Why Differential Attainment Isn’t an Individual Problem
- Jul 1
- 7 min read
Dr. Omosefe Christina is a Medical Doctor, Entrepreneur, and Founder of Elite Exams. She blends frontline clinical practice with medical education and community programmes to help International Medical Graduates (IMG) and African families flourish in their careers and communities in the UK.
For years, when postgraduate exams show gaps between IMG and UK-trained doctors, the feedback and response have been predictable: offer communication and language support, mentoring, and cultural awareness training. These measures help, but they treat differential attainment as an individual problem.
The real issue is structural. Differential attainment does not exist because IMGs lack clinical knowledge or expertise in their fields. It persists because assessments and learning environments were designed around a particular type of candidate and have never interrogated whether their own design is fair.
Structural competency, the ability to recognise how institutional structures produce unequal outcomes and to intervene, is missing from medical education. Without it, we keep blaming individual doctors for lapses that occur within their medical training.
The problem we’ve misnamed: From “individual gaps” to “system design failures”
When an IMG fails an exam or assessment, the conversation usually goes like this: they need better communication coaching, their accent may have affected the examiner, or they need more mock practice. These responses address only the symptoms. They don’t examine why the assessment itself is built around communication expectations that were never explicitly taught, or around cultural norms embedded in UK medical practice rather than in the clinical competence the exam claims to measure.
Research from BMJ Open and the British Journal of General Practice (2024) is clear: even after accounting for knowledge and clinical experience, IMG doctors face significantly lower pass rates.[1] [2] This gap exists because the assessment measures cultural fit as much as clinical reasoning.
Structural competency asks three critical questions before we decide what an individual IMG “needs.” First, what system pattern produced this outcome? Assessment structures often reward UK-style communication and doctor-patient interaction, assume local knowledge, and measure conformity alongside competence. Second, who benefits from this pattern? UK-trained doctors, who learned in this system, and the system itself, which doesn’t have to change. Third, what needs to change upstream to prevent repetition? The assessment itself, not the individual doctor. Without such reviews, training supervisors and programme directors often mistake structural problems for individual weaknesses, and the harm multiplies.
How training systems create differential attainment
In medical education, we expect a developed academic curriculum, assessment criteria, feedback loops, post-training allocation, supervisor relationships, learning materials, and informal networks through which opportunities are allocated. Each piece was created for efficiency, but together they can disadvantage IMGs.
Take the training post allocation. When a trainee needs specific clinical experience, opportunities are often allocated based on criteria favoring those embedded in local networks: doctors whose supervisors recommend them, who attended medical school locally, or whose approach “fits” the department. An IMG, even with stronger clinical credentials, may be invisible to these informal networks simply because they are new.
Assessment structures also matter. Many postgraduate exams contain scenarios built on assumptions about NHS pathways, communication norms, and subtle cultural references. While Royal Colleges don’t explicitly require familiarity with English medical culture, scenarios written by and for doctors trained in that culture embed assumptions invisible to anyone outside it. IMGs present their top-level clinical knowledge, but the cultural cues remain hidden barriers.
Feedback systems can compound the issue. A supervisor might tell an IMG trainee, “You need to use the X consultation.” This might actually mean, “You do things differently than we expect,” reflecting discomfort with a different consultation style rather than a skills gap. Without structural thinking, such feedback is viewed as personal criticism rather than constructive guidance.
GMC analysis found that IMGs had less access to structured feedback and fewer career progression opportunities, resulting in significantly lower pass rates in specialty training applications. The difference wasn’t knowledge, it was access to the right information, the invisible curriculum.
What leaders and educators miss: The invisible curriculum
Every training programme has two curricula. The explicit curriculum outlines learning outcomes, knowledge, and skills. The invisible curriculum shows how things are actually done, what is valued, who receives opportunities, and how communication must be tailored to be taken seriously.
For IMGs, the invisible curriculum is a hidden barrier. No one teaches it, yet everyone expects them to know it. When they don’t, the blame falls on the individual. Structural competency means explicitly naming this curriculum by making unspoken expectations visible, examining what assessments actually measure, and recognising that “fit” isn’t a competency. Hiring or promoting based on cultural fit builds a homogeneous team, not the strongest one.
Adopting structural competency
Revisit the structure. Before the exam, we have to consider what we are actually measuring. Is clinical reasoning being tested, or cultural familiarity? Would the doctor understand the assumptions behind the scenarios? Is the communication technique expected to be universal in good medicine, or just local to UK practice? Re-design the assessments to separate clinical competence from sociocultural conformity.
Map the invisible curriculum. It is equally important to work directly with IMGs. What do you think we expect that’s never been explicitly taught? What assumptions do supervisors make about what you should already know? Turn those invisible expectations into explicit learning objectives.
Allocate opportunities deliberately. Equal opportunities for IMGs in research posts, teaching roles, leadership opportunities, and specialty training placements, these shouldn’t go only to people in informal networks. Create transparent pathways. Actively sponsor IMGs into spaces in which visibility and opportunity happen.
Structure feedback around learning, not judgment. Educators should offer feedback that adds value to training by asking for the clinical reasoning behind certain decisions. Feedback that assumes incompetence leads to a defensive stance. Feedback that assumes competence and asks for an explanation creates learning.
Examine training post design. IMGs often get relegated to posts that are harder to manage or less prestigious, sometimes because supervisors think they “need” those experiences. It would be most helpful to question such assumptions. Allocate posts based on learning need and career path, not on a perceived clinical “gaps.”
Build learning loops into your programme. Every cohort should include a structured debrief, rather than passive surveys and questionnaires. Semi-formal feedback from IMGs can help identify answers to questions such as ‘What surprised you about the system? What wasn’t clear? What expectations were hidden?’ Use that data to change the programme for the following cohort.
The hidden harm: When systems fail, people pay
Ignoring measures to integrate IMGs is not only inefficient but counterproductive. IMGs are told to work harder, improve their English, be more confident, and adapt to culture, but they are not informed that the system wasn’t designed with them in mind. The gap between individual blame and systemic responsibility creates moral injury, where capable doctors are told their failure is personal when it is structural.
Data from the GMC Workforce Report 2025 show IMGs make up 42% of the UK medical workforce, yet their specialty training success rate is 23%, compared to 69% for UK-trained doctors. This is not a knowledge gap, it is a system gap. When IMGs leave, taking their expertise with them, it is often framed as personal failure, when in fact the system could not accommodate them.[3]
Building medical education systems that work
The most effective programmes do not wait for national directives, they embed persistent learning into their structures. Feedback loops should be created every year to determine what worked, what created barriers, and which assumptions were wrong. Flattening hierarchies allows feedback to flow upward, and measuring what matters extends beyond exam pass rates to include integration, access to networks, and quality of feedback. Programs embedding structured reflection on differential attainment see improvements in IMG outcomes and overall programme quality.
From blame to design: A different kind of leadership
Structurally minded educators ask different questions: instead of “Why are IMGs struggling?” they ask, “What about our training design assumes UK medical socialisation?” Instead of “What support do IMGs need?” they ask, “What should we change so the system supports everyone?” Instead of “How do we help IMGs fit in?” they ask, “How do we build a learning environment where difference is an asset?”
Real structural competency in medical education means assessment measures competence, not conformity, curricula make invisible expectations visible, feedback assumes capability, opportunity allocation is transparent, and learning loops interrogate differential outcomes.
The future of medical education
Postgraduate training faces a simple choice: design systems that filter out capable doctors because of differences, or systems that learn from international expertise. Differential attainment is not inevitable, it is designed, whether deliberately or through neglect, which means it can be redesigned.
When medical educators develop structural competency and see both the trainee and the system shaping them, medical education will not only respond to equity gaps, but it will prevent them. The future will be defined not by measuring individuals against a fixed standard but by redesigning systems that create unequal outcomes in the first place.
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Read more from Dr. Omosefe Christina
Dr. Omosefe Christina, Medical Doctor, CEO and Founder
Dr. Omosefe Christina creates digital learning platforms that turn frontline experience into practical support for international doctors in the UK. She is the CEO of Elite Exams, which supports the medical education of internationally trained doctors aspiring to become independent GPs. She builds digital systems, courses, platforms, and automated learning pathways to support doctors who migrate to the UK.
References and Further Reading:
[1] Woolf K et al. Perceived causes of differential attainment in UK postgraduate medical training. BMJ Open. 2016;6(11):e013429.
[2] Brown et al. Language of primary medical qualification and differential MRCGP exam attainment. BJGP. 2024.
[3] General Medical Council. Workforce Report 2025.
[4] Metzl JM & Hansen H. Structural competency: theorizing a new medical engagement with stigma and inequality. Social Science & Medicine. 2014;103:126–133.
[5] General Medical Council. The Invisible Curriculum: The Role of the Hidden Curriculum in Shaping Medical Training.
[6] The King’s Fund. Medical Education and Workforce Planning.
