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Student support is essential, but so is protecting the public
Medical students can acquire the knowledge and skills that they need only by coming into close contact with vulnerable members of society. Once they graduate, new doctors are expected to conform to principles of professional conduct that have the safety of patients at their heart,1 so the award of a medical degree confirms more than academic achievement. It says that the graduate is fit to practise under supervision as a doctor and can be trusted by public and profession alike. In the United Kingdom, graduation in medicine automatically leads to provisional registration as a doctor, and the regulatory body has no discretion in the matter.2
Medical schools therefore have a considerable responsibility to identify and appropriately manage students whose conduct may put patient safety at risk. No member of the public should be harmed by participating in the learning of students or through the actions of a newly graduated doctor who is not fit to practise.
Examples of conduct that would seriously call into question the suitability of medical students to continue with their course and enter practice include exploiting vulnerable patients, dishonesty, repeated inappropriate behaviour, or failure of treatment for chronic substance misuse.
This is a little researched area, and systematic analyses are not available. Internationally several approaches to the management of student misconduct exist. In New South Wales, for example, the doctors' licensing authority also registers medical students from the start of their course, enabling continuity of supervision, with the added advantage of separating responsibilities for academic and conduct or health issues.3 There are, however, potential legal obstacles to this approach in some jurisdictions. Strict privacy laws that are included in much legislation about human rights may limit the information that can be passed between organisations, at least without consent. Also the prospect of a third party terminating a student's course could prove challenging. Elsewhere many universities rely on regulations and honour codes, with medical students being regarded in the same way as other students.4 Most medical schools in the United Kingdom have taken a different approach with the introduction of procedures that specifically consider fitness to practise separately from academic matters.5
Whatever process is used for managing misconduct, the first step is to identify it. This may not be easy, except in cases of grossly dysfunctional behaviour, and a pattern is often built up over time. Medical schools should have mechanisms in their assessment and appraisal systems to identify students whose conduct is causing concern. Effective reporting and central recording of information is essential so that an overview of a student's progress can be maintained.
Doctors have a key role in identifying conduct problems in their colleagues. Medical schools should prepare their students for this important aspect of professional life by developing themes of learning that introduce students to their responsibility if they believe that a colleague's conduct could put patients at risk.
When an alleged problem about conduct becomes known, the medical school should have two concerns: pastoral care for the student and protection of the public. Each is important, but the latter must always take priority. If there is a prima facie case that raises serious concerns about patient safety, the student should be suspended until the matter is resolved.
Rehabilitation and return to the medical course should always be considered,
but may not be possible or successful. Once a student has been
dismissed from the medical school their career usually cannot be
tracked efficiently. There is always the possibility that they will
attempt to achieve a medical qualification
for
example, in another country.
Students whose health could affect patient safety also pose special
challenges. It is important to establish an environmentespecially
in areas such as substance misuse and mental illnesswhere
medical students feel able to seek help for themselves with
confidence rather than resort to concealment for fear of jeopardising
their career. Medical students have the same rights of
confidentiality as any other patient, and there must be a clear
separation between those managing the students' health and those
managing the medical school.6 All the
medical school needs to know is whether the student is fit to
continue the course. But failure to follow professional advice about
the student's health in a way that could affect patient safety
introduces a conflict between the doctor's duty of confidentiality to
the student and their wider responsibility to protect patients. So
far as the United Kingdom is concerned, the General Medical Council
would expect that doctor to put patient safety above their duty of
confidentiality by notifying the medical school. This would
preferably be with the student's consent, but without it if
necessary.
Reliable figures on the numbers of students involved in serious misconduct
are difficult to obtain, but they are likely to be very small. For
example, one medical school in the United Kingdom with about
1000 medical students has dismissed two students for serious
misconduct in the past three years. Nevertheless, the issues are very
bigthe rights of the
individual student to pursue his or her chosen education and career
can collide with the safety of the public. At the end of the day,
public safety must take priority.
Peter Rubin
Dean's Office, Medical School, Queen's Medical Centre, Nottingham NG7 2UH (peter.rubin@nottingham.ac.uk)
Footnotes
Competing interests: PR is chairman of the GMC Education Committee.
| 1. | General Medical Council. Good medical practice. London: GMC, 2001. |
| 2. | Medical Act 1983. London: HMSO, 1993. |
| 3. | New South Wales Medical Board. www.medeserv.com.au/nswmb/ (accessed 9 Aug 2002). |
| 4. | Stanford University Medical Catalogue. The Fundamental Standard. www-med.stanford.edu/school/catalog/bookone/univpolicies.html#honorcode (accessed 9 Aug 2002). |
| 5. | University of Nottingham. Faculty of Medicine and Health Sciences. www.nottingham.ac.uk/mhs/admissions/applying.html#fitness_to_practice (accessed 9 Aug 2002). |
| 6. | Academic Medical Centers Task Force. Blood-borne pathogen disease in health science students: recommendations from the Lexington Conference, November 6-7, 2000. J Am Coll Health 2001; 50: 107-120[Medline]. |
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