International Business Times
NHS whistleblower Narinder Kapur has cautioned Indian doctors and nurses from coming to work in the UK due to what he believes is an “biased and corrupt” system. In 2010 Kapur was unfairly dismissed from his role as head of neuropsychology at Addenbrooke’s hospital in Cambridge, resulting in him suffering serious financial problems and having to sell his home in Southampton.
In 2012 an employment tribunal ruled that the Cambridge University hospitals NHS foundation trust had “not conducted itself as a reasonable employer” due to not exploring alternatives to firing Kapur. He said he lost roughly £1m ($1.4m, €1.2m) because of the incident, which arose after he raised concerns about staff shortages and unqualified staff working without proper supervision, resulting a breakdown of relationships with a manager. The tribunal ruled that accusations of fraud against Kapur to be unfounded and referred to him as a man “of the highest integrity”.
Speaking exclusively to the IBTimes UK, Kapur said: “Once you start raising lots of concerns and you point out bad practice, they see you as a troublemaker. They want to get rid of you, and once they decide to get rid of you, that’s it. They didn’t hesitate in telling lies about me; it was just horrible. They go out of their way to finish you off and have no mercy.”
Kapur said that the Indian government had failed to look into the issue, making him question the use of having an ‘Overseas Citizen of India’ card if his government did not take on his concerns. He said he had hoped Prime Minsiter Narendra Modi and the Indian High Commission in the UK would have been more helpful with his situation.
The neuropsychologist explained that when British-Indians suffered, people in India suffered too. He pointed out that many Indians in the UK send money back to their families, but if are victimised in the work place they are no longer able to do this. He also said that all the charity work he did for India was badly impacted by what happened to him in 2010.
“I would say to Indian doctors and nurses in India: think twice before you come here,” Kapur warned. “It’s a horrible system and unless they change it I wouldn’t advise them to come. It’s definitely biased against minorities, especially if they raise concerns.”
In order to combat the targeting of British-Indian medics, the British Association of Physicians of Indian Origin (BAPIO) have decided to set up a special body to help whistleblowing Indian doctors who face victimisation. The organisation has a long history of fighting for the rights of British-Indian doctors, including a successful case in 2005 where 15,000 Indian doctors were removed from their posts to give priority to local doctors.
Ramesh Mehta, president of BAPIO, explained that 10-15 Indian doctors are being trained with negotiation skills that will enable them to mediate between whistleblowing doctors and management staff to ensure the elimination of any “unconscious bias”.
For those Indians doctors who are looking to work in the UK, Kapur cautioned: “If doctors or nurses want to come over from India to work in this country, they’ve got realise that they’re coming to a Stalinist system. If they don’t like you, they get rid of you. We’re not asking for anything special, we’re just asking for fairness to ensure that this suffering doesn’t happen. It’s happening all the time. It’s happening to white people as well, but it’s happening to BME [black and minority ethnic] people more.”
by Narinder Kapur visiting professor of neuropsychology, University College London, London WC1E 7HJ 26 November 2015 BMJ
Human bias can be defined as a disposition to think, feel, or act in a particular way. It may stem from longstanding personality attributes, from particular sets of knowledge or past experience, or from a current predicament. Unconscious bias occurs when such tendencies are outside our awareness and conscious control. Some unconscious bias can seem positive—for example, intuition and “gut instinct”—but not always.
The Nobel Prize winning psychologist, Daniel Kahneman, has postulated the operation of fast and slow cognitive processing systems, where the fast, unconscious system is particularly prone to errors such as unconscious bias.1 In recent years our understanding of cognitive bias has advanced, both as a general phenomenon 2 and as a phenomenon within specific domains such as racism.3 Unacceptable disparities in ethnic representation at senior levels raise the issue of conscious or unconscious racial bias in the NHS.4
In clinical decision making, several studies have shown that errors can occur that are based on unconscious bias.5 Consider confirmation bias—that is, seeking information that supports a decision or viewpoint and ignoring or not seeking evidence that would be contradictory.
For example, a patient with a history of heart disease and a recent stent sees a doctor for blank spells, fever, and confusion. The doctor orders an ECG. It’s normal, so he orders an echocardiogram, which is also normal. The next day he orders a cardiac angiogram, which is also normal. The next day the patient has a seizure, so the doctor orders a brain scan, which shows high signal abnormality in both temporal lobes, strongly suggestive of limbic encephalitis, which is substantiated by subsequent investigations. The doctor kept looking for evidence to confirm his initial hunch rather than looking for alternative possibilities.
Feelings at work
Biases in healthcare settings may also arise in how we feel and express emotions,6 as well as in social settings, such as clinician-patient interactions.7 For example, consider a teetotal doctor who sees a patient in clinic who smells of alcohol and has tattoos and piercings. He is complaining of chest pains and blank spells.
The doctor feels perturbed by the patient, conducts only a brief interview, tells him that he’s fine, and does not order any investigations. The doctor forgets to ask about any family history of cardiac disease. After a few weeks the patient is admitted as an emergency, having had a cardiac arrest, and his family history of heart disease emerges.
How staff are treated
Conscious and unconscious biases can also be evident at an organisational level,8 in relationships among staff,9 and in management settings such as disciplinary hearings: these hearings are designed to be semi-judicial affairs, often with legal professionals present.
A doctor may be dismissed for an “irretrievable breakdown in relationships with colleagues,” for example, because of unconscious racist bias on the part of his or her colleagues, unconscious bias in some members of the internal disciplinary panel because of their past dealings with those colleagues, or both. In a landmark case, a UK High Court judge ruled on the importance of unconscious memory fallibility, such as when people recall distorted versions of events but confidently believe them to be true.10 The head of the UK Supreme Court, David Neuberger, has recently warned of the possibility of unconscious bias in legal settings.
Assessment and modification
Unconscious bias can be assessed. The US Implicit Association Test has been widely used in a range of settings (http://implicit. harvard.edu/implicit/), and similar instruments have been developed in the United Kingdom (www.shirepro.co.uk). In parallel, advances in cognitive modification methodology help reduce bias, including promoting knowledge and awareness of forms of unconscious bias, presentation of scenarios where such bias may occur, and confronting individuals with examples that run counter to thinking habits that promote unconscious social bias.11 12
Health systems such as the NHS have a duty to accept that conscious bias and unconscious bias exist and to take steps to eradicate them.
I thank Veronica Bradley for her comments on this paper. Competing interests: The author is a member of the Royal College of Surgeons’ Confidential Reporting System for Surgery (CORESS) advisory committee. Provenance and peer review: Not commissioned; not externally peer reviewed. Patient consent not needed (patient anonymised, dead, or hypothetical).
1 Kahneman D. Thinking, fast and slow. Penguin, 2011.
2 Banaji M, Greenwald A. Blind spot: hidden biases of good people. Delacorte Press, 2013.
3 Van Ryn M, Burgess DJ, Dovidio J, et al. The impact of racism on clinician cognition, behaviour, and clinical decision making. Du Bois Rev 2011;8:199-218.
4 Kline R. The “snowy white peaks” of the NHS: a survey of discrimination in governance and leadership and the potential impact on patient care in London and England. Middlesex University, 2014. http://www.mdx.ac.uk/__data/assets/pdf_file/0012/59799/The-snowy-whitepeaks-of-the-NHS.pdf.pdf.
5 Stone J, Moskowitz G. Non-conscious bias in medical decision making: what can be done to reduce it? Med Educ 2011;45:768-76.
6 Croskerry P, Abbass A, Wu A. Emotional influences in patient safety. J Patient Saf 2010;6:199-205.
7 Byrne A, Tanesini A. Instilling new habits: addressing implicit bias in healthcare professionals. Adv Health Sci Educ Theory Pract 2015;20:1255-62.
8 Seshia S, Makhinson M, Phillips D, et al. Evidence-informed person-centred healthcare (part I): do “cognitive biases plus” at organizational levels influence quality of evidence? J Eval Clin Pract 2014;20:734-47.
9 Tse H, Lam C, Lawrence S, et al. When my supervisor dislikes you more than me: the effect of dissimilarity in leader-member exchange on coworkers’ interpersonal emotion and perceived help. J Appl Psychol 2013;98:974-88.
10 Howe M, Knott L. The fallibility of memory in judicial processes: lessons from the past and their modern consequences. Memory 2015;23:633-56.
11 Croskerry P, Singhal G, Mamede S. Cognitive debiasing 2: impediments to and strategies for change. BMJ Qual Saf 2013;22 (suppl 2):ii65-ii72.
12 Reilly J, Ogdie A, Von Feldt J, Myers JS. Teaching about how doctors think: a longitudinal curriculum in cognitive bias and diagnostic error for residents.
BMJ Qual Saf 2013;22:1044-50. Cite this as: BMJ 2015;351:h634