Identifying medical students at risk of subsequent misconduct
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c2169 (Published 27 April 2010) Cite this as: BMJ 2010;340:c2169
All rapid responses
I would disagree with Dr. Lancaster below in that Yates and
colleagues have in theory demonstrated statistically significant links (p-
values all below 0.05) using methods of multivariate regression analysis,
with each risk factor having quite a high odds ratio.
However two considerations would render these findings rather
meaningless.
First, there are severe limitations of the study from a technical
point of view. The ideal approach would perhaps have been to study entire
medical student cohorts graduating from medical schools according to
certain outcome endpoints. This could be done historically, however there
would be considerable procedural and medicolegal hurdles, I imagine, in
gaining records. In this case the outcome of interest (GMC disciplinary
proceedings for serious professional misconduct) has been the only
inclusion criterion for the study - therefore working backwards.
Second, there can be no ethically acceptable repercussion of this
study, or even from further research that the authors suggest. From a
fundamental humanitarian point of view, there can be little implementation
of measures that aim to scrutinise medical students based on their gender
or socioeconomic background. At some point or other, such interventions
would reach standards of discrimination, and burden the system with even
more litigation.
The third risk factor identified, poor perfomance in preclinical
years, is academic performance - and this is monitored rigorously in
medical school already.
In summary, this is unfortunately a study that will have great
capacity for headline-grabbing by virtue of its persuasive p-values, but
will hopefully be of little use to medical education or regulation as a
whole. I therefore disgree with Alison Reid's conclusion that "an
appropriate response at the undergraduate level" to target male medical
students is necessary or ethical.
We cannot be slaves to statistics; it is a tool in overall decision-
making.
Competing interests:
None declared
Competing interests: No competing interests
Dear Dr Reid
I read with interest the aforementioned article.
Whilst I agree each student must be considered on an individual
basis, from my own experience, and that of my friends, the reason such
students struggle is due to lack of support. Most of them will be the
first members of their family attending university, thus the financial,
emotional and academic pressures will be unprecendented.
They will have limited resources to utilize, few role models and many
opportunities to stray.
Perhaps these students should have older "buddies" in their formative
years at medical school, from similar backgrounds but in more senior years
and thus can support and guide the students through the difficult path
that is university.
Best wishes
David
Competing interests:
A white, male, proletarian doctor who struggled to gain entry into medical school.
Competing interests: No competing interests
In misrepresenting their outcome measure, Yates and James (1) may
have
missed an even more significant finding based on potential selection bias.
They define “professional misconduct” as if it were the same as being
“found
to have shown professional misconduct”. These are related but not
identical
outcomes. An alternative interpretation of their findings would be that
the
British disciplinary process is biased against males from less privileged
backgrounds who struggled in the early years of their academic career. On
the other hand, the profession may be overly sympathetic to misbehaving
women from higher social classes who had settled into medical school
without problems.
Reid’s premise that student behaviours should be monitored and
responded
to is neither supported nor challenged by the observations of Yates and
James: we should be careful before we condemn working class young men
from schools that prepared them less well for the private school culture
of
British Medical Schools. in the absence of supporting evidence, the
claim in in the subtitle that "FItness to practise should be determined by
both
academic and non-academic ability" should be reconsidered and removed
from the electronic version of this editorial since the evidence presented
only
supports responding to behaviours not abilities.
If we are to monitor students, it should be on the basis of clearly
identified standards of behaviour and achievement, regulated by an
independent and accountable body with a clear and accessible appeal
procedure that does not discriminate against
those who cannot afford representation.
1. Yates J, James D. Risk factors at medical school for subsequent
professional misconconduct:multicentre retrospective case-control study.
BMJ 2010;340:c2169
Competing interests:
I am a man who was educated at
comprehensive school and initially
failed first year medical school
exams.
Competing interests: No competing interests
In their case-control study, Yates and colleagues identify three
factors, including male gender, associated with increased risk of serious
professional misconduct. Dr Reid describes these factors as predictors of
misconduct. It is not possible from the Yates study directly to assess the
value of the identified factors in predicting misconduct among doctors, as
we do not know the prevalence of cases in the population at risk. However,
this can be estimated from background information. At a rough estimate, 8
medical schools in a forty year period are likely to have graduated 20 to
30 thousand doctors, of whom perhaps 75% are likely to have been male. If
we assume that the 59 cases analysed in Yates' study are all the cases
reported for graduates of those schools in the five year study period,
then the positive predictive value of being male for professional
misconduct over that five year period would lie between 0.002 and 0.003:
useless as a predictor. It is interesting that there is a greater
likelihood that misbehaving doctors will be male than female but, as one
would expect from common sense, being male is in no sense a predictor of
professional misconduct. I note that Yates and colleagues do not make
this claim in their report.
Competing interests:
None declared
Competing interests: No competing interests
Student Appraisal could reduce misconduct?
As a medical student about to embark on my final year, it was with
great interest that I read this article. I entirely agree that academic
and non-academic aspects of fitness to practice should have equal
importance (1), with early support being vital. Identifying “difficult”
students will always be demanding. As medical students, we rotate through
many different placements, changing teams and consultants every few weeks
with sporadic examinations thrown in between. This gives us a wide range
of clinical experiences throughout the NHS, but there is no one doctor to
act as mentor, to assess our personal conduct and attitudes in clinical
practice. Gauging these qualities takes time and I find that the first few
weeks of any placement are spent ascertaining the consultant’s
idiosyncrasies and how the team works. There is little opportunity for the
consultant to assess our non-academic aspects, and without any compulsory
or quality time spent with him or her, we are generally able to escape
without exposing our personal attitudes.
On the other hand, ask any medical student who they believe amongst
their peers isn’t suited to medicine or has a problematic attitude; they
will often have a consensus of opinion. As students, we get to know our
fellow peers on the wards, watching each other take histories, examine and
communicate with patients and doctors alike. On qualifying, we are
expected to review our colleagues’ strengths and weaknesses so perhaps,
students appraising each others’ professionalism may be beneficial to flag
up any concerns? Obviously, it may prove difficult to receive responsible
and truthful character references from students, and in some
circumstances, combined references from doctors, educators and students
may be necessary with an independent panel assessing the “challenging”
student over a period of time. Students need time to mature and be guided
on what good clinical practice is, therefore, snap judgements should never
be made. A useful adjunct may be a short course run by medical schools
for senior medical students, designed to give advice on appraising each
other; advice that could prove valuable for years to come.
Another big hurdle would be the reluctance of students to appraise each
other at all. However, I believe that as we progress through medical
school, we become more aware of our responsibilities and acknowledge the
overwhelming importance of safeguarding patients from harm, be it from
illness or our colleagues. We must place more trust in medical students to
judge each other’s abilities, rather than rely solely on examinations and
consultant assessments.
1. Reid, A. (2010). Identifying medical students at risk of
subsequent misconduct. BMJ 340: c2169-c2169
Competing interests:
None declared
Competing interests: No competing interests