Pledges and charters in medical schools: catalysts for change or performative promises?

Personal stories, citizen journalism and social media – sources of information made more visible through wide access to the internet – have contributed to rising social consciousness. The pandemic lockdown, which resulted in people spending more time online, brought many into closer proximity to events across the country and the world. As a result, engagement with social justice movements also rose across categories, and with it a sense of responsibility to effect change.

With a similar rise in activism among medical students, such as higher participation in discussions and movements, medical schools might seem to be a microcosm of wider society. Discourse has increased around racism, misogyny and LGBTQ+ issues, not only in medical education journals but also more widely in newspapers and public discussion forums. So the encouragement from trade unions, global movements and organisations for medical schools to sign pledges, charters or initiatives demonstrating their support of the aims detailed in the document is not surprising.

Recent examples of charters and pledges include:

• The British Medical Association (BMA) racial harassment charter (2020)
• Statement of solidarity with Jewish students at Bristol University (2021)
• UK Medical Schools Charter on so-called LGBTQ+ “conversion therapy” (2021)
• Stonewall’s Diversity Champions Programme (2021)
• An initiative led by medical student societies to advocate for reform to the NHS bursary provision (2023)
• BMA’s ending sexism in medicine pledge (2023).

At first glance, these pledges and initiatives seem to be clear, well-intentioned statements about institutions’ stances on matters that could be reassuring to students. There might also be guidance about how to demonstrate or promote positive behaviours or cultures in line with the pledges. They may offer sources of accountability and provide benchmarks for progress.

However, upon deeper reflection I have found myself questioning their utility and have become concerned that they could even be detrimental to progressive action.

When the conversations in institutions begin with “What happens when this pledge is signed?”, they risk overlooking what has been happening before. What was the institution’s stance on the matter before this? Did the culture on campus and experience of staff and students reflect this? I think it is important for institutions to understand what processes and structures had already been implemented and critically examine what challenges are preventing their progress and why. This will allow identification and prioritisation of tangible actions and facilitate a more strategic approach to generating impactful change.

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There is a danger that pledges and charters – neatly packaged, with definable and measurable outputs that allude to the work required being similarly succinct – oversimplify highly complex topics. At best, these pledges will garner interest and revive enthusiasm; they might even attract pockets of funding. There is also the risk that faculty will see involvement as an opportunity to progress their careers, especially if implementation of the charter is attached to a leadership position. Individuals wishing to become involved should seek to understand what work has been and is being done (often by minoritised staff whose work is not formally recognised nor adequately resourced), and how these efforts can be supported and developed further. Institutions should make a concerted effort to invest in existing structures and staff, in addition to supporting new initiatives.

Another important consideration is how we measure change and evaluate the impact of interventions. We need to be brutally honest with why and how we evaluate initiatives. Are we measuring purely to demonstrate that we have done something or are we truly invested in measuring tangible change? How can we quantify such broad and intersecting domains in a meaningful way? Even qualitative feedback, which might capture the effect more successfully, is often scrutinised, with subjectivity and contextualisation used to critique its robustness.

Signing charters and pledges requires more than just a signature. The work is likely to be time-consuming and complex. Below are tips for institutions to consider when supporting EDI initiatives:

1. Consider the resources that you have allocated to supporting this work. Financial commitment, inclusion of tasks on job descriptions and acknowledgement of work in appraisal and promotion pathways is essential to ensure sustainability and reflect the institution’s commitment and the value of the work being done.
2. Seek out and engage with staff already doing EDI work. Many of these staff will have worked closely with students and staff and will have a good understanding of the nuances within your institution.
3. EDI work cannot be successful in isolation; even the smallest projects will require buy-in across teams and might involve policy changes. This interdisciplinary approach, although more time consuming, promotes sustainability and success.
4. Accountability is important for institutions, their staff and their students. There should be transparency in the process and institutions should make their objectives, plans and timeframes available for review.
5. Careful consideration should be given to evaluation methods and what are defined as measures of success.

Pledges and charters should be a reminder to review ongoing work, reflect on the impact that has been made, re-evaluate strategies and consider refreshing ideas and initiatives. We should always consider the desired and unintended consequences that signing pledges might have for staff, students and the university.

Lois Haruna-Cooper is a clinical (teaching) lecturer in the Centre for International Medical Education Collaborations at University College London (UCL). She is also a co-chair of UCL Medical Schools’ equality, diversity and inclusion committee and a member of the Medical Schools Council EDI Alliance.

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