Policy responses and statements
Background: This consultation was on a revised version of the guidance Medical students: professional behaviour and fitness to practise and other proposed options to promote consistency in student fitness to practise. Why is this consultation process taking place? Until the 1990s, few medical schools had a robust mechanism to remove students from a course who were academically able but whose conduct or health raised questions about their fitness to practise as doctors. Instead, the medical schools relied on the generic university-wide disciplinary procedures, which did not necessarily require the professional standards set out in Good Medical Practice. Following consideration by a working group set up by the Council of Heads of Medical Schools (CHMS) (now known as the Medical Schools Council) on ‘Connection between medical graduation and provisional registration’ and following advice from Eversheds Solicitors, all universities with medical schools agreed in 2001 to introduce fitness to practise committees. At present, universities with medical schools vary considerably in statute and regulation. For this reason among others, there may be significant inconsistency between fitness to practise procedures in universities. In 2005, the General Medical Council (GMC) and Medical Schools Council (MSC) established the joint Student Fitness to Practise (SFTP) Working Group. The purpose of this group is ‘to discuss and determine principles and practical arrangements through which universities and the GMC can confirm the fitness to practise of medical applicants, students and graduates at the point of entry to the provisional register’. In order to improve consistency in student fitness to practise and protect patients and promote public confidence and trust in the profession, the SFTP Working Group consulted on and published guidance, Medical students: professional behaviour and fitness to practise (SFTP guidance), in September 2007. The SFTP guidance focuses deliberately on behaviour (or conduct) issues and does not deal with health issues. Copies of the guidance were sent to the deans of medical schools and a pamphlet outlining the expected behaviours by medical students was sent to all UK medical students. The aim of the guidance was to balance a positive approach to professional behaviour of medical students with the more specific advice for medical schools on how to develop consistent fitness to practise procedures. Implementing the guidance: In October 2007, the Working Group asked medical schools as part of the GMC Quality Assurance for Basic Medical Education Annual Returns questionnaire to reflect on the initial use and future developments of the SFTP guidance. The purpose of reviewing the reception of the guidance within a short time of its publication was to identify areas of good practice as well as challenges for implementing the guidance into the local arrangements. This early work laid the foundations for a systematic and regular mechanism of evaluating the impact and usefulness of work on student fitness to practise. It also helped to identify aspects of the guidance that could be improved in order to make it a more useful tool for medical schools in developing consistency in SFTP. A full report on the feedback from the medical schools is in Annex A (96.7k,pdf). Summary of findings: In general, there is ongoing support for the guidance and it has been well received by the medical schools. It has been widely disseminated to both staff and students. Aspects of it will inform curricular development and learning objectives. Most schools are taking practical steps to integrate the guidance into their local policies and procedures as well as ensure students are more aware of their professional responsibilities. The most difficult areas for implementing the guidance involve the interface with the university procedures and interpreting key concepts with the guidance such as the threshold of acceptable behaviour. There are still concerns involving sharing information about students. A number of schools have taken steps to ensure that students are aware that fitness to practise information can be shared with a number of organisations in the interest of public protection. However, schools would still welcome further advice and a process for disseminating fitness to practise information to other medical schools, professionals and the GMC. Mental health and disability was identified as an area where further guidance and support would be most welcome. Issues were raised applying the sanctions and dealing with the boundary between informal and formal concerns. A number of schools would also like clarity on admissions and fitness to practise. Most schools would like the GMC to develop a process for disseminating case studies and good practice as well as give advice on specific cases, provide training/workshops and possibly be involved in local panels. Engaging people on student fitness to practise: As a result of this feedback and ongoing work on student fitness to practise, the GMC/MSC joint Working Group held a one-day workshop event on 30 April 2008 in London. The purpose of the workshop was to consider the scope, effectiveness and implementation of the SFTP guidance as well as develop other work streams in this area. The event was well attended by over 85 people with all medical schools represented. A number of medical students, postgraduate deans, Foundation Programme directors as well as experts in health and disability attended. Key people from the GMC also attended whose areas of work interface with and impact on student fitness to practise, including Registration, Fitness to Practise, Standards and Communications. The main themes picked up by the group discussions indicated the need for greater: a. Support for advice on health issues in student fitness to practise. b. Support for ensuring a division between student support and fitness to practise. c. Clarity on the definition of student fitness to practise that recognises the educational / learning journey of medical students. d. Clarity on the implications of Foundation Programme Year 1 doctors undergoing student fitness to practise procedures at medical schools. e. Clarity on the threshold of student fitness to practise. f. Detail on aspects of the procedures such as applying the sanctions, the panel composition and training investigators / panellists. g. Support for using the QABME process to help develop consistency between medical schools through evaluation of process and ensuring the SFTP guidance was implemented. h. Reflection on an anonymised database of cases to be made available to medical schools. i. Support for a protocol for sharing information based on the advice from the Information Commissioner’s Office and a move towards more consistency in how information is shared with postgraduate deans, Foundation Programme directors and employers would be supported. j. Support for the development of mechanisms to encourage cross-institutional discussion and support such as meetings and newsletters. COMMENTS ONGENERAL MEDICAL COUNCIL/MEDICAL SCHOOLS COUNCILSTUDENT FITNESS TO PRACTISE CONSULTATION - REVISED VERSION OF 'MEDICAL STUDENTS - PROFESSIONAL VALUES AND FITNESS TO PRACTISE'The Royal College of Physicians of Edinburgh is pleased to respond to the GMC on its Student Fitness to Practise consultation - Revised version of 'Medical Students: professional values and fitness to practise'. General commentsThere are several aspects of the revised version that are to be welcomed. These include the increased emphasis on the learning journey of the medical student and of the various elements that may determine Fitness to Practise (FtP) decisions on a case-by-case approach, taking into account, for example, the year of study and degree of maturity of the student. In addition, there is now a greater emphasis on ensuring that student FtP has a large supportive and remedial function, which should be addressed before serious FtP proceedings are considered. It is desirable to try to achieve greater consistency between Medical Schools without being too prescriptive, so that local factors can be accommodated. This includes acknowledging differences in the legal systems between Scotland and England. The early issue of this revision with integration of guidance on health and FtP is to be welcomed, as this guidance is now much more complete. The current guidance should be allowed to work in practice for some time before any substantial further revision should be attempted. The threshold diagrams and outline occupation health protocol are very helpful. Specific comments:1a. Does this section of the guidance improve an understanding of the professional responsibilities of medical students? Yes. Para 11: The phrase "are often acting in the position of a qualified doctor" is inappropriate. Taken literally, this situation is now unusual and really only applicable to students’ assistantships, which are now uncommon because of medical legal constraints. As it stands, the sentence could be seen as sanctioning medical students doing the work of qualified doctors. It is suggested that the phrase is removed, leaving the statement that students must be aware that their activities can and will affect patients. Para 16b: This whole section is expressed as a set of positive principles and responsibilities and wherever possible, expressing these in negative or double-negative terms should be avoided. For example, one could replace "not mislead or misrepresent their position or abilities" with "accurately represent their position or abilities". Similarly, under 16f a more consistent statement would be "avoid discrimination against patients by allowing ...". Para 20: This paragraph states the obvious and does not add anything to the document. If it is to be retained, then "to it" at the end of the first sentence is not grammatically correct. Para 23: This appears to repeat Para 11 and could be removed. Para 34d: The double negative "not misrepresent" could be replaced with "accurately represent". Para 37b (and see Para 50): Why is this such a weak statement? The stem statement is "students should …" and would be better stated “should register with a general practitioner” or “would be expected to register with a general practitioner”. Para 37d: The word "accurately" should be inserted before "assess". Para 37g: This is a rather clumsy paragraph. A suggestion might be "ensure an independent objective assessment of the risk posed to patients by their health, seeking advice when necessary …". 1b. Do you think this section is or could be used as a tool to help students understand their professional role and responsibilities? Yes. We think this could be used as a tool by medical schools as part of their personal and professional development themes in the curriculum. The GMC could encourage this by active dissemination and through the QABME process. Students could be offered a tutorial at the start of each year to ensure they are aware of their professional role and responsibility. Part 1.2. Revising the Guidance: the scope of student fitness to practise 1c. Would it be useful to include a decision-making chart (or charts) as an Annex in the SFTP guidance to clarify the approaches taken by medical schools? The flow chart in Annex C seems a useful visual representation of those processes in general use and is helpful. 1d. Does the revised section offer useful advice on the interface of student support with student fitness to practise? Yes, this is a useful statement. It is important that students are encouraged to seek help early so that health issues do not become a fitness to practise concern. Para 42: The word "may" could be replaced with "will" since there are few, if any, circumstances in which a medical school would not offer support to a student undergoing fitness to practise procedures and sanctions. 1e. Does the section strike the right balance between supporting students in a learning environment and protecting patients? Yes. 1f. Does the advice on health in student fitness to practise help to clarify how health issues could be addressed by medical schools? Yes, this is helpful, but as stated elsewhere, some of the issues are more relevant to the Admissions Working Group than to this consultation. The statements about occupation health services are of interest (paragraphs 50, 51 and 53). Taken together with Annex D, this seems to be predicated on the idea that all medical schools will have their own occupational health service, staffed by occupational health physicians and nurses. In reality, this may be relatively uncommon, and it is doubtful whether all universities have an occupational health service (as opposed to a university health centre providing GP type care). Medical students are, of course, patients of the National Health Service and have access to the resources thereof. The support staff for students in medical schools are used to working with students’ general practitioners, NHS specialists when appropriate (and for specific issues such as blood-borne virus testing), occupational health departments in the NHS. Unless there are specific problems and issues that are not made explicit in this consultation, there is no compelling argument for change. Certainly, the idea that the occupational health service should be the first point of contact for raising concerns about medical students, rather then the student support staff of a medical school, seems unusual and is not supported by any cogent arguments. 1g. Would a general protocol for Occupational Health as set out in Annex C be useful to include in this guidance? Yes. Please see above. 1h. Should student health services and GPs be encouraged to inform medical schools about students that may raise concerns? How should this be done and to whom? Does the revised guidance address this issue appropriately? Most certainly - yes. All medical schools must have clear lines of communication for reporting in such concerns, normally through an Associate Dean for Student Affairs, a senior administrator or similar position. As mentioned above, the revised guidance, if anything, rather muddies these waters. A student should be encouraged by their GP to inform medical schools of a disability so they can receive support. If the student refuses and the issue could affect patient safety then they should inform the student that they have an obligation to inform the medical school. (As a minor pedantic point, it is grammatically undesirable to start sentences with the word "but", still more, paragraphs (paragraphs 46 and 57).) 1i. Does this section of the guidance clarify the roles and responsibilities of medical schools, students and the GMC in fitness to practise at the point of registration? Yes. This section seems clearer and helpful. It is important that the GMC is able to give students advice at an early stage as to whether they would be eligible for registration with regard to issues that may have happened before entering medical school or early in their undergraduate career. 1j. Does this section in the guidance help medical schools address concerns about F1 doctors? Yes. Students should be aware of the importance of achieving all foundation year 1 competencies before registration. The word "consequently" is incorrect here. As the paragraph states, the European Directive about basic medical training is entirely time-based and makes no reference to competences. Thus, the second sentence does not follow from the first. In fact, paragraph 70 of the consultation document is a more accurate statement. Otherwise, this section is clear. 1k. What other aspects should be addressed in this section? In relation to the various scenarios in paragraph 73 of the consultation document, there should be recognition of the realities “on the ground”. At least in Scotland, Foundation doctors are the responsibility of the Postgraduate Deanery. The Deanery, in turn, is part of NHS Education Scotland. The Postgraduate Dean is appointed and employed by NHS Education Scotland rather than the University. He/she, in turn, appoints the programme director and associate directors for foundation. In South-East Scotland there is excellent communication between the postgraduate deanery and the medical schools in relation to foundation, with effective two-way flows of information and good feedback regarding performance of our graduates. We have a single Fitness to Practise Committee, which considers cases from both the undergraduate programme and foundation. However, it is clear that the overall responsibilities and accountability in relation to foundation are completely different from those of the undergraduate programme and reside almost entirely with the postgraduate deanery and, through them, with NHS Education Scotland. Given that scenario, it seems clear to us that fitness to practise issues should be conducted by the deanery where the F1 doctor is located. The same would apply to F1 doctors who are not UK graduates. 1l. How does your medical school (if applicable) address issues of fitness to practise for F1 doctors? Please see above. For example, the medical school in Edinburgh operates a joint Fitness to Practise Committee. However, where a foundation doctor is involved, the investigation and preparation would all be carried out by the postgraduate deanery (part of NHS Education Scotland). 1m. What further advice or guidance would be useful in addressing fitness to practise issues for F1 doctors? If there are any concerns regarding a patient at medical school a report should go to the foundation tutor. Part 1.3. Revising the Guidance: the threshold for student fitness to practise 1n. Does the definition of student fitness to practise set the appropriate level and scope expected in medical students? Yes In general this is satisfactory, although the paragraph again repeats the content of paragraphs 11 and 23 and seems unnecessary here. Para 71: This also seems a repetition of much previous content. Para 73: A more accurate statement would be "It is a responsibility of medical schools to decide if individual medical students are fit to practise as doctors by the time they graduate.". The current version, particularly if read in isolation, could be taken to mean that the GMC has no responsibility for the fitness to practise of new doctors. It is also the case that medical schools have many other responsibilities to fulfil. 1o. Should the guidance refer to the possible sliding scale of seriousness of fitness to practise concerns to emphasise the learning pathway? What are the risks of referring to this issue in the guidance? No. This issue should not be addressed in the guidance. There is a contrary view that students who are not suited to medical practice should switch to an alternative career at the earliest possible stage. The true tragedy is the student who studies for 5 or 6 years before appropriate decisions are made. Where there are balancing factors related to immaturity, personal circumstances etc then these can be left to the wisdom and discretion of the Fitness to Practise Panel. We do not think this requires high level guidance. 1p. Do the explanations for applying the threshold improve clarity and understanding about using the threshold? No. The section 77 and 78, illustrating the threshold of student fitness to practise to be helpful, is not particularly helpful when set alongside the section on categories of concern, which has already been the subject of extensive consultation. It does not add anything to the overall document. Para 75: It is not evident why it is necessary to recommend that university disciplinary procedures should precede medical school fitness to practise procedures. Depending on the precise circumstances, there may be situations where the opposite is desirable. Unless some justification for this sequence can be offered, it does not merit inclusion. 1q Are there other circumstances that could be included? - Part 1.4. Revising the Guidance: making decisions 1r. Does this section address decision-making in the right detail? Yes. The level of detail is appropriate, other than the civil standard of proof (see 1v). 1s. Does the revised section improve understanding and clarity on making decisions? Yes. 1t. Is it useful to set out the different roles of the investigator and panel? Yes. 1u. Does the more detailed section on sanctions help improve understanding about how they should be used and applied? Yes. 1v. Should the guidance recommend that medical schools apply the civil standard of proof (balance of probabilities)? The current content in relation to the move to a civil standard of proof is inadequate. In fact, as far as can be seen, it does not figure in the section on "Making Decisions" at all and is confined to a single sentence in paragraph 138 and a single bullet point in paragraph 144. Particularly for readers who are not familiar with the legal niceties of different standards of proof, a much more detailed account of the significance and implications of this change must be included if this recommendation is going ahead. This might include examples of different outcomes where the two different standards have been applied. It does seem desirable that there should be congruence with the standards for practising doctors, but without a great deal more information and explanation it is really not possible to extrapolate how this might influence undergraduate fitness to practise hearings. Part 1.5. Revising the Guidance: key elements in student fitness to practise arrangements 1w. Does this section of the guidance help medical schools develop a more consistent approach to fitness to practise procedures? Yes. In terms of paragraph 130, presumably the GMC are aware of the Transfer Of Information forms and procedures that are being introduced by the Foundation managers, led by Professor Derek Gallen. In the interest of developing consistency it may be useful, in the absence of direct GMC representation, to suggest that each panel should have a member from another medical school/deanery (perhaps nominated by the GMC). 1x. Is there anything else that should be included or set out in more detail? Medical students, like all students, have the right to appeal to the Central University against exclusion. Appreciating that the issues for medical students (and for other vocational professional courses) are different, the University of Edinburgh has established a University level Fitness to Practise Committee constituted with the appropriate expertise amongst its members. Students subject to exclusion by the Medical School Fitness to Practise Panel would have the right of appeal to that Committee, not to the normal University Appeals Committee. This seems good practice and perhaps the guidance should specifically recommend such an approach? Decision-making chart (Annexe C)This is useful in setting out the main pathways and could be included in the guidance. The degree of student/F1 doctor insight into their difficulties is crucial in determining how problems are dealt with, whether they are of conduct or health in origin: a student whose Fitness to Practise is thought to be impaired through health or disability may need to be considered by a full panel if they do not recognise their limitations. Part 2. Developing options and tools to support student fitness to practise2a. Please say which of these options would provide further support to student fitness to practise? Para 83a: Considering the small number of cases involved, this seems an unnecessary layer of bureaucracy and the obvious potential for the GMC to cross check self-declarations with medical schools would be sufficient in itself. Para 83c: This would not be particularly helpful. There is a danger of real cases being wrongly identified with particular hypothetical examples rather than being dealt with individually on their merits, as recommended elsewhere in the document. Para 83i: As mentioned above, this is already happening and 83e seems desirable in this, as in various other areas of educational provision. All other options seem desirable. 2b. Can you rank in order of importance (starting with the most important), which tools would be most valuable? b, h, i, g, f, e and d. 2c. Are there any other mechanisms that can be developed by the GMC or MSC to support student fitness to practise? It is important that this is an integral part of the medical student curriculum in 1st year. 2d. What areas of SFTP should be considered for a training package for medical schools? There is no obvious case for selecting out particular areas for a training package, which should cover the whole spectrum of the guidance. 2e. What would you like included in a training package and how would you like this to be delivered? See above. While face-to-face provision would be welcome, an on-line format seems most efficient. 2f. What further practical measures may be useful? As stated in previous consultations, it is difficult to understand the objections to having a medical student register with the GMC. As time goes by, the requirements and stipulations from the GMC in relation to student fitness to practise become both more explicit and more extensive. The obligations on students and staff of the medical schools become more onerous. Student registration would, undoubtedly, be of enormous benefit in helping both students and staff to ensure that these vital areas of medical student education and training are given the attention they deserve. The terms and conditions of student registration could be designed so that they are proportionate in relation to the situation of medical students. It would emphasise their particular situation in relation to the rest of higher education - which underlies virtually all of the guidance in this document. Part 3. Opportunities to engage and influence students3a. What are best ways of developing useful guidance for medical students on their professional behaviour and values? Other than widespread consultation with appropriate bodies, including experts in the medical schools and elsewhere, it is unclear what other processes can be recommended. 3b. What other ways should medical schools and the GMC develop to get students to engage with professional values? As mentioned above, the single most obvious and helpful measure would be to introduce some form of student registration as a tangible, concrete manifestation of the particular values and responsibilities pertaining to these students. 3c. How should professionalism best be assessed as part of the curriculum? It is not clear how this relates to the current consultation, but there are well-established techniques, such as workplace based assessment, portfolio submissions, e-learning and peer assessment. Almost any form of assessment can be used to assess specific aspects of professionalism, including essays, vivas and OSCE stations. Effective personal mentoring by staff, and sufficient continuity of contact between individual staff and students to allow accurate assessment of professionalism, are important aspects, which relate directly to the structure and design of medical curricula. Copies of this response are available from: Lesley Lockhart, Tel: 0131 225 7324 ext 608 [19 September 2008]
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