When medical students go off the rails

BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7364.556 (Published 14 September 2002) Cite this as: BMJ 2002;325:556

Student support is essential, but so is protecting the public

  1. Peter Rubin, dean of medicine and health sciences (peter.rubin{at}nottingham.ac.uk)
  1. Dean's Office, Medical School, Queen's Medical Centre, Nottingham NG7 2UH

    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,1so 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 Sout 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.3There 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 environment—especially in areas such as substance misuse and mental illness—where 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 big—the 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.


    • Competing interests PR is chairman of the GMC Education Committee


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