Intended for healthcare professionals

Opinion

Teaching about gambling harms in medical school—an opportunity

BMJ 2022; 378 doi: https://doi.org/10.1136/bmj.o2267 (Published 20 September 2022) Cite this as: BMJ 2022;378:o2267
  1. Jenny Blythe, GP and NIHR doctoral fellow,
  2. May van Schalkwyk, specialty public health registrar and NIHR doctoral research fellow
  1. London School of Hygiene & Tropical Medicine

The coroner’s verdict into the suicide of 24 year old Jack Ritchie, who had been affected by disordered gambling since his teens, not only concluded that warnings and information about gambling harms were “insufficient” but found evidence that, in the UK, “GPs currently have insufficient training and knowledge to deal effectively with gambling problems . . . this was of particular concern given many gamblers affected are likely to contact a GP as their first attempt to seek help.”1

In this regard, the recent introduction of routine screening for gambling harms through GP online consultation platforms is a welcome development.2 The Royal College of General Practitioners has also endorsed a postgraduate competency framework “to assess, treat, and manage problem gamblers.”3

However, more changes are clearly needed, and medical school represents an opportunity to teach all future doctors, not just those entering primary care, about gambling harms. Importantly, medical school teaching could adopt a broader conceptualisation of gambling harms than the “problem gambler” framing that has dominated the approach in recent decades. This narrow perspective favours the gambling industry’s commercial and political interests, as it views the problem as confined to a small number of people experiencing harms due to their inability to gamble in the “right” way; it overlooks those experiencing harm from their gambling outside the diagnostic criteria of a “problem gambler”; and it doesn’t consider harms experienced by family and friends (“affected others”) and wider society.4

What would such an educational approach entail? Possible activities could include:

  • Taking histories from simulated patients that identify gambling as potentially affecting wellbeing, as gambling is associated with poor mental and physical health in those who experience disordered gambling and in affected others;

  • Public health teaching that integrates gambling as a commercial determinant of health and identifies the need for policies to prevent gambling harm at the population level456;

  • Ethics teaching that recognises that gambling harms are experienced inequitably by the most deprived and vulnerable groups78;

  • Paediatrics teaching that explores potential safeguarding issues (including being witness to gambling related intimate partner violence) and adverse childhood events that can lead to intergenerational harms experienced from growing up in a family or community where others experience harms from gambling9; and

  • Normalising asking a screening question when taking social histories from patients, such as, “Have you or has someone close to you ever been harmed by gambling or someone else’s gambling?”

Independence and funding

To ensure that medical education maintains its integrity and independence from industry influences, it’s imperative that educational resources shared with students are independent of funding from the gambling industry. This is recognised in other areas, such as efforts to protect medical training from drug industry influence.10

Notably, in April 2022 NHS England announced that it would end the dual commissioning and funding arrangement with GambleAware for NHS specialist gambling clinics, its decision being “heavily influenced” by patients and clinicians expressing concern about using or providing “services paid for directly by industry.”11 Medical schools should establish policies directed at ensuring independent and evidenced educational resources on gambling harms, including mechanisms to assess for conflicts of interest and the independence of provider organisations.

There are additional areas where medical students will need support to develop their skills. Firstly, if gambling harms are identified by students in their patient clerking, directing patients to support is vital. Students should be empowered with the knowledge and skills to direct their patients to high quality services that can support the needs of their patient and the people close to them.

Secondly, it is acknowledged that students are an at-risk group for gambling harms,12 either directly or by being an affected other. Teaching about gambling harms could trigger medical students to disclose this, and they may worry about doing so, particularly if they have fears about what this might mean for future registration or employment. Empowering universities’ student pastoral services to screen for harms and to support students who disclose being affected by gambling harms is vital—keeping in mind that, as the coroner in Ritchie’s inquest concluded, “it was not his fault.”1

Finally, while it’s imperative that people affected by gambling harms receive the high quality and evidence based care that health professionals and the health service have a duty to provide, this should not detract from efforts to prevent this harm from occurring in the first place. Doctors should be ready and able to deal with gambling harms, but the success of any gambling policy should be reflected in them having to rarely, if ever, encounter someone experiencing such preventable harms.

Footnotes

  • Competing interests: JB is an independent researcher based at the London School of Hygiene & Tropical Medicine, funded by the National Institute for Health Research (NIHR) Applied Research Collaboration North Thames. She is also an honorary senior lecturer at Barts and the London Medical School and a salaried GP at a practice that uses an online consultation platform including a screening question about gambling harms.

  • MvS is funded by the NIHR doctoral fellowship (NIHR3000156), and her research is also partially supported by the NIHR Applied Research Collaboration North Thames.

  • The views expressed by JB and MvS are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

References