Identifying problem medical students early

Basic medical education is needed to produce graduates who can enter postgraduate training and be part of future healthcare delivery, for perhaps 40 years. Expected graduate outcomes in the United Kingdom are described in Tomorrow’s Doctors.¹ Predicting what the future holds is difficult, and the outcomes naturally tend to focus on educational principles and current roles for doctors. A new version of Tomorrow’s Doctors will be released in 2009 following a routine periodic review,² with a more contemporary, broadly based, and detailed description of the outcomes, embracing the current concept of “fit for purpose,” or readiness to work as junior doctors in the NHS.

A central feature of being a doctor is the professional role, arguably best captured within the CANMEDS (Canadian Medical Education Directions for Specialists) documentation and Good Medical Practice.^{3 4} Doctors in all specialties have a privileged place of trust in the lives of patients. We must put patient care first, sort out potentially complex problems, communicate options, perform sophisticated management in teams, manage health care (budgets and people), understand our limits, and take steps to care for ourselves.

Outside of work we have personal and family lives. Getting the balance right can be difficult, both in and across personal and professional roles. As a profession we often manage this poorly, and have high rates of drug misuse and mental health problems.^{5 6} Medical students also have quite high rates of stress and mental health problems,⁷ although prefer not to report this.⁸ Worryingly, there is some evidence that professional problems during student times are associated with a higher risk of professional problems in later practice.⁹

What can medical schools do about this? Is this nature or nurture? Can we select for and support “good professionalism”? Most medical schools commit substantial resources to selection processes. They can select from many academically strong, motivated applicants and in theory should be able to minimise the numbers of students who enter with the potential to become a “problem student.” They also have several years of teaching, assessing, role modelling, and student support to help students to achieve self awareness and to identify and guide problem students. There is General Medical Council guidance for the development of professionalism and dealing with student fitness to practise concerns (also under review to improve their practical applicability). These are particularly important for managing the relatively few students with serious problems who cannot be remediated.¹⁰

How common are students with problems? There is a paucity of good data on this, but the anecdotal answer is quite common. Many cases present as poor academic performance in students accustomed to doing well. However, relatively few students have genuine academic performance problems and this presentation is often a proxy for other problems: adjustment to higher education and independence; family pressures; realisation that medicine is not the right career; and poor mental or physical health. Most medical schools have a range of student support services, both academic guidance and pastoral care. Many students do well with learning skills development, time out to deal with issues at home and simply gaining maturity. Students who do least well are those with motivation and mental health or personality problems. Loss of motivation can be hard to deal with because telling parents about changes to career plans is difficult if family and teachers promoted an indecisive vocational choice. Students with mental health problems are not common, but can be hard to detect and difficult to manage. The most worrying features may be dishonesty, violent behaviour, and lack of insight and ability to change.¹¹

One strategy that should improve the management of problem students is a change of culture in medical schools. Most problems can be solved without impeding progress. Early intervention is crucial, so students should present or be referred early to support services to gain more benefit. It is important for the schools to work out early what kind of problem is present and to refer students for appropriate support. Ideally, the student support service is separate from academic management and student societies (although these can nevertheless be part of support) because this provides better confidentiality. It is also essential that students listen to advice that might be difficult to absorb because this should help them to make difficult decisions. A small number of students are really better off either taking a year out to think about things, with the option of returning, or leaving the course gracefully and finding another course that leads to a rewarding career. The earlier this is done, the easier life is in the long run.

Although medicine is a wonderful career for most students, it can also be challenging and difficult. It is not for everyone and certainly is not for people who lack insight and the ability to seek advice and develop coping skills. Both medical schools and students have their parts to play in ensuring that the future of the profession is in good hands.

Competing interests: None declared.

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

See the commentary that accompanied “Medical students’ compliance with simple administrative tasks and success in final examinations: retrospective cohort study” (Student BMJ 2002;10:328, http://student.bmj.com/issues/02/09/papers/328.php).

1. General Medical Council. Tomorrows Doctors, 2003. Online at http://www.gmc-uk.org/education/undergraduate/undergraduate_policy/tomorrows_doctors.asp (accessed November 2008)
2. General medical Council. Review of Tomorrow’s Doctors. Available at: http://www.gmc-uk.org/education/undergraduate/news_and_projects/review_of_undergraduate_education.asp (accessed November 2008)
3. The Royal College of Physicians and Surgeons of Canada. The CanMEDS 2005 Physician Competency Framework. Available at: http://meds.queensu.ca/medicine/obgyn/pdf/CanMEDS2005.booklet.pdf (accessed November 2008)
4. General Medical Council. Good Medical Practice. 2006 Edition. Available at: http://www.gmc-uk.org/guidance/good_medical_practice/index.asp (accessed November 2007).
5. Tyssen R, Vaglum P. Mental Health problems among young doctors: an updated review of prospective studies. Harvard Review of Psychiatry 2002; 10: 154-165.
6. Bennet J, O’Donovan D. Substance abuse by doctors, nurses and other health care workers. Current opinion in Psychiatry, 2001; 14: 195-199.
7. Midtgaard M, Ekeburg O, Vaglum P, Tyssen R. Mental health treatment needs for medical students: a national longitudinal study. European Psychiatry 2008; 23: 505-511.
8. Chew-Graham CA, Rogers A, Yassin N. ‘I wouldn’t want it on my cv or their records’ – medical students’ experiences of help-seeking for mental health problems. Medical Education 2003; 37: 873-880.
9. Papadakis MA, Hodgson CS, Tehrani A, Kohatsu ND (2004). Unprofessional behaviour in medical schools associated with subsequent disciplinary action by a State Medical Board. Academic Medicine, 74, 980-99.
10. General Medical Council, 2007. Medical Students: Professional Behaviour and Fitness To Practise. At: http://www.gmc-uk.org/education/undergraduate/undergraduate_policy/professional_behaviour.asp
11. Hays RB, Jolly BJ, Caldon LJM et al (2002). Is insight important? Measuring the capacity to change. Medical Education, 3, 965-71.

   

 Printable version      Download PDF    E-mail this to a friend    Respond to this article    Request Permissions