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Rapid Responses: Rapid Responses published:
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When medical students go off the rails
- Jonathan HS Fuller, Imperial College, London, W6 8RP (15 September 2002)
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Setting the bar from the start
- sheila otto (15 September 2002)
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Are deans naive?
- R Pal (15 September 2002)
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Stopping medical students going off the rails
- Melissa M Sayer (15 September 2002)
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"If you can't stand the heat....."
- Dil Sen (18 September 2002)
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When medical students go off the rails
- Peter Taysum (21 October 2002)
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Is there any mention about learning disbility ?
- Kadiyali Srivatsa (12 December 2002)
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Jonathan HS Fuller, Senior Lecturer, Department of Primary Health Care and General Practice, Faculty of Medicine,, Imperial College, London, W6 8RP
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Editor, The editorial by Peter Rubin highlights an area that is difficult and complex, not least because there are a large number of ways a student can go off the rails, and for a large number of reasons. Our experience at Imperial College, seeing students who have failed their exams, is that many of them have suffered major problems in their non academic lives and need help coping with them. What is sad, but probably not surprising, is how few have tried to obtain help when the difficulties started, or when they started to effect their work. Of course these are not the students that Peter Rubin was considering, although those that misbehave often, although not always, do badly academically. The 'fitness to practice' procedures that most medical schools are setting up are an important step forward. Obtaining evidence that is defensible will be more of a challenge. Often it is a number of small events that should set the alarm bells ringing. Ensuring that these are recorded may be difficult. What about students with health problems. I am aware of students with depression, who suddenly disappear. Having depression should not disqualify students from becoming doctors, but disappearing might, even if it is linked to a treatable illness. A major problem is the lack of continuity from admission to medical school through postgraduate career. Not only should information be passed foward, but there should also be feedback to the school. This should be a area for research. If at all possible we should learn more about the student career of doctors that perform poorly. With all the possible precautions in place, there will be students that surprise us. There is much to learn, and given the low number of students about whom this is an issue in each school, much to be gained by sharing information. Jon Fuller |
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sheila otto, instructor Albany medical college Albany, NY 12006
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In the first week of the first year of medical school, we attempt to set a standard of professionalism. We ask students to reflect on why they came here, what they expect of fellow physicians and what makes joining this profession different from other ocupations. Substance abuse affects about 10% of those in the profession at one time or another and to enforce this awareness, we invite a physician in recovery to speak to students first hand about his/her experience. Finally we give them tools for help and reporting.(NY state has very strict and specific guidelines) It is our intention to give the message that this is important, a priority and that they must recognize this from the start. |
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R Pal
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Dr Rubin's article amused me slightly in that he perceives medical students who qualify to be apt and dealing with the general public, the vulnerable of society etc. Consider this Dr Rubin. I was in medical school about two years ago. Medical school was particularly difficult for me given I did not have the financial backing that most students get. Now, throughout my medical school training, I witnessed a medical student who chose the best blonde patients, I attended parties where the level of O2 was nil given the cannabis that was passed between students. Regular cheating happened in MCQs by students who photocopied the previous years papers and so forth. I walked into the Union to find medical students vomiting after drinking alcohol in large quantities. I should never go into what the competition was next. Every night, the boys drank like fish and ended up in lectures with hangovers. Now this is what normal medical school is like. These people are now qualified doctors with subsequent promotions. Ofcourse it depends on what you perceive as misconduct. Diffrent deans have different perceptions of reality in medical schools. If you placed your standards on medical students of our year - I am sure none of us would have qualified ! RPal |
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Melissa M Sayer, Lecturer in medical education St Bartholomew’s and The Royal London School of Mee
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Thank you for Peter Rubin’s excellent editorial, calling for medical student support systems to be strengthened1. I’d like to make two points, in response. Our research into new and existing methods of pastoral care provision finds that student concern surrounding the issue of confidentiality is the single greatest barrier to their involvement2. Students mistrust and misunderstand the purpose of pastoral care and avoid seeking help for fear of jeopardising their careers. This is perhaps not surprising. In his article, Peter Rubin rightly emphasises the need for an environment where medical students ‘feel able to help themselves with confidence’. However, he then suggests that pastoral care systems should decide (and inform the medical school) if students are able to continue on their course. A student should have little confidence in admitting their weaknesses and approaching such an influential body for support and guidance. To maximize uptake (and thereby effectiveness), all support systems must have transparent, understandable codes of conduct for both users and providers. Surely the first step to managing students who ‘go off the rails’ is not, as suggested, ‘identifying’ the problem; but in time-honoured medical tradition, preventing it emerging in the first place? The key is providing effective, accessible pastoral care for every student, not only for those who are struggling. Pastoral care during medical training is in everyone’s best interests and crucial to the educational process itself3- 6. The stresses of medical school are well documented6-10. The prevailing culture requires increased levels of personal robustness from students, thereby placing even more pressure on the psychologically fragile.11 To paraphrase Peter Rubin’s laudable call for patient protection – steps should be taken to ensure no medical student is harmed by their participation in training! 1 Rubin P. When medical students go off the rails. BMJ. 2002 ;325:556-7 2 Sayer M, Colvin B & Wood D. The Pastoral Pool: An Evaluation of a New System of Pastoral Care Provision Med Educ 2002 Jul;36(7):651-8 3 Coombs RH & Virshup BB Enhancing the Psychological Health of Medical Students: the Student Well-Being Committee. Med Educ.1994; 28:47- 54 4 Firth-Cozens J. Medical Student Stress. Med Educ 2001; 35:6-7 5 Challis M, Flett A, Batstone G. An Accident Waiting to Happen? A Case for Medical Education. Medical Teacher . 1999; 21 (6): 582-585 6 Wolf TM. Stress, Coping and Health: Enhancing Well-Being during Medical School. Med Educ 1994; 28: 8-17. 7 Firth J. Levels and Sources of Stress in Medical Students. BMJ. 1986; 292: 1177-1180 8 Clark D.C. and Zeldow P.B. Vicissitudes of Depressed Mood during Four Years of Medical School JAMA 1988; 260: 2521-8 9 Vitaliano P.P., Russo J., Carr J.E. and Heerwagen J.H.. Medical School Pressures and their Relationship to Anxiety. Journal of Nervous and Mental Disease .1984;172 730-6 10 Bjorksten O, Sutherland S, Miller C, Stewart T. Identification of Medical Student Problems and Comparison with Those of Other Students. Journal of Medical Education.1983; 58: 759-767 11 Association for University and College Counselling. Degrees of Disturbance: The New Agenda The impact of increasing levels of psychological disturbance amongst students in Higher Education, A Report from the Heads of University Counselling Services. AUCC, UK;1999 |
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Dil Sen, Occ.Physician & Hon.Lecturer Univs.Manchester & Liverpool grove House, Manchester M16 0RB
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I read Prof.Rubin's editorial with considerable interest especially since I have just deposited my eldest child to a medical school some distance from his (former) home. Training to be a doctor is not easy and medical students are under enormous pressures right from the start. The undergraduate course for medicine is not only one of the longest but possibly one of the most demanding both in terms of the amount of learning required, and as a result of the interactions involved with 'real' people, people with physical, psychological and even terminal problems. The health, safety and welfare of our medical students ( and the responsibilities of our medical colleges, tutors etc) is, and should be, as important as the safety of the public. Or is it still ( as it was when I was training between 1975-80) a case of "If you can't stand the heat, stay out of the kitchen"? |
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Peter Taysum, Deputy chairman for welfare, Medical Students Committee, BMA
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Editor, I was interested to read this editorial, but was unsure as to why it was published. Peter Rubin himself states that the problem of medical students going off the rails is likely to be very small, whilst pointing to the lack of reliable evidence. Probably the reason for this editorial is that the GMC is currently rewriting Student Health and Conduct and has been widely consulting on this document. The rewrite has probably come about in part as a reflection of the introduction of the Human Rights Act into EU member states law in 2001, and partly a reflection of changes that have taken place at the GMC since Graeme Catto took over, and Peter Rubin became Chair of the education sub-committee. It is clear that protecting the public is of key importance; one would hope that people entering the medical profession are doing so, at least in part, to help people. It certainly seems to be what potential medical students believe when they apply to study medicine, and are told not to say at interview. It would be nave not to expect that a very small proportion of entrants to medical school may not be suited to medicine. Lets not side step the difficult issue here, we are talking about trying to prevent people such as Harold Shipman entering medical school, although I personally am not sure how this would be achieved. But, lets not confuse this issue with people who have ill health or a disability. Lets not, for that matter, link people with substance abuse problems to Shipman either. The article states there should be an environment conducive to students seeking help with problems, which is a laudable aim that I wholeheartedly agree with. However, in the same paragraph it demonstrates that this environment does not exist, and never will whilst the GMC is stating that doctors should breach confidentiality by ratting on students to the medical school. This really is overkill, and I hope that it will not be included in the new Student Health and Conduct, as it is already covered in the GMC publication Confidentiality. In purely legal terms, and this is not being pedantic, I would also have to take issue with the point Peter Rubin makes by stating that public safety must take priority. In fact if addressing the Human Rights Act, the act states that the right of the individual must be balanced against the rights of the public. More than that, if we as a profession cannot look after ourselves, and create a culture where all of the medical profession, including students, can seek help in a caring confidential environment then how can we possibly claim to have the ability to look after other people? Yours sincerely Peter Taysum MPHIL, MSC, MA(HONS) LES SC ECO
Peter Taysum is a 4th year Medical Student at the University of Newcastle upon Tyne |
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Kadiyali Srivatsa, GP TW10 6LG
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Sir It’s good to talk about various reasons why medical students go off the rails, but did anyone discuss learning disabilities? We have noticed some doctors finding MCQ exam difficult, but why? Good health is not only physical but psychological well being too. We can talk about depression, alcholism and bad behaviour but is this associated with adult dyslexia? American university have recognised these problems and are addressing the issue. Why not here? Competing interests: None declared |
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