STRENGTHS AND LIMITATIONS OF THIS STUDY

This study explored the experiences of BAME, Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ+) medical students at a single London-based university using the methodology of phenomenography, as understanding of Professional Identity Formation (PIF) through an intersectional lens remains limited among medical students in the UK.

All students who identified as BAME and LGBTQ+ attending University College London Medical School across the 6-year training programme were eligible for participation.

Semistructured interviews were conducted until theoretical saturation was reached with six students recruited, one of whom was in the ‘early’ years (years 1–3) and the remainder were in the ‘later’ years (years 4–6).

Strengths of the study include gaining in-depth insight of the unique challenges faced by BAME, LGBTQ+ medical students and the effect this had on their PIF.

Limitations include that the study was conducted at a single London-based university and although theoretical saturation was reached, representation was higher among ‘later’ year students in years 4–6 of their undergraduate programme.

Introduction

The importance of positively fostering professional identity among medical students and doctors is increasingly being recognised. Although numerous definitions exist, professional identity is widely considered as the ‘attitudes, values, knowledge, beliefs and skills that are shared with others within a professional group in the workplace’.1 Specifically, within medical education, professional identity is often regarded as when individuals start ‘thinking, acting and feeling like a physician’,2 with delays or conflicts in its development associated with burnout and attrition among healthcare professionals.3 4

The dynamic, evolving nature of Professional Identity Formation (PIF)5; however, presents unique challenges on the core components considered essential within a competency-based undergraduate medical curriculum.6 Often ‘taught’ as part of professional practice or professionalism in the UK,7 this incorporates the four domains outlined by the General Medical Council on the knowledge and skills expected of physicians. These include remaining up to date, demonstrating effective teamwork, treating patients and colleagues with respect and acting with integrity.8 This guidance, however, does not take into account the several different, and often conflicting conceptualisations of PIF and the various pedagogical interventions suggested for its enhancement within undergraduate training.9 10 Although simplistic, Monrouxe and Rees11 broadly distinguish the various concepts for developing professional identity into two main categories, the individualist and sociocultural approach. The former recognises the process by which ‘individuals make sense of who they are with respect to their personal attributes and how these relate to the desired values, attitudes and attributes of a physician’.12 Pedagogical interventions for enhancing the individualist approach include reflective writing, where medical students critically reflect on challenging encounters with the aim of increasing their self-awareness, empathy and attention to patient care.13 In contrast, the sociocultural approach recognises the process by which medical students are able to attribute meaning to their work and develop their skills through their interactions with patients and colleagues.14 15 Several different factors have been associated with this process. While Cruess et al15 emphasise the importance of role models, Vivekananda-Schmidt et al16 argue the importance of ‘participation in practice’ where through active engagement, seeing patients and being involved in their management, medical students are able to develop their own way of practice. Despite the differing conceptualisations, consensus on positively fostering PIF as an ethical framework by which medical students practice medicine is widely acknowledged within the literature.13

PIF from an intersectional lens

The last few years have seen an increasing awareness of Equality, Diversity and Inclusivity (EDI)-related issues in medical education. In addition, statistics published by the UK Medical Schools Council (MSC) demonstrate increased diversity in the medical school cohort with a higher percentage of Black, Asian, Minoritised Ethnic (BAME), lower income and medical students with disabilities over the last 5 years in the UK.17 Despite these advances, academic performance gaps continue to be demonstrated among BAME students in the UK Foundation Programme aptitude tests,18 with the extent of this gap varying considerably between medical schools. Understanding how students academically perform from more deprived backgrounds and for those with disabilities is, however, more difficult to ascertain with limited data available. Specifically, within the context of PIF, it has been suggested that this is typically presented from a ‘white’ lens, with the experiences of BAME students and physicians overlooked in the literature.19–21Although this is changing, with a growing body of literature looking more closely at the experiences of medical students from under-represented backgrounds, one of the difficulties remains in the categorisation of ‘minoritised groups’. For example, in a study by Volpe et al22 on the experiences of nine students in a predominantly white, rural medical school in the USA, students had to identify with at least one minoritised group identity including, minority ethnic or racial group, Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ+), first-generation student and even ‘other’. While higher levels of stress, feelings of isolation and self-doubt were identified, with such broad inclusion criteria, it assumes that the challenges faced were universal across all minoritised groups. By doing so, it limits the exploration of the nuances in perceptions and experiences and potentially leads to a reductionist view for supporting the various different minoritised groups. Understanding PIF from an intersectional lens also remains limited. Originally defined by Crenshaw,23 intersectionality recognises that ‘individuals are characterised by their position within multiple social systems(eg, gender, race, class, sexual orientation)’,24 which are then stratified within systems of inequity. It has been suggested that by adopting an intersectional lens medical educators can optimise the support they offer.25 However, this requires awareness of how PIF may be influenced by the various social categories and in turn, aligns to the professional standards and behaviours expected of future physicians.26 Among the extant literature, two studies both based in the USA looking at the experiences of BAME, LGBTQ+medical students identified that they were less likely to be ‘out’27 and considered themselves to have an ‘additional burden’ compared with their white LGBTQ+ counterparts.28 It has also been suggested that LGBTQ+ medical students are less likely to choose ‘prestigious specialties’29 and have a higher risk of developing mental health conditions.30

There remains, however, a paucity of research on the experiences of BAME, LGBTQ+ medical students in the UK, with most healthcare studies focusing on the patient experience.31 Despite the growing recognition of the importance of intersectionality, all three of these studies focused on a particular identity trait.32–34 Unsurprisingly, higher rates of harassment from patients and colleagues were reported among LBGTQ+ medical students.32 33 Studies focusing on the experiences of BAME and LGBTQ+ individuals within the wider literature however, highlight the unique challenges faced by this community, including multiple microaggressions from a racial perspective and stigmatisation from their own cultural communities due to predominantly heterosexual-based values.35Poorer physical and mental health outcomes36 along with higher rates of exclusion and isolation from both the LGBTQ+ community and their own ethnic communities have also been highlighted.31 With this gap in the literature, the aim of this study was to explore the experiences of BAME, LGBTQ+ medical students and how this affected their PIF through an intersectional lens. The research questions were as follows:

What are the unique experiences faced by medical students who identify as BAME and LGBTQ+?

How can the undergraduate programme support the experiences of BAME, LGBTQ+ medical students?

Based at a single medical school in London, University College London Medical School (UCLMS), the objective was to enable a more guided support system to be implemented in the undergraduate Bachelor of Medicine, Bachelor of Science (MBBS) programme.

MethodsDesign

This was a qualitative study based on the methodology of phenomenography. Originally described in the 1970s, phenomenography explores how ‘people experience, conceptualise, perceive and understand various aspects of phenomena in the world around them’.37 Rather than analysing the phenomenon itself, it divides an experience into a ‘referential’ and ‘structural’ aspect, with the former referring to the meaning or significance they may take from an experience.38 In contrast, the ‘structural’ aspect relates to the experience itself and this is often further broken down by the ‘internal horizon’ and ‘external horizon’.39 ‘External horizon’ refers to how an individual differentiates the experience by context and background.39 For example, when first encountering a seriously ill patient, medical students may struggle to cope with the emotions of grief and loss. In contrast, the ‘internal horizon’ focuses on the relationship between the various parts of the experience,40 so how the medical student dealt with seeing and speaking to the ill patient on their management and care. By creating a unique analytical framework, variations on how individuals attach meaning to their experiences can be presented and both researchers considered that the methodology of phenomenography would enable them to fully capture the experiences of participants with the aim of identifying suitable strategies for addressing any issues or challenges faced.40 This was important as the objective of this research study was not just to explore the experiences of BAME, LGBTQ+ medical students in the MBBS programme but also to address any potential barriers affecting their PIF.

Participants

All UCLMS MBBS students identifying as BAME and LGBTQ+ enrolled in the 6-year MBBS programme were eligible for this study. The actual number of eligible students was unknown, as data relating to LGBTQ+ status were not gathered by the university. The UCL MBBS Course is currently split into the ‘early’ years (years 1–3)and ‘later’ years (years 4–6), with the ‘early’ years including the mandatory integrated Bachelor of Science in year 3. The ‘early’ years involve basic science teaching followed by direct exposure to the healthcare environment in the latter 3 years of the programme.

Information for the study was advertised on the UCLMS noticeboard through their Virtual Learning Environment Moodle, UCLMS EDI Instagram page and UCL LGBTQ+Medics Network’s newsletter and social media platforms (online supplemental appendices 1 and 2). Five of the six participants were recruited through the UCL LGBTQ+Medics Network social media platforms and one through snowball sampling. Once participants registered their interest, they were sent a written consent form (online supplemental appendix 3) for completion prior to data collection. All participants were aware that they had 3 months from the interview to withdraw their consent. Data were collected over the 5-month period from October 2022 to February 2023 with six participants recruited. All participants were allocated a unique code and pseudonym. Of these six participants, five were in their ‘later’ years of the UCL MBBS programme (table 1).

Table 1

Participant information

Data collection

Forming the most popular method for data collection in phenomenographic studies, individual semistructured interviews were conducted for this study.41 The principal researcher, DL, was trained on conducting semistructured interviews from the principal supervisor, RC, who has experience in leading qualitative research studies. Consisting of eight questions, with additional prompts and probes, the interview schedule was piloted on a fifth-year UCLMS student, with experience in semistructured interviews prior to its incorporation (online supplemental appendix 4). Two questions were subsequently amended following feedback to ensure that they were not leading participants.

All interviews were conducted by the principal researcher, DL, a fifth-year medical student and typically lasted an hour. Participants were given the option of having the interview face to face, in a private room on UCL’s main campus or remotely through the online platform, Zoom. Consent was confirmed prior to commencing the interview, including permission for audio recording. A written transcript was generated from each interview through a third-party transcription process following a confidentiality agreement. Only the principal researcher had access to the original transcripts and audio recordings. All personal information from the original transcript was subsequently redacted before being shared with the principal supervisor, RC. RC used the amended transcripts for data analysis. Data collection continued until theoretical saturation was reached. Although theoretical saturation is considered vital for adding to the rigour of qualitative studies, its application in phenomenography has been questioned.42 It has been suggested that attempting to collect data until it is considered ‘complete’ to ensure generalisability to the wider population, detracts from the unique, personal experiences being shared as part of such research.42 Despite these criticisms, for this study, theoretical saturation was considered by both researchers, as the point when no new themes emerged during the process of data collection and analysis. This was to ensure that the study could be completed within a realistic time frame that would not compromise DL’s learning in their penultimate year of the MBBS undergraduate programme.

Data analysis

With the focus on presenting the variations in individual experiences, a key feature of phenomenographic studies includes the iterative data analysis process. While various analytical frameworks have been suggested, Marton et al43 describe the four stages, with the initial stage relating to the researcher becoming familiar with the data collected. The data are then subsequently ‘sorted’ into ‘pools of meaning’, which are compared and contrasted to generate categories. Using the above framework, both the written anonymised transcript and the principal researcher’s own notes were coded, line by line, before being categorised. To further enhance reliability and minimise researcher bias, the principal supervisor, RC, independently analysed the amended transcripts to generate a coding framework using the same technique. Both the principal researcher and supervisor met on a regular basis, creating the analytical framework (online supplemental appendix 5). Three iterations of a shared analytical framework were sent between both researchers before concluding on the final version.

Ethical considerations

One of the key considerations in the study was the role of the principal researcher, DL in this study. As a relative novice to educational research, support and supervision were provided by a member of the faculty, RC, who has a background in medical education. RC’s main role, at that point, was as a clinical lecturer at UCLMS and Head of the Gender Equality Network and she identifies as BAME.

As a fifth-year student. DL’s interest in this topic arose from their own experiences as a BAME, LGBTQ+ student. While DL was particularly interested in how this group of students could be supported, naturally their own background introduced certain issues related to the impact of researcher bias. This was judiciously discussed between DL and RC along with the intense level of commitment that conducting such a study would take alongside their undergraduate studies prior to commencement. Although it was felt that participants would feel more comfortable speaking to a fellow peer than a member of the faculty,44 concerns about peers acting as investigators on sensitive topics and how they subsequently view these participants in the future was acknowledged. To note, one of the participants was a fellow peer and it was made clear prior to all interviews of DL’s role as a researcher and that participant’s anonymity would be maintained. Due to the sensitive nature of the information being collected, all participants were also directed to support services available through the university and relevant external organisations both during and after the interview. Participants were also given the option of taking time out or terminating the interview, which none of them required. To mitigate the impact of researcher bias, DL and RC met regularly, especially during the data collection and analysis process to discuss their findings and DL’s own notes during the interview. This provided an opportunity for peer debriefing to be undertaken and for DL to explore any concerns about their own well-being. This proved crucial in enabling a richer and in-depth analysis of the data to be undertaken. Although member-checking was considered, it was felt that due to the sensitive nature of the data collected asking participants to ‘check’ their transcripts could potentially be triggering. Therefore, member-checking was not undertaken in this study.

Patient and public involvement

None.

Results

In the final iteration of the analytical framework, six main themes were identified and constructed from the participant’s experiences, which were then categorised into three main areas (table 2).

These themes will be discussed in further detail below with direct quotes from participants.

Challenges to intersectionality

Three main themes relating to conflicts between BAME and LGBTQ+ identity and how participants’ BAME background influenced their LGBTQ+ identity exploration were identified in this area. The final theme related to how individuals felt there were no true safe spaces to be themselves.

Conflicts between BAME and LGBTQ+ identity

One of the main themes related to the conflict participants felt when attempting to assimilate what were perceived to be two very different identities.

I feel like as [BAME identity] LGBT it’s kind of like, it almost feels like you don’t fit in with the LGBT people sitting together and you also don’t fit in with the [BAME identity] people. […] And it’s kind of like you almost feel like you have to choose.—006, Mira (‘later’ years, she/her)

The effect of this clash was clear with many participants describing a deep sense of shame for being who they were and in turn, hiding their LGBTQ+ identify out of fear.

I think the way in which my religion taught me to hate myself for who I fundamentally was, led me to outright reject my religion […].I always felt like there was the part of me that felt like I was fundamentally broken or evil, and that was so much reconciliation growing up, between my faith and my sexuality and it was almost—it—it in fact, it was too much for my mental health.—005, Claude (‘later’ years, he/him)

Participants also described the stigmatisation they experienced because of perceived stereotypes based on their religious or cultural backgrounds.

I almost feel an assumption sometimes from certain white LGBT people that, because I’m religious that I’mhomophobic…and I kind of find that uncomfortable.—006, Mira (‘later’ years, she/her)

The effect of being made to choose between their BAME and LGBTQ+ identity created unique challenges on how participants viewed themselves as future clinicians. While they already felt they were being held to a ‘higher standard’ than their white counterparts, being LGBTQ+ was considered an additional clash with the ‘typical doctor image’.

People have this image of what a doctor is… and they respect that image of the doctor, and if you don’t present that doctor image, you won’t get it. And I feel like, in medical school, being LGBT is very clashing with that image in a way—006, Mira (‘later’ years, she/her)

I try…to keep my head a little bit lower. In terms of like not being picked out, so not wearing anything too representative of both sides like I'm looking as white and as straight as possible at all times.—004, Olivia (‘later’ years, she/they)

For most participants hiding their LGBTQ+ identity was also critical due to the fear of being rejected from their community.

My parents are like, very deeply devoted and… I don't know if you know, but all the [BAME identity of 004—Olivia] are somehow interconnected to each other and they talk behind everyone’s back and, You know, once one [BAME identity that Olivia belongs to] adult knows, everyone knows it. It just spreads like wildfire. So, it’s like if you wanna keep the secret, you just wanna keep your head down.—004, Olivia (‘later’ years, she/they)

It was clear that participants felt a sense of isolation and a lack of belonging because they were unsure of where, and how, they ‘fitted’ in. There was also an overall belief that being LGBTQ+ and BAME ‘did not go together’ and for many, suppressing their LGBTQ+ identity was considered crucial, not just for their own psychological safety but also out of fear of the reprisals they would face from their own ethnic community.

BAME background influencing LGBTQ+ identity exploration

The second key theme in this area related to the differences that participants felt when exploring their LGBTQ+ identity compared with their white counterparts.

Because they [BAME LGBTQ+individuals] aren't out in high school, they don't get to do the sort of ‘normal teenage things’ of, like, having a crush and seeing whether they reciprocate, confessing to someone and have it go either right or wrong or even having their first relationship. […] I never got to learn that… because I was too busy trying to not let people know that like I was like LGBTQ+—002, Aris (‘later’ years, they/them)

While there were limitations in the exploration of their LGBTQ+ identity during adolescence, this was superseded by a sense of ‘catching up’ on starting university.

Growing up despite that feeling of loneliness and being misunderstood, I knew there was this desire, to get out of my current situation. And for me that was through pouring myself into my studies and education and getting a place to university. I knew that would be the next step to really seeing the wider world, seeing what else is out there—005, Claude (‘later’ years, he/him)

For one participant though, the continuing challenges of living at home were described.

I live at home with my parents and they are quite a big part of my life. Even if I wanted to present in another way it wouldn’t really be possible anyway. And I think it kind of sometimes gets to the point of like, because I’ve sort of presented like this for so many years, I’m not really sure what I want to do anyway. […] If I just sort of spent lots of time away from home or something like that, I’d kind of be able to break those barriers down.—004, Diana (‘later’ years, she/her)

While coming to university and moving away from home offered most participants a chance to explore their LGBTQ+ identity, ‘hiding’ this aspect from their own ethnic community remained important, limiting the scope for these participants to truly develop their authentic self. It was also clear that the concurrent development of both the authentic, LGBTQ+ and BAME identity with their professional self was emotionally exhausting for most participants. As a result, many chose to only develop their BAME identity along with their professional identity as a future doctor, as it was considered less likely to clash and therefore, easier to do.

‘No true safe spaces’ for BAME and LGBTQ+ students to be themselves

It was clear that participants felt a real sense of isolation and this was often heightened by various initiatives, which were not considered to be fully inclusive despite being orientated for medical students who identified as LGBTQ+.

I didn’t feel like they [EDI initiatives] were inclusive, but it was inclusive in a silo if that makes sense? It was inclusive like, ‘Here’s the space for the gays and we’re going to be inclusive over here.’ It’s not like fully inclusive.—006, Mira (‘later’ years, she/her)

Participants also highlighted how they felt that the majority of LGBTQ+ spaces felt white-centric.

I could also get the sense that like [LGBTQ+medics at a social] didn't have to worry about like being like a visible minority. Because while London is very diverse, like there’s still concerns about being a visible minority, […] I could just sort of tell that like they didn't have to worry about that sort of thing, which colours your experience of life.—002, Aris (‘later’ years)

I just felt that I really could not be open to this like bunch of strangers. Because they all looked very different to me, they all had like completely different life experiences to me. I think there was one session on sort of like discussing your biggest concerns about being LGBTQ+in the medical school and some of their concerns did match up to mine, but not many of them really did.—003, Diana (‘later’ years)

For many participants, this sense of isolation was further compounded by the lack of awareness of the medical school’s ‘social scene’ and in particular, the structure and hierarchy associated with sports club.

I did try out [sport] at first and I went to the sports night, thinking about it as a sport night […] the games were quite sexual actually […] I was so, so, so glad I wasn’t chosen but at the same time I felt so bad for the participants. Like what if they weren’t that willing to do that,—001, Ace (‘early’ years, she/her)

The challenges of navigating the ‘drinking culture’ was also described by all participants, with no difference seen between UK and international medical students.

And it was basically us at the pub, which is fine. Like now… this sounds really weird, but now I am familiar with the concept of pubs… but like again I was 18, I never really properly like frequently drank before and I was the only first year and a table of, like, people who aren't first years. And I was just, like, slightly terrified. Yeah… so it was kind of like intimidating- also because I think I was the only [specific BAME identity].—002, Aris (‘later’ years, they/them)

It was interesting to note that despite the various EDI events being designed to enable medical students to feel more welcome and ‘part of the group’, it often had the opposite effect, negatively affecting participant’s sense of belonging. With the latter being key to the development of professional identity, many participants felt ‘left out’ at LGBTQ+ events, which were considered white-centric and at sports club events. With alcohol featuring strongly in the latter, it appeared that this had a direct negative effect on how well these participants felt they fitted into the medical school environment.

Benefits to intersectionalityInsights into the self

One of the main themes that emerged in relation to the benefits of intersectionality related to how it afforded participants greater awareness and insight into their self and the challenges faced by others in a similar position. For many, it was an opportunity to raise awareness of the complexities relating to inclusive healthcare, which was considered lacking within the undergraduate programme.

I am quite vocal about it [trans health] and I sort of try to educate my peers about their situation because as far as we are taught in the medical school for the past nine/ten weeks, there’s nothing about it in the curriculum.—001, Ace (‘early’ years, she/her)

For participants in their ‘later’ years, they described how their experiences had affected the way in which they saw and examined patients, with one participant recounting their experience with a Trans patient,

I feel like it would be a bit unfair to the patient if, like he had been given a cis-het medical student who wasn't like properly educated about this beforehand—002, Aris (‘later’ years, they/them)

There was a sense that by being BAME and LGBTQ+, participants were more attuned to patient’s experiences from minoritised communities due to a shared understanding of the complexities they faced.

I think I try to pay loads and loads of attention to intersections and things that I personally don’t understand, […] because…it’s not like nobody understands lived experiences, it’s that nobody even wants to put the effort in.—006, Mira (‘later’ years, she/her)

This sense of responsibility to ‘educate’ their peers and ensure that it did not affect the care for those in a similar position to themselves was seen among all participants, illustrating the advantages of intersectionality in patient care.

Protective factors

The importance of peer support networks and increased visibility within the undergraduate programme and clinical environment emerged strongly as the key themes participants found helpful in developing their sense of acceptance and belonging within the medical school.

Peer support networks

The importance of peer support networks was cited by all participants as their biggest source of support.

I would say that I’m lucky in that I’ve found quite a few friends who are supportive of me being who I am.—001, Ace (‘early’ years, she/her)

The most positive thing for me at university was just all the amazing source of sources of support I got from my friends during my time at university.—005, Claude (‘later’ years, he/him).

With all of these networks developing serendipitously, participants acknowledged the trust it required in being comfortable and psychologically safe to ‘open’ up.

I think this is the whole thing of like living with a group of medics and it’s like you know, speaking to them all the time and like you end up kind of sharing quite personal things. That was, that was very like cathartic. And that was really the biggest thing in terms of like support that medical school has for me. […] I don’t think I’ve been as open with anyone as I have with like my medic friends.—003, Diana (‘later’ years, she/her)

While some participants had not accessed more formalised networks, such as the RUMS (Royal Free, University College and Middlesex Medical Students’ Association) LGBTQ+ Society, they were nevertheless considered an important source of support for others who may be struggling.

The RUMS LGBTQ+society really helps me because also […] there’s like, there is a community here that I didn’t see before and I think that was a moment.—006, Mira (‘later’ years, she/her).

For all participants finding someone they could be fully open with was vital in developing their self-acceptance. While this developed naturally for most participants, it was acknowledged that having formal networks was useful in providing students with access to additional support.

Visibility within the university and clinical environment

Visible signs of allyship and representation were also important for participants. These ranged from perceived ‘small’ acts such as staff members adopting pronouns on their email signatures to displaying rainbow lanyards within the ‘later’ years environment.

The medical school admin and emails with staff members adopting the pronouns was very significant. it made me feel like the system is more inclusive […] And so you were more likely to approach them.—004, Olivia (‘later’ years, she/they)

Seeing doctors with Rainbow NHS badges or rainbow lanyards, or just any sort of bit of visibility like that makes me feel like this is a safe space. I feel like, as someone who has been through a lot of LGBT focused trauma in the past, it’s so important for me to be in a place at work, which I know is a safe space—005, Claude (‘later’ years, he/him)

Participants in their ‘later’ years also described the importance of role models, especially seeing senior LGBTQ+ figures in the medical school in prominent positions.

I think it is also helpful having like… like LGBTQ+members of staff at UCL as well, in quite like high up positions as almost role models.—005, Claude (‘later’ years, he/him)

Interestingly, all named LGBTQ+ role models were white, and it was acknowledged by participants that being ‘out’ and BAME was still considered taboo. While it was felt that this would help, participants also believed that it was unfair to place this degree of responsibility on individuals.

It just takes people, brave enough to be a representing face. But then, why should someone have to take that sacrifice?—005, Claude (‘later’ years, he/him)

All participants were also asked if there were any specific interventions that they considered would be helpful for increasing inclusivity for BAME, LGBTQ+ medical students. While all agreed that more teaching and learning was required to specifically address the issues from an intersectional lens, there were no concrete suggestions on how this could be implemented within the undergraduate programme.

Discussion

By looking at the experiences of BAME, LGBTQ+ medical students at UCLMS, this study was able to identify the unique challenges faced by this group. While participants felt that they were more commonly characterised by others based on their ethnicity, neither identities emerged as the sole identity, instead, they were inexplicably intertwined in how participants saw themselves. Both identities were, however, considered to be in contention with each other and with the ‘typical’ physician. Similar to previous findings looking at PIF among BAME or LGBTQ+ medical students, this study identified how participants felt that they had to work harder and suppress their true identity.19 21 33 45 However, by adopting an intersectional lens, this study was able to recognise the additional barriers faced by this group of medical students, navigating LGBTQ+ spaces that were considered white-centric and the deep sense of fear of being ‘cast-out’ from their ethnic community. Crucially, developing a close network of ‘like-minded’ friends was vital in cultivating a sense of belonging. While this was very much dependent on chance, participants did voice the importance of having formalised networks but that these spaces needed to be more ethnically diverse with greater representation from the BAME, LGBTQ+ community. The degree of conviction this needed from individuals who were willing to be openly ‘out’ was, however, equally acknowledged. A wider discussion on the policies and actions required at an educational level, that addresses the challenges posed by identity formation from an intersectional lens is however, required.

Although this study provided valuable insight, there were limitations. First, it was conducted at a single London-based medical school and with local population demographics varying significantly, there are difficulties in extending these findings on a national level. London has one of the highest diversity rates in the UK, where 46% of the population identified as BAME compared with only 7% in the North-East.46 This is also illustrated at the medical school level, where 54% of medical students registered as BAME at UCLMS compared with 9% in Dundee in 2020.17With data from the MSC17 demonstrating clear differences in academic performance gaps regionally between BAME medical students compared with their white counterparts. This suggests that the environment plays a crucial role in the support and access to resources available to those from minoritised communities. While this may be equally reflected for those who identify as LGBTQ+, presently this data is not collected either at a university level or nationally. However, with a recent report by the Scottish Equality Network identifying that LGBTQ+ individuals living in rural areas face greater discrimination due to more traditional gender roles and conservative communities,47 it is probable that regional differences exist on how ‘out’ individuals can be and the support they receive. Extending this study to a wider level would, therefore, provide further insight into the potential barriers that individuals may face who identify as BAME and LGBTQ+ in rural settings.

Second, despite the vigorous recruitment drive through UCLMS MBBS noticeboard and social media channels, the number of participants recruited in the study was small with greater representation in the ‘later’ than ‘earlier’ years. While a small sample size is not unusual in qualitative research with the focus being instead to gain in-depth and rich data,42 a large number of participants had not been anticipated given the research question being asked and the degree of courage required to speak about personal experiences. This may explain why representation was greater in the ‘later’ year students, with this group being more confident about ‘who they are’ compared with ‘earlier’ year students who may still be struggling with reconciling their BAME and LGBTQ+ identity. The small sample size may also explain the limited insight gained on how medical educational practices adapt to ensure that issues related to intersectionality are addressed in the undergraduate programme. Interestingly, during the process of data collection and analysis, it was noted that no new themes emerged after the fourth interview. However, as two students had expressed interest in participating, they were included in the study to see if further insight could be yielded. No additional insight was gained and it was acknowledged that this may be due to both participants being in their ‘later’ years. In addition, the small numbers recruited may explain why certain themes did not emerge strongly, especially in relation to the experiences of international versus UK-born students. It had been expected that for the former, certain elements of ‘British’ culture related to drinking alochol and university life may have introduced additional challenges. It also has to be acknowledged that how reflective the study findings are to the overall BAME, LGBTQ+ medical student community is difficult to ascertain because the actual numbers are unknown, with details on the latter not currently being collected by the university. Third, member-checking was also not undertaken in this study after due consideration from the researchers, as it was felt that with the nature of the data collected, this could be triggering for some participants. Within the literature, the limitations of member-checking have also been described with participant apathy not uncommon and perhaps more worryingly, requests for changes to the data affecting the data analysis process.48 Finally, while the role of DL as an inside researcher was useful in creating a sense of rapport with participants, reducing the impact of imprinting was crucial. Therefore, both the principal researcher and supervisor independently analysed and developed a coding framework before meeting to compare their notes and create a unified, analytical framework. To note, the principal supervisor, RC, only had access to the redacted transcripts to limit any bias and potentially any concerns that students could have on how their progress may be affected through their participation in this study.

Despite the limitations, the insight afforded by this study on PIF from an intersectional lens is clear. As a relatively under-researched area both within medical education and in the UK, understanding the complexities of PIF from a BAME and LGBTQ+ perspective is vital for supporting medical students. Some may question that this understanding is not unique, that there was limited insight on how educational practices specifically adapt and that the protective factors could be universally applied across medical education. It, however, did identify that widening the scope of established initiatives to be more inclusive is vital for creating a safe space for individuals to explore their identity. By addressing these unique barriers, perhaps visibility among the BAME, LGBTQ+ medical community will improve, the benefits of which still appear to be outweighed.

Data availability statement

Data are available on reasonable request. No outside data were used for this study. Due to the sensitive nature of the data collected and to protect the participant’s anonymity, any requests to view the data collected will be carefully considered on request.

Ethics statementsPatient consent for publication

Not applicable.

Ethics approval

This study involves human participants and ethical approval was gained from UCL Research Ethics Committee (ID 23087/001). Participants gave informed consent to participate in the study before taking part.

Acknowledgments

I would like to thank all the participants for their support and for consenting to be part of this study. This study would also not be possible without the support of UCLMS, in particular Dr Faye Gishen and Dr Jayne Kavanagh.