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Remediation in student fitness to practise

This piece focuses on remediation: why it is important, what the key principles behind it are, how students can demonstrate it, and how schools can support them in this process. It is primarily addressed to medical schools.       

Introduction

Medical students, just like students training to join healthcare professions, are studying to join a regulated profession, which will put them in contact with patients and vulnerable members of the public. Because of this, and the trust placed in the profession, medical students have to demonstrate certain standards of behaviour. These are set out in our new professionalism guidance, Achieving good medical practice, and reflect the standards expected from all registered doctors in the UK.

Sometimes students act outside these standards. While at university, medical schools have internal processes to manage this, called student fitness to practise procedures. Through these procedures, medical schools look at whether a student’s fitness to practise is impaired, and can impose sanctions if they think that is the case. The purpose of a sanction is to protect patients and the public, to maintain trust in the profession, and to make sure that the student’s case is dealt with effectively. Sanctions should give a student the opportunity to learn from their mistakes. This process also links to the obligation of medical schools to only graduate students who are fit to practise.

Fitness to practise is independently assessed by the GMC when graduates apply for provisional registration. The GMC has a statutory duty to only register graduates who are fit to practise. The GMC Registration team will investigate any applications that raise student fitness to practise concerns.

Registration data

In the past seven years (2010-16), the GMC have refused provisional registration to UK graduates 30 times on the grounds of fitness to practise. To put this number into context, this is out of over 51,000 applications received during the same period (i.e. about 0.06% of applications).

There have been 16 subsequent applications to the 30 refusals (around 53%). 13 of the 16 re-applications have been successful in gaining provisional registration. When applicants reapply they should show that they’ve taken into account any advice we’ve given them and show that they’ve undertaken remediation where appropriate.

What is remediation?

In broad terms, remediation refers to rectifying or correcting a certain behaviour that has generated concerns. More specifically, in the context of fitness to practise, remediation is where a student or graduate addresses concerns about their conduct, behaviour or health.

Remediation can take a number of forms, including volunteering, expressions of regret or apology (reparations), coaching, mentoring, training, and rehabilitation (this list is not exhaustive). Where fully successful, it is less likely the individual’s fitness to practise is impaired.

Why is remediation important?

The GMC’s first responsibility above all others is to protect patients and the public’s trust in the profession. That remains the most important part of the process and is a prerequisite for anything else. If there are fitness to practise concerns about a student or graduate, allowing them to graduate and join the register may pose an unacceptable risk to patient safety or to the reputation of the profession.

Wherever it is safe and appropriate to do so, students who have not met the required standards should be given the opportunity to remediate. When it is proven that they have remediated, they can continue towards registration and practice. This is also important because students and graduates have acquired a degree of specialised skills which should be utilised and retained within the workforce if possible.

What are the key principles?

In general, demonstrating remediation is difficult to do, especially in the case of certain concerns such as probity or misconduct. This is because once the individual has acted in a certain way (for example being dishonest), it is difficult to present convincing evidence that the behaviour was an exception or a one-time occurrence.

Nevertheless, when we look at fitness to practise concerns, these are the key principles to consider.

  • It is not possible for someone to remediate if they do not have insight into their actions. It is crucial for students to reflect on their actions and try and understand why these were deemed unprofessional in the first place.
  • Being referred to student fitness to practise often means the student has not followed the principles of Achieving good medical practice (and, by extension, Good medical practice). Students should look at those principles to see where they have deviated from the guidance, and think what they could do to demonstrate remediation for those specific principles.
  • Similarly, if a graduate has been refused provisional registration on the grounds of fitness to practise, they should consider the reasons given for refusal and the actions that generated those concerns. Any efforts towards remediation should be centred on these.
  • There isn’t a set way to demonstrate remediation. Each case is different and the way in which a student can show they have remediated will depend on the specific circumstances. But regardless of the nature of the case, key elements are:
    • reflection and self-assessment
    • sincerely expressing remorse
    • taking steps to improve by learning from mistakes
    • putting measures in place to prevent similar events from recurring
    • having evidence of the steps taken and measures put in place.
  • Any efforts to remediate should be driven by the student. The GMC and the student’s medical school can give support and some direction, but cannot tell the student what they have to do. The student should decide on the best plan of action and use their initiative to carry that out.
  • In addition to evidence of how they have remediated for their actions, students can consider providing references or testimonials about their character, and how representative of their character the actions that raised concerns were.
  • Remediation as a process is continuous and can require a significant investment of time and resources. Students and graduates will need to be aware of this and ensure they are dedicated to demonstrating remediation for their actions. But in the long-term, when successful, it helps the individual in becoming a better doctor in the future.

You can also look at our learnings from previous cases where provisional registration was refused on the grounds of fitness to practise.

What could the medical school do to help students with SFTP concerns remediate?

As mentioned above, any efforts for remediation have to be driven by the student. Their school can support them by raising the following as potential things to consider – but in the end the student must choose the appropriate course of action themselves.

  • Reflective essays.
  • Courses or programmes (e.g. driving awareness).
  • Evidence of abstinence from drugs or alcohol.
  • Volunteer work.
  • Evidence the student complied with things like conditions or a recommended treatment plan.

You can also look at an example of a programme designed to support remediation, from the University of Cardiff School of Medicine.

Useful resources