparities_in_the_risk_and_outcomes_of_COVID_August_2020_update.pdf.
  32. Chakravorty, I. et al. An Online Survey of Healthcare Professionals in the COVID-19 Pandemic in the UK: : SUSHRUTA J. Health Policy Opin. 13, (2020). https://doi.org/10.38192/13.2.9
  33. Wyatt, T. R. et al. ‘Whispers and shadows’: A critical review of the professional identity literature with respect to minority physicians. Med. Educ. 55, 148–158 (2021).
  34. fair-to-refer-report_pdf-79011677.pdf. https://www.gmc-uk.org/-/media/documents/fair-to-refer-report_pdf-79011677.pdf
  35. NHS England » Evaluation of the NHS Workforce Race Equality Standard (WRES). https://www.england.nhs.uk/publication/evaluation-of-the-nhs-workforce-race-equality-standard-wres/.
  36. Participation, E. Equality Act 2010. https://www.legislation.gov.uk/ukpga/2010/15/contents
  37. Unwin, E., Woolf, K., Wadlow, C. & Dacre, J. Disciplined doctors: Does the sex of a doctor matter? A cross-sectional study examining the association between a doctor’s sex and receiving sanctions against their medical registration. BMJ Open 4, e005405 (2014). https://doi.org/10.1136/bmjopen-2014-005405
  38. Disciplinary action against physicians: Who is likely to get disciplined? - The American Journal of Medicine. https://www.amjmed.com/article/S0002-9343(05)00150-6/fulltext
  39. The state of medical education and practice in the UK. https://www.gmc-uk.org/about/what-we-do-and-why/data-and-research/the-state-of-medical-education-and-practice-in-the-uk
  40. Woolf, K., Rich, A., Viney, R., Needleman, S. & Griffin, A. Perceived causes of differential attainment in UK postgraduate medical training: a national qualitative study. BMJ Open 6, e013429 (2016)
  41. Slowther, A., Lewando Hundt, G. A., Purkis, J. & Taylor, R. Experiences of non-UK-qualified doctors working within the UK regulatory framework: a qualitative study. J. R. Soc. Med. 105, 157–165 (2012).
  42. Majid, A. What lies beneath: getting under the skin of GMC referrals. BMJ 368, (2020). https://doi.org/10.1136/bmj.m338
  43. Wise, J. Poor induction and lack of honest feedback is blamed for higher rate of GMC referrals among BAME doctors. BMJ 365, l4391 (2019). https://doi.org/10.1136/bmj.l4391
  44. Humphrey, C., Hickman, S. & Gulliford, M. C. Place of medical qualification and outcomes of UK General Medical Council “fitness to practise” process: cohort study. BMJ 342, d1817 (2011). https://doi.org/10.1136/bmj.d1817
  45. Rimmer, A. Ethnic minority and non-UK doctors don’t think GMC treats all doctors fairly, survey finds. BMJ 348, g3716 (2014). https://doi.org/10.1136/bmj.g3716
  46. Fitness to Practise: Review of Serious Misconduct. https://www.gdc-uk.org/docs/default-source/research/20170409seriousness-review-final-report.pdf?sfvrsn=d34194fc_2
  47. Review of decision making in our fitness to practise procedures. https://www.gmc-uk.org/about/what-we-do-and-why/data-and-research/research-and-insight-archive/review-of-decision-making-in-our-fitness-to-practise-procedures
  48. Godlee, F. The GMC, racism, and complaints against doctors. BMJ 312, 1314–1315 (1996). https://doi.org/10.1136/bmj.312.7042.1314
  49. Figure 4 - HE student enrolments by personal characteristics 2013/14 to 2017/18 | HESA. https://www.hesa.ac.uk/data-and-analysis/sb252/figure-4.
  50. Differential attainment in medical education and training | The BMJ. https://www.bmj.com/content/368/bmj.m339.
  51. Kmietowicz, Z. Are medical schools turning a blind eye to racism? BMJ 368, m420 (2020). https://doi.org/10.1136/bmj.m420
  52. McManus, I. C., Richards, P., Winder, B. C., Sproston, K. A. & Styles, V. Medical school applicants from ethnic minority groups: identifying if and when they are disadvantaged. BMJ 310, 496–500 (1995). https://doi.org/10.1136/bmj.310.6978.496
  53. McManus, I. C., Esmail, A. & Demetriou, M. Factors affecting likelihood of applicants being offered a place in medical schools in the United Kingdom in 1996 and 1997: retrospective study Commentary: League tables will help Commentary: Some legal aspects arising from the study. BMJ 317, 1111–1117 (1998). https://doi.org/10.1136/bmj.317.7166.1111
  54. Linton, S. Taking the difference out of attainment. BMJ 368, (2020). https://doi.org/10.1136/bmj.m438
  55. Tackling racial harassment: universities challenged | Equality and Human Rights Commission. https://www.equalityhumanrights.com/en/publication-download/tackling-racial-harassment-universities-challenged.
  56. Dyson, M. Caring, supportive, collaborative: a future vision for the NHS. The British Medical Association is the trade union and professional body for doctors in the UK. https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/the-future/caring-supportive-collaborative-a-future-vision-for-the-nhs
  57. Racial harassment charter for medical schools. The British Medical Association is the trade union and professional body for doctors in the UK. https://www.bma.org.uk/advice-and-support/discrimination-and-harassment/racial-harassment-in-medical-schools/racial-harassment-charter-for-medical-schools
  58. What is revalidation? https://www.gmc-uk.org/registration-and-licensing/managing-your-registration/revalidation/introduction-to-revalidation
  59. GMC. Publication and Disclosure Policy. 27. https://www.gmc-uk.org/-/media/documents/DC4380_Publication_and_disclosure_policy_36609763.pdf
  60. How do we check doctors are giving good care? https://www.gmc-uk.org/registration-and-licensing/managing-your-registration/revalidation/how-do-we-check-doctors-are-giving-good-care.
  61. Re: Whistleblower was unfairly dismissed in case lasting 12 years, tribunal rules. g2881 (2021). https://www.bmj.com/content/348/bmj.g2881/rr/695954
  62. Markwell, A. L. & Wainer, Z. The health and wellbeing of junior doctors: insights from a national survey. Med. J. Aust. 191, 441–444 (2009). https://doi.org/10.5694/j.1326-5377.2009.tb02880.x
  63. Gerada, C. Doctors and suicide. Br. J. Gen. Pract. 68, 168–169 (2018). https://doi.org/10.3399/bjgp18X695345
  64. Suicide in doctors and other health professionals. https://www.practitionerhealth.nhs.uk/suicide-in-doctors-and-other-health-prof.
  65. Sarafis, P. et al. The impact of occupational stress on nurses’ caring behaviors and their health related quality of life. BMC Nurs. 15, 56 (2016). https://doi.org/10.1186/s12912-016-0178-y
  66. Tawfik, D. S. et al. Physician Burnout, Well-being, and Work Unit Safety Grades in Relationship to Reported Medical Errors. Mayo Clin. Proc. 93, 1571–1580 (2018). https://doi.org/10.1016/j.mayocp.2018.05.014
  67. Bhugra, D. et al. A descriptive study of mental health and wellbeing of doctors and medical students in the UK. Int. Rev. Psychiatry 31, 563–568 (2019). https://doi.org/10.1080/09540261.2019.1648621
  68. Howe, A. Doctors’ health and wellbeing. BMJ 347, f5558 (2013). https://doi.org/10.1136/bmj.f5558
  69. New indicators will track doctors’ careers to expose racism | The BMJ. https://www.bmj.com/content/370/bmj.m3659.