Head To Head

Should undergraduate medical students be regulated? No

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1806 (Published 05 May 2010) Cite this as: BMJ 2010;340:c1806
  1. Edward Davies, editor
  1. 1BMJ Careers, London WC1H 9JR
  1. edavies{at}bmj.com

    Jane Dacre and Peter Raven (doi:10.1136/bmj.c1677) are convinced that regulation will prevent potentially dangerous medical students from becoming dangerous doctors, but Edward Davies thinks it an absurd over-reaction

    Janet Smith suggested the idea of student registration in the Shipman inquiry.1 It was not strictly within the remit of the inquiry, and had it been in place would have done nothing to stop the serial murderer Harold Shipman, but it was raised nonetheless.

    The subsequent recommendations on medical regulation from the chief medical officer, in Good Doctors, Safer Patients, took on the baton and ran. Recommendation 23 said: “Medical students should be awarded ‘student registration’ with the General Medical Council, and medical schools should have a GMC affiliate on their staff who should operate fitness to practise systems in parallel with those in place for registered doctors.”2

    Need

    With such high profile support for student regulation you would expect the problem to be serious. And so it is somewhat surprising that a survey of postgraduate deans found that, of the 5833 doctors in their first year of practice in 2005, just 16 UK graduates were so much as “giving cause for concern.”3

    Registering students with the GMC is not only a sledgehammer to crack a nut but duplication of effort since every UK medical school already has to have fitness to practise procedures in place, independent of any wider university measures.

    Consistency

    The main argument against the current system is inconsistency across the different schools. If two students face a different outcome for the same misdemeanour by virtue of little more than geography, there is clearly a problem. So last year the GMC introduced new guidance on medical students’ professional behaviour and fitness to practise for use throughout the UK.4 This was a sensible and welcome move.

    But to suggest a GMC affiliate at each medical school or central register would in some way enhance uniformity seems without foundation. Medical schools already have staff overseeing student fitness and welfare—whether they be portfolio mentors, clinical supervisors, or even the dean—and they now have national guidance. Adding a GMC affiliate at each school would at best be another layer of bureaucracy and at worst dilute lines of responsibility for the students. Such ambiguity would serve neither student nor future patient.

    Judgment

    GMC registration would also leave judgment to a distant regulator, undermining the common sense of those who are in place and know the students and situation best. For example, the guidance on medical students’ professional behaviour and fitness to practise includes under its categories for concern being uncommitted to work, neglect of administrative tasks, poor time management, and non-attendance.4

    This could be a tailor made description of half the students at my university. Does it really make sense to drag these teenagers through a lengthy and expensive official fitness to practise hearing to decide whether they are potential malpractising doctors or normal students, when each one already has a personal supervisor scrutinising their behaviour anyway. Is this money well spent?

    Cost

    And potential cost is a major consideration. Before a single student has erred or fitness to practice hearing has been held, the “Initial Regulatory Impact Assessment” provided with Good Doctors, Safer Patients suggests that the model of student registration proposed by the chief medical officer would cost roughly £1m (€1.2m $1.5m) a year.5 That is about £30 a student.

    There are better ways of using this money. One argument for student registration is to instil a culture of professionalism, responsibility, and engagement with the GMC’s standards. Based on a GMC estimate of one of its medical school events costing £5000,3 it could run two events, every term, at every medical school in the country, and still spend £160  000 less than it would cost simply to put every student’s name on a register. This would surely do more for engagement.

    Role of doctors

    But cost, accountability, and consistency aside the bottom line is far simpler: students are not and should not be the GMC’s responsibility. Whether I am going to my doctor for brain surgery or because my toddler has a sniffle, I want to know that the doctor I am seeing is among the best trained and best regulated in the world. What I do not ever want to see is a student.

    The GMC’s strapline is “Regulating doctors, ensuring good medical practice.” A student should neither be practising nor a doctor. There would have to be a very serious threat to patient safety to merit any blurring of the line between student and doctor, and 16 “concerns” out of 5833 first year doctors simply does not indicate that there is.

    There is a world of difference between the teenager, armed with just his A levels, away from home for the first time, developing his skills, and the 50-something neurosurgeon heading up a world leading service. To think we as patients or they as doctors are best served by the same type of regulation is absurd.

    Students are already regulated. If the national guidance and local procedures are failing then they should be improved, but that is not an argument to involve the sledgehammer of the GMC.

    Notes

    Cite this as: BMJ 2010;340:c1806

    Footnotes

    • Competing interests: The author has completed the unified competing interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares (1) no financial support for the submitted work from anyone other than their  employer; (2) no financial relationships with commercial entities that might have an interest in the submitted work; (3) no spouses, partners, or children with relationships with commercial entities that might have an interest in the submitted work; and (4) no non-financial interests that may be relevant to the submitted work.

    • Provenance and peer review: Commissioned; not externally peer reviewed.

    References

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