Medical students: professional behaviour and fitness to practise

This guidance sets out:

• the professional behaviour expected of medical students
• areas of misconduct and the sanctions available and
• the key elements in student fitness to practise arrangements.

This guidance is aimed at medical students and anyone involved in medical education.

You can download the guidance by clicking the link on the right.

Introduction

The purpose and status of this guidance

1. In 2005 the General Medical Council (GMC) and the Medical Schools Council (MSC) established the joint Student Fitness to Practise Working Group which has developed this guidance for medical schools and medical students. The guidance relates to:
   1. the professional behaviour expected of medical students
   2. areas of misconduct and the sanctions available
   3. the key elements in student fitness to practise arrangements.
2. The GMC and the MSC hope and expect that both medical schools and medical students will find this guidance useful.
3. Medical students have certain privileges and responsibilities different from those of other students. Because of this, different standards of professional behaviour are expected of them. Medical schools are responsible for ensuring that medical students have opportunities to learn and practise the standards expected of them.
4. The aim of this guidance is to balance a positive approach to professional behaviour of medical students with more specific advice for medical schools on how to develop consistent fitness to practise procedures.
5. This guidance considers medical students' fitness to practise in relation to their behaviour alone and not in relation to their health. However, poor health can affect a student's fitness to practise either directly or by being a cause of misconduct.
6. This guidance is aimed at medical students and anyone involved in medical education, including fitness to practise assessments, investigations and decisions.
7. In relation to the GMC’s statutory role, this guidance is advisory rather than mandatory. However, GMC quality assurance reports on medical schools may recommend that they comply with the guidance or may commend an institution for good practice. Also, given that the GMC has to be satisfied that graduates applying for registration are fit to practise, it would be surprising if a medical school thought it sensible to disregard this guidance.
   

Recent developments

8.  This guidance takes the following recent developments into account.

• The Medical Act 1983 has been changed to allow the GMC to request proof of fitness to practise before a graduate can provisionally register as a doctor. This means there is no longer an automatic link between graduation and provisional registration, and it allows the GMC to consider the fitness to practise of graduates. This is done through a declaration form at the point of registration. You can see the declaration form on the GMC’s website, www.gmc-uk.org/students.
• The 2006 version of Good Medical Practice.Among other things, this edition incorporates new ‘Duties of a Doctor’ in relation to working in partnership with patients, protecting and promoting the health of patients and the public, and supporting patients in caring for themselves to improve and maintain their health.
• The Medical School Charter published by the MSC and the Medical Students Committee of the British Medical Association. This covers the responsibilities of the medical student, the responsibilities of the medical school, privacy and equal opportunity, administration and support, and student representation.
• The 2006 report by the Commission for Healthcare Regulatory Excellence on student fitness to practise. This reviews current practices in the healthcare professions, and areas for consideration such as regulatory intervention and professional values.

The professional behaviour expected of medical students

9. The purpose of this part of the guidance is to advise on the kinds of professional behaviour that are expected of medical students in order for them to be fit to practise.
10. It aims to guide medical schools and students on how to define professional behaviour. It does not provide an exhaustive list but should encourage students to strive for high standards in their professional and personal lives.
11. This part of the guidance sets out certain types of behaviour that could demonstrate that students are fit to practise as doctors, and are not likely to put patients unnecessarily at risk. It uses the headings of Good Medical Practice (the GMC guidance that sets out the standards for all doctors to follow) to demonstrate that students, as well as doctors, have responsibilities in maintaining the standards of competence, care and behaviour.
    

The principles of professional behaviour for medical students

12. Although medical students have legal restrictions on the clinical work they can do, they must be aware that they are often acting in the position of a qualified doctor and that their activities will affect patients. Patients may see students as knowledgeable, and may consider them to have the same responsibilities and duties as a doctor.
13. Undergraduate medical education gives students the opportunity to learn professional behaviour in a supervised environment that is safe for patients. It is also an opportunity for medical schools to identify types of behaviour that are not safe, and to take appropriate action to help students improve their behaviour; or if this is not possible or is unsuccessful, to ensure they do not graduate as doctors.
14. One of the key priorities of the GMC is to set the standards for professional behaviour. Good Medical Practice isthe GMC’s core guidance for doctors and sets out the principles and values on which good practice is founded. Tomorrow’s Doctors isthe GMC's guidance for undergraduate medical education, and states that the principles in Good Medical Practice must form the basis of medical education.
15. Tomorrow’s Doctors has recommendations on health and behaviour that focus on the responsibilities of medical students, medical schools and doctors to protect patients. It also requires medical schools to provide support, to have procedures to identify medical students who give serious cause for concern, and to prevent unfit students from graduating. The GMC reviews student fitness to practise arrangements at medical schools through its Quality Assurance of Basic Medical Education (QABME) procedures to ensure they are appropriate. However, the current edition of Tomorrow’s Doctors does not set out in detail the professional behaviour expected of students.
16. Students must be aware that their behaviour outside the clinical environment, including in their personal lives, may have an impact on their fitness to practise. Their behaviour at all times must justify the trust the public places in the medical profession.

Good clinical care

17. Being able to provide good clinical care is fundamental to becoming a doctor. This objective should guide a student’s behaviour in both their clinical and academic work. This is set out clearly in both Good Medical Practice and Tomorrow’s Doctors. Medical students should reflect on how they can support and promote good clinical care as part of their medical education.
18. In order to demonstrate that they are fit to practise, students should:
    1. not exceed their limitations and ask for help when necessary
    2. not mislead anyone by misrepresenting their position or abilities
    3. make sure they are supervised appropriately for any clinical task they  perform
    4. respect the decisions and rights of patients
    5. be aware that treatment should be based on the patient’s priorities and the effectiveness of treatment options, and that decisions should be arrived at through assessment and discussion with the patient
    6. not unfairly discriminate against patients by allowing their personal views to affect adversely their professional relationship or the treatment they provide or arrange (this includes their views about a patient’s age, colour, culture, disability, ethnic or national origin, gender, lifestyle, marital or parental status, race, religion or beliefs, sex, sexual orientation, and social or economic status)
    7. behave with courtesy
    8. report any concerns they have about patient safety to the appropriate person
    9. be aware that they must acquire knowledge, skills and professional attitudes in order to provisionally register with the GMC.

Maintaining good medical practice

19. Students must be aware of their responsibility to maintain their knowledge and skills. This principle should be fundamental to all aspects of their medical education and in helping them to develop throughout their careers.
20. Both Good Medical Practice and Tomorrow’s Doctors stress the requirement to keep up to date and to apply the knowledge necessary for good clinical care. Doctors and students may be required to participate in assessments and performance reviews throughout their careers.
21. In order to demonstrate that they are fit to practise, students should:
    1. attend compulsory teaching sessions or make other arrangements with the medical school
    2. complete and submit course work on time
    3. be responsible for their own learning
    4. make sure they can be contacted and always respond to messages
    5. reflect on feedback about their performance and achievements and respond constructively
    6. be familiar with guidance from the GMC and other organisations, such as medical schools, hospitals and trusts
    7. respect the knowledge and skills of those involved in their education.

Teaching and training, appraising and assessing

22. Medical education has strong professional and academic aspects to it. Medical students must engage with patients and gain experience in clinical settings.
23. Good Medical Practice requires doctors to be willing to contribute to the education of students and colleagues. Tomorrow’s Doctors requires students to develop and demonstrate teaching skills. Doctors and students are also expected to be honest and objective when appraising or assessing the performance of others, in order to ensure students and colleagues are maintaining a satisfactory standard of practice.
24. In order to demonstrate that they are fit to practise, students should:
    1. demonstrate basic teaching skills
    2. be aware of the principles of education in medicine
    3. be willing to contribute to the education of other students
    4. give constructive feedback on the quality of their teaching experience.

Relationships with patients

25. Medical students will have extensive contact with patients during their medical course. Although there are limits to these clinical encounters and students are supervised, patients may consider the student to be in a position of responsibility, and so may attach added importance to their opinions or comments.
26. Good Medical Practice and Tomorrow’s Doctors require doctors and students to build relationships with patients based on honesty, openness, trust and good communication. Both publications focus on behaviour that respects patients and their carers (including children, young people and other vulnerable groups) as well as protecting their rights.
27. This is achieved by working in partnership with patients, for instance by encouraging them to get involved in decisions about their care. Relatives, carers, partners and anyone else close to the patient should also be treated with consideration and be given support when needed. Doctors and students are expected to maintain a professional boundary between themselves and their patients or anyone close to the patient. They must not use their professional position to cause distress or to exploit patients.
28. Good Medical Practice and Tomorrow’s Doctors state that patients must give informed consent to any activity. This includes participating in teaching or research, as well as in any activity undertaken by a medical student.
29. Both publications also state thatpatients have a right to expect information about them to be held in confidence. A patient’s case must not be discussed, in a way that would identify them, with anyone not directly involved in their care, or in a public place. Academic work that contains specific information about a patient must not identify the patient if it is to be seen outside the patient’s care team.
30. In order to demonstrate that they are fit to practise, students should:
    1. respect patients and treat them with dignity
    2. be aware of ethical issues in their professional behaviour with patients
    3. be open and honest when dealing with patients, their carers, relatives, partners or anyone else close to them
    4. make sure that patients have consented to a student being involved in their care
    5. make sure they are clearly identified as students
    6. dress in an appropriate and professional way and be aware that patients will respond to their appearance, presentation and hygiene
    7. make sure they follow the GMC guidance on consent and confidentiality.

Working with colleagues

31. Medical students need to be able to work effectively with colleagues inside and outside of healthcare in order to deliver a high standard of care and to ensure patient safety.
32. Good Medical Practice and Tomorrow’s Doctors require doctors and students to develop skills to work in multi-disciplinary teams. This involves respecting the skills and contributions of colleagues and other professionals, and developing effective communication with other members of the team and with patients.
33. It is also important that doctors and students protect patients from harm posed by another colleague’s behaviour, performance or health. They should take steps to raise any concerns with the appropriate person .
34. In order to demonstrate that they are fit to practise, students should:
    1. demonstrate skills that allow them to deal with uncertainty and change in the workplace
    2. be able to work effectively in a team and to take on different roles as appropriate, including taking responsibility for tasks
    3. develop and demonstrate teamwork and leadership skills
    4. be aware of the roles and responsibilities of other people involved in delivering healthcare
    5. respect the skills and contributions of colleagues and other professionals and not unfairly discriminate against them
    6. raise concerns about overall practice in a healthcare setting or about colleagues, including other students, medical practitioners and other healthcare workers, with the appropriate person if patients are at risk of harm.

Probity

35. Probity means being honest and trustworthy, and acting with integrity. Good Medical Practice requires doctors to make sure that their behaviour at all times justifies the trust that patients and the public place in the medical profession. Tomorrow’s Doctors requires students to demonstrate honesty.
36. In order to demonstrate that they are fit to practise, students should:
    1. bring attention to any concerns about, or errors in, their clinical work
    2. be honest, genuine and original in their academic work, including when conducting research, and take effective action if they have concerns about the honesty of others
    3. be honest and trustworthy when writing reports and logbooks, and when completing and signing forms
    4. be honest in CVs and all applications and not misrepresent their qualifications, position or abilities
    5. not plagiarise others' work or use their own work repeatedly in a way that could mislead
    6. be honest and trustworthy in any financial dealings, especially if they are managing finances, and make sure that any funds are used for the purpose they were intended for
    7. co-operate with any formal inquiry by their medical school or other organisation into their health, behaviour or performance, or that of anybody else
    8. comply with the laws of the UK and, where relevant, any laws that apply specifically in England, Wales, Scotland or Northern Ireland
    9. comply with the regulations of their medical school, hospital or other organisation.

Health

37. It is important that medical students are aware that their own poor health may put patients and colleagues at risk.
38. Good Medical Practice requires doctors to seek and follow advice from a suitably qualified professional about their health. This is particularly important if they have, or suspect they have, a serious condition that could be passed on to patients, or if they are receiving treatment that could affect their judgement or performance.
39. In order to demonstrate that they are fit to practise, students should:
    1. be aware that their own health problems may put patients and colleagues at risk
    2. seek medical or occupational health advice if there is a concern about their health
    3. accept that they may not be able to assess their own health, and be willing to be referred for treatment and to engage in any recommended treatment programmes
    4. protect patients, colleagues and themselves by being immunised against common serious communicable diseases if vaccines are available
    5. be aware that they are not required to perform exposure prone procedures (EPPs) in order to achieve the expectations set out in Tomorrow’s Doctors; students with blood-borne viruses (BBVs) can study medicine but they may have restrictions on their clinical placements, and will need to limit their medical practice when they graduate
    6. not rely on their own or another student’s assessment of the risk posed to patients by their health, and should seek advice, when necessary, from a qualified clinician or other qualified healthcare professional
    7. be aware that medical graduates must let it be known if their health poses a risk to patients or the public.

 

Areas of misconduct and the sanctions available

40. The purpose of this part of the guidance is to define fitness to practise, the threshold of acceptable behaviour, and the scope of the formal procedures of medical schools. It also sets out some areas of concern identified by medical schools. Poor behaviour in these areas may have implications for a student's provisional registration with the GMC. This part of the guidance also identifies the available sanctions for students who behave unprofessionally or in a way that puts patients at risk.
41. Although health and behaviour can both affect a student's fitness to practise, this guidance deals only with behaviour; but poor behaviour may result from underlying health problems. Medical schools may wish to use their fitness to practise procedures to consider serious health problems. This is especially the case when the problems have implications for the safety of patients or colleagues, even when there are currently no complaints about the student's behaviour. But health problems are outside the scope of this guidance.
42. This guidance aims to help medical schools make more consistent decisions on any fitness to practise cases they consider. Each medical school deals with only a small number of cases through its formal procedures so it is not practical to produce an exhaustive list of examples and outcomes. The behaviour of students must be considered on a case-by-case basis by fitness to practise investigators and medical school panels.
43. Medical schools should consider providing support and confidential pastoral care to help students who need to improve their behaviour. When fitness to practise concerns are identified, it may be appropriate to offer support to the student before, alongside, or instead of using fitness to practise procedures. However, this decision must be based on an assessment of the risk to patients and the public. Anyone who provides pastoral care should not also be involved in investigating or making decisions that could affect the student’s career, even though personal tutors are often the ones who raise the initial concern.

The meaning of student fitness to practise

44. In relation to a doctor's fitness to practise the GMC states:

‘To practise safely, doctors must be competent in what they do. They must establish and maintain effective relationships with patients, respect patients’ autonomy and act responsibly and appropriately if they or a colleague fall ill and their performance suffers.

‘But these attributes, while essential, are not enough. Doctors have a respected position in society and their work gives them privileged access to patients, some of whom may be very vulnerable. A doctor whose conduct has shown that he cannot justify the trust placed in him should not continue in unrestricted practice while that remains the case.’ (Indicative sanctions guidance for fitness to practise panels, April 2005)

45. This statement should be taken into account when deciding if medical students are fit to practise. Although students cannot always be held to the same standards as registered doctors, the underlying principles are similar. It is important that students with serious fitness to practise problems do not put patients or the public at risk.
46. It is common for medical students both to interact with patients and to have access to confidential patient information. Patients may view students as being in a position of trust and responsibility. They are often willing to allow students to be involved in their treatment as they accept that this is an important part of a student's education. But this willingness is based on trust that students will behave professionally, and that trained professionals will supervise them appropriately.
47. Students must be aware that any poor behaviour during their medical course can affect their ability to provisionally register as a doctor. The GMC can prevent a graduate from provisionally registering, even if the behaviour in question occurred before or early on in medical school, if it is serious or persistent behaviour that calls into question the graduate’s fitness to practise as a doctor.
48. Students are expected to behave in a professional and responsible manner. Their behaviour should be measured against the principles set out in this guidance and in Tomorrow’s Doctors, taking into account the principles set out in Good Medical Practice.If a student's behaviour falls below these expected levels, the medical school should consider if this amounts to a fitness to practise concern, and therefore warrants consideration through its formal procedures.
    

The threshold of acceptable behaviour

49. One of the functions of the GMC and medical schools is to develop standards and criteria for medical students to make sure they are fit to practise as doctors.
50. The GMC has the legal authority to decide the standards and outcomes that students must demonstrate at the point of graduation in order to provisionally register with the GMC. These are set out in Tomorrow’s Doctors.These standards and outcomes form the basis for a decision to be made as to whether a student will be safe and effective as a doctor.  The GMC expects medical students to work towards the standards set out in both Good Medical Practice and Tomorrow's Doctors.
51. It is the responsibility of medical schools to decide if individual students are fit to practise as doctors by the time they graduate.
52. A student’s fitness to practise is called into question when their behaviour raises a serious or persistent cause for concern about their ability to continue on a medical course, or to practise as a doctor after graduation. This includes, but is not limited to, the possibility that they could put patients or the public at risk.
53. In these circumstances, a student should be considered by formal fitness to practise procedures at the medical school. If a student’s poor behaviour is to be considered through a university's general disciplinary procedures, this does not prevent it also being considered through the medical school’s formal fitness to practise procedures. The two procedures will operate under different criteria, and it is important that they do not occur simultaneously.
54. Medical schools should consider the behaviour of medical students in relation to how it may have an impact on patient and public safety, and public confidence in the medical profession.
    

Categories of concern

55. This part of the guidance sets out areas of concern that may call into question whether a student is fit to practise. This is not an exhaustive list but indicates the most common concerns identified by medical schools.
56. These are also areas in which the GMC has taken action against doctors and which might be taken seriously at the point of provisional registration. The GMC might take action in relation to fitness to practise if a doctor has:
    1. made serious or repeated mistakes in diagnosing or treating a patient's condition
    2. not examined patients properly or not responded to reasonable requests for treatment
    3. misused information about patients
    4. treated patients without obtaining their consent or other valid authority
    5. behaved dishonestly in financial matters, in dealing with patients, or in research
    6. made sexual advances towards patients
    7. misused alcohol or drugs.
57. Several of these examples could clearly relate to the fitness to practise of medical students as well as doctors.
58. The following table shows the types of concerns identified in fitness to practise procedures at medical schools. Within each category, there is a list of examples of allegations that medical schools have considered to be so serious or persistent that they went to formal fitness to practise procedures.
59. Decisions about the behaviour of students must be considered on a case-by-case basis, and should be based on whether the behaviour calls into question either the student’s ability to continue on a medical course, or their fitness to practise as a doctor after graduation.

Table 1: Some areas of misconduct and examples

Areas of misconduct	Some examples of misconduct
Criminal conviction or caution	Child pornography Theft Financial fraud Possession of illegal substances Child abuse or any other abuse Physical violence
Drug or alcohol misuse	Drunk driving Alcohol consumption that affects clinical work or environment Dealing, possessing or using drugs even if there are no legal proceedings
Aggressive, violent or threatening behaviour	Assault Physical violence Bullying Abuse
Persistent inappropriate attitude or behaviour	Uncommitted to work Neglect of administrative tasks Poor time management Non-attendance
Cheating or plagiarising	Cheating in examinations Passing off others’ work as one’s own
Dishonesty or fraud, including dishonesty outside the professional role	Falsifying research Financial fraud Fraudulent CVs or other documents
Unprofessional behaviour or attitudes	Breach of confidentiality Misleading patients about their  care or treatment Sexual harassment Inappropriate examinations or failure to keep appropriate boundaries in behaviour Persistent rudeness to patients, colleagues or others Unlawful discrimination

Making decisions

60. It is important to distinguish between the role of the investigator appointed by the medical school and the role of the fitness to practise panel. The investigator considers the initial evidence and decides if it is serious enough to be referred to a fitness to practise panel. The panel's role is to deliberate formally and decide whether the student is fit to practise, and what sanctions, if any, should be imposed. The investigator should consider only whether the behaviour is so serious or persistent as to call into question the student’s ability to continue on a medical course, or their fitness to practise as a doctor after graduation.
61. The investigator must act in a proportionate way by weighing the interests of patients and the public against those of the student. It is important to consider whether the behaviour is better dealt with through student support and remedial tuition rather than through a formal panel hearing. However, if the investigator decides the behaviour is so serious or persistent as to call into question the student's ability to continue on a medical course, or their fitness to practise as a doctor after graduation, the case should be referred to a fitness to practise panel. This is in spite of any mitigating factors such as health problems.
62. Any mitigating factors should be considered by the panel members when they are deciding on the appropriate outcome. The panel members should also make sure the warning or sanction they decide upon is proportional to the behaviour and will deal effectively with the fitness to practise concern.
63. Like investigators, panels should keep in mind the balance between patient safety and the interests of the medical student.
64. All decisions should be taken in light of any guidance set by the GMC and should be consistent with the regulations and procedures of the medical school.
65. The panel should give reasons for its decision to impose the sanction and specify any timeframe or conditions that may apply.
66. There should be a clear formal appeals process. There is further guidance on procedures in the part of this guidance entitled ‘The key elements in student fitness to practise arrangements’.
    

Outcomes of student fitness to practise hearings

67. Possible outcomes of hearings include:
    1. the student receives no warning or sanction
    2. the student receives a warning as there is evidence of misconduct but the student’s fitness to practise is not impaired to a point requiring any of the sanctions listed below
    3. the student receives a sanction. Beginning with the least severe, the sanctions are:
       • undertakings
       • conditions
       • suspension from medical course
       • expulsion from medical course.
68. Medical schools should have a clear policy on how long warnings and sanctions will remain on a student's record. This should be at least the length of time it usually takes for a student to get provisional registration with the GMC. When applying for provisional registration, the student must declare the warnings or sanctions to the GMC, and the medical school should make sure that the GMC is aware of them. If the sanctions are severe, they can remain on the medical school’s record after the student has applied for provisional registration. The medical school's policy should also explain how it will deal with information about the case if the student takes longer than is usual to apply for provisional registration, or never applies at all.
69. Students who receive a warning or sanction, short of being expelled, should also receive supervision or monitoring, or both, to satisfy the medical school regarding their fitness to practise. They should also be provided with remedial or pastoral support, or both.
70. It should be made clear to any student who receives a warning or sanction why they have received it, its intended purpose, its expected duration, and whether or when their fitness to practise will be considered again in a formal hearing.
71. It should be made clear to students that they can withdraw from their course rather than going through the formal fitness to practise procedures. It should also be made clear, if they do withdraw, whether it will be possible for them to return to their course later, or transfer to a different course at the university.

Warnings

72. Warnings are formal statements that indicate that the student’s behaviour is unacceptable. Warnings should be given when a student’s behaviour raises concerns but it is not so serious that their fitness to practise is impaired. There should be adequate support for the student to address any underlying problems that may have contributed to their poor behaviour.
73. Any subsequent incidents may be considered in light of earlier warnings. Patterns of poor behaviour may give rise to more serious concerns about a student’s fitness to practise.
74. A warning means the behaviour does not merit a sanction. But it should remain on the student’s record and the student must declare it to the GMC when applying for provisional registration.
75. A warning might be appropriate particularly when:
    1. the behaviour in question does not involve dishonesty, offences of a sexual nature or a lack of insight or responsibility, and
    2. there have been no previous concerns about the student's fitness to practise.
76. Panels might want to consider issuing a warning if:
    1. there was no direct or indirect patient harm, and
    2. the panel is satisfied that the student will take the warning seriously, and
    3. the student has insight into why their behaviour was inappropriate, and
    4. the behaviour was serious enough to warrant formal recognition.

Sanctions

77. The purpose of the four types of sanction is to ensure that students whose fitness to practise is impaired are dealt with effectively, including possibly being removed from their medical course. A sanction also gives the student the opportunity to learn from their mistakes.
78. Panels should consider whether the sanction will protect patients and the public and will maintain professional standards. If the behaviour involves dishonesty, offences of a sexual nature, or a lack of insight, lower-level sanctions are unlikely to be appropriate.

Undertakings

79. An undertaking is a promise given by the student in writing to the panel that they will not behave in a certain way in the future. This sanction applies when there is a finding that the student’s fitness to practise is impaired. The student should consent to disclose this sanction to the appropriate people and it must be declared to the GMC at the point of provisional registration.
80. If the student breaks the undertaking, they can be dealt with by other sanctions.
81. Undertakings should be proportionate, workable and measurable.
82. Panels might want to consider an undertaking if:
    1. it will be sufficient to protect patients and the public, and
    2. it covers all the conditions the panel would otherwise have imposed, and
    3. the behaviour did not involve dishonesty or a sexual offence (as defined above), and
    4. the student has insight into the seriousness of the problem and is willing to respond positively to any interventions, and
    5. the student has apologised and expressed genuine regret.

Conditions

83. Conditions are appropriate when there is significant concern about the behaviour of the student. This sanction should be applied if the panel is satisfied that the student might respond positively to remedial tuition and increased supervision. The panel should consider any evidence such as reports on the student’s performance, health or behaviour.
84. If a panel has found a student’s fitness to practise impaired because of poor physical or mental health, the conditions should include medical supervision as well as academic supervision. The student should consent to disclose this sanction to the appropriate people and it must be declared to the GMC at the point of provisional registration.
85. Conditions should be proportionate, workable and measurable.
86. Panels might want to consider conditions if:
    1. patients will not be put at risk as a result of the student being allowed to continue on the course, and
    2. the behaviour did not involve dishonesty or a sexual offence (as defined above), and
    3. the student understands the seriousness of the problem and is willing to respond positively to any interventions, and
    4. the student has apologised and expressed genuine regret, and
    5. there is a realistic chance that the student will positively change their behaviour.

Suspension from medical course

87. Suspension prevents a student from continuing with their course for a specified period and graduating at the expected time. Suspension is appropriate for misconduct that is serious but not so serious as to justify expulsion from the medical school.
88. When a student returns from suspension, they are expected to comply with any further conditions. They should consent to disclose the suspension and conditions to the appropriate people and must declare the suspension and conditions to the GMC at the point of provisional registration.
89. The panel might want to consider a suspension if:
    1. a less severe sanction is not appropriate, and
    2. the behaviour is unlikely to be repeated, and
    3. the student has insight into the seriousness of the pro blem and is willing to respond positively to any interventions, and
    4. there is a realistic chance that during the period of suspension the student will positively change their behaviour.

Expulsion from medical course

90. The panel can expel a student from the medical school if they consider that this is the only way to protect patients, carers, relatives, colleagues or the public. The student should be helped to transfer to another course if appropriate. However, the nature of the student’s behaviour may mean that they should not be accepted on certain courses, or even on any other course.
91. Expulsion, the most severe sanction, should be applied if the student’s behaviour is considered to be fundamentally incompatible with them continuing on a medical course or eventually practising as a doctor.
    

 

The key elements in student fitness to practise arrangements

92. This part of the guidance defines the suggested core elements within student fitness to practise arrangements. These core elements are:
    1. awareness and education
    2. communication
    3. confidentiality and disclosure
    4. the roles of personal tutors, investigators and panel members
    5. applying the threshold of acceptable behaviour
    6. timescales
    7. panel composition
    8. support for medical students
    9. appeals.

Awareness and education

93. Medical schools should issue fitness to practise policy documents that state the responsibility of the medical school to raise the awareness of prospective students, current students and staff with regard to student fitness to practise issues. This includes explaining the opportunities for pastoral care and the medical school's formal procedures. Staff, including all NHS staff who have regular contact with students in an educational or supervisory capacity, should be familiar with the medical school's guidance.
94. It should be made clear that the medical school will welcome and consider information or concerns about students from any source, including NHS staff and patients or their carers.
95. Medical schools’ fitness to practise policy documents should clearly distinguish between their roles in handling complaints and in considering fitness to practise cases, but should also explain the relationship between these two roles. The fitness to practise policy documents should also describe the respective roles of the medical school, the university, the Office of the Independent Adjudicator, the NHS and the GMC.

Communication

96. Processes should be in place to allow for clear and prompt communication at all stages with everyone involved whenever fitness to practise concerns emerge. These processes should be clearly stated in the medical school’s documents, such as admissions statements and fitness to practise policy documents.

Confidentiality and disclosure

97. Medical schools will need to consider information storage and confidentiality. It may be appropriate to keep certain documents separate from a student’s file with cross reference markers. Medical schools should state in fitness to practise policy documents that they may pass personal information to other organisations, such as the GMC, other medical schools or postgraduate deaneries, if a student receives a warning or a sanction. Medical schools are expected to be aware of, and comply with, the Data Protection Act in order to protect the confidentiality of students.
98. Medical schools must have clear guidelines on the disclosure of information about cases where a student's fitness to practise has been considered in a formal procedure. The Office of the Information Commissioner has given this advice: ‘The Data Protection Act 1998 does not represent a complete barrier to disclosure, rather it would allow it where it is necessary and proportionate and where certain conditions have been met. Where there is a real issue about a student’s fitness to practise and where this represents a risk to patients or members of the public then disclosure would seem to be justified.’This will have implications for the responsibilities of, for example, occupational health practitioners, teachers and trainers, personal tutors and students.

The roles of personal tutors, investigators and panel members

99. A student's personal tutor should not also act as an investigator or as a member of the fitness to practise panel. This allows the tutor to support the student and ensures the objectivity of the investigator and the panel members who will be making decisions about the student’s future.

Applying the threshold of acceptable behaviour

100. Medical schools' fitness to practise policy documents should state how they interpret and apply the definition in this guidance of the threshold of acceptable behaviour. They should explain that unacceptable behaviour may result in formal fitness to practise procedures and in sanctions being imposed. They should also refer to any relevant documents used by the medical school to define fitness to practise, for example Good Medical Practice, Tomorrow’s Doctors, or this guidance.

Timescales

101. Medical schools’ fitness to practise policy documents should include clearly defined timescales for the various stages of the procedures, taking into account how long a student may be prevented from continuing their course. In exceptional cases, the timescales may be extended to ensure the procedure is fair. This might be, for instance, to ensure that everyone involved is available. However, it is in everyone's best interests for the defined timescales to be adhered to if possible.

Panel composition

102. Medical schools' fitness to practise policy documents must clearly describe the composition of the panel. In determining panel composition, the school should consider whether it would be practical to include:
     1. someone from outside the medical school
     2. someone with legal knowledge
     3. a student representative who does not know the student being investigated.
103. The panel should have a medical or health professional majority. All panel members should receive training for their role, be appropriately experienced, and have access to all relevant documentation.

Support for medical students

104. Medical schools should allow students to be represented at fitness to practise hearings or have a supporter present. Medical schools’ fitness to practise policy documents should set out how this will work in practice. The representation and support must protect the students’ rights in line with the Human Rights Act 1998.
105. Medical schools’ fitness to practise policy documents should be clear about how equality and diversity are incorporated into their procedures. This should include the need for reasonable adjustments to be made for those students who need them.

Appeals

106. Medical schools' fitness to practise policy documents should clearly state the procedure and scope for appeals. They should recognise that the criteria for fitness to practise for medical students differ from those that apply to other students. Appeals policy documents could include, among other things:
     1. limiting the appeals panel’s remit to referring the case back to another medical school fitness to practise hearing
     2. whether appeal hearings can reconsider the facts of the case or are limited to deciding whether due process was followed
     3. details on the composition of appeals panels.

 

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Endnotes

1. For convenience, the text refers to medical schools but much of the guidance will also apply to universities.
2. For convenience, the text refers to 'behaviour' rather than 'conduct', as in the context of this guidance we see the two words as having the same meaning. However, 'behaviour' does not include performance or competence.
3. It would be appropriate for students to raise concerns with their educational or clinical supervisor or their medical school dean.
4. It would be appropriate for students to raise concerns with their educational or clinical supervisor or their medical school dean.
5. It would be appropriate for students to raise concerns with their educational or clinical supervisor or their medical school dean.
6. If a student does have the opportunity to perform EPPs they should be aware of the Department of Health’s publication Health clearance for tuberculosis, hepatitis B, hepatitis C and HIV: New health care workers (2007). This guidance applies to medical students in England only.
7. Offences of a sexual nature include child pornography or other cases if the courts have imposed sanctions such as registration as a sex offender, rehabilitation or therapy.
8. Correspondence from the Office of the Information Commissioner, 2006