Myths and questions about professionalism and fitness to practise
This is not true.
Our guidance to medical schools, Professional behaviour and fitness to practise, makes it clear that a health condition does NOT mean there is a student fitness to practise concern (paragraph 14). Most students will continue their studies managing their health condition without their fitness to practise ever coming into it.
The only circumstances that might involve student fitness to practise are when a student is not showing insight into their condition, not seeking appropriate medical advice, or not complying with treatment. This becomes a student fitness to practise issue because the safety of the student or others around them, as well as confidence in the profession may be compromised.
See also: Your health - dos and don'ts in our guidance, Achieving good medical practice.
This is not true.
We encourage students to tell their medical school if they have a health concern. This is because your school has a lot of mechanisms in place to support you, but they won't know to do so unless you reach out to them.
Your medical school wants you to excel and will provide support to make sure this is the case. They can support you in lots of ways, for example:
- use of their services: student support, university health services, occupational health, disability support, confidential counselling services.
- putting adjustments in place for your studies or clinical placements. These include giving you helpful equipment, making changes to the facilities, and changes to the school's provisions (eg extra time for assessments, enlarged writing, and placements in nearby locations).
Not only does telling your medical school about your health mean that your school can support you, it also shows you have insight into your condition and are being open and honest about your health.
See also: examples of reasonable adjustments in our guidance Welcomed and valued.
See also: our guidance for medical schools about Supporting medical students with mental health conditions.
This is not true.
Many concerns won't cross the threshold for your school to initiate student fitness to practise procedures. This is defined in Professional behaviour and fitness to practise, our guidance to medical schools, but in short your actions have to be serious enough for there to be concerns about patient safety or trust in the profession. If the concerns don't cross that threshold, your school will manage them outside student fitness to practise proceedings. Some schools have a health and conduct committee, which sits below the fitness to practise process, to manage concerns that don't cross that threshold. This lower level process is essentially supportive in nature.
Even if formal student fitness to practise procedures are initiated, your school has to complete an investigation first, where they decide whether referring you to a student fitness to practise panel is the best course of action. The investigators will only refer you if they think your fitness to practise might be impaired.
Investigations often end with no action, a warning, or an agreement with the student (undertaking) and don't reach a panel. In the 2015/16 academic year, more than two thirds of student fitness to practise investigations closed without reaching a panel.
If you are referred to a student fitness to practise panel, the panel will consider all the facts to decide what is an appropriate and proportionate action based on the concerns. Expulsion is an extremely rare outcome, only in the most serious circumstances.
See also: Table 2 in Professional behaviour and fitness to practise for more details on where different outcomes are appropriate.
This is not true.
According to the data we received from medical schools, in 2015/16 there were only 10 cases where a medical student was expelled through formal student fitness to practise procedures.
To put this number into context, this is across 35 UK medical schools and over 40,000 medical students. It only represents 2% of the cases that schools reported as professionalism or student fitness to practise concerns.
This extreme action can only be taken in very serious circumstances, either when it is seen as the only way to protect patients, carers, relatives, colleagues or the public, or where a student's behaviour is seen to be fundamentally incompatible with continuing on the course or becoming a doctor (paragraphs 143-144 in Professional behaviour and fitness to practise).
See also: table 2 in Professional behaviour and fitness to practise for more details of where different outcomes (including expulsion) are appropriate.
This is not true.
Medical schools send us information about ongoing and closed student fitness to practise cases and investigations when students are in their final year of study. This information helps our Registration team process the provisional registration applications of final year students who are about to graduate more quickly.
This means when you come to apply, we have the information we need and plenty of time to examine the details of the case. In the overwhelming majority of cases, applications with a declaration about fitness to practise will be granted provisional registration.
In 2016 13% of applications for provisional registration included declarations about fitness to practise issues. Only six applicants (0.08% of all applications) were refused provisional registration.
Medical schools also send us fully anonymised information on ongoing student fitness to practise cases each year. This allows us to see how well our guidance is being implemented and to distinguish any trends across medical schools.
See also our question further down this page: "If a student declares fitness to practise concerns to the GMC, what information is needed and what are the consequences of non-disclosure?".
This is not true.
Any concerns about students, including those managed by student fitness to practise panels, are internal matters for the medical schools to manage.
We've issued advisory guidance with the Medical Schools Council on student fitness to practise, but it is up to the schools to integrate this into their local processes.
Decisions on student fitness to practise cases are taken by the medical school. Appeals to decisions can be made to the university or to external bodies, but not to us.
Our decision to register a graduate as a doctor is separate from any student fitness to practise decision, and also from the university decision to graduate a medical student.
Using the guidance
We want this guidance to be a constant companion for medical students as they study to become the doctors of the future. The guidance is based on Good medical practice (2013), and links their learning now to their practise in the future.
Professional behaviour matters, even before students work with patients. Both the GMC and medical schools have a role in ensuring the students of today are the excellent doctors of tomorrow.
By linking the guidance to Good medical practice this will support students' transition to practice by ensuring that a common set of guidelines on professional behaviour apply across the continuum of medical education and training.
The guidance came into effect on 1 September 2016, to tie in with the new academic year for medical students.
All students seeking to graduate and gain provisional registration must at that point be able to demonstrate all the Outcomes for graduates. These include outcomes for the doctor as a scholar and a scientist, the doctor as a practitioner and the doctor as a professional. The legal advice we received indicates that the standards and requirements set in Outcomes for graduates are effectively 'competence standards'.
What does this mean in practice?
This means that the GMC is not able to require adjustments that would alter or lower the standard of competency. Whilst recognising that the competence standards cannot be adjusted or lowered, we are very clear that consideration must be given to making adjustments to the method by which these competencies are assessed which could include making adjustments to practical procedures.
We have no legal ability to grant a conditional, restricted or limited licence to practise at the point of initial registration, and medical schools are not empowered to grant students dispensation from the requirements set in Outcomes for graduates.
How can the school make a decision?
If, once the medical school has received all the relevant advice (as appropriate for each case), the consensus is that the student is not able to meet all the outcomes required, we would regrettably advise that the student should not be allowed to graduate. This is because by graduating a student with a recognised primary medical qualification, the medical school is declaring them fit to practise as doctor, and putting them forward for provisional registration - which would not be granted if the student did not meet the outcomes.
Before coming to any conclusion, we would strongly advise schools to engage closely with the student, and ensure that they have participated fully in any discussion about the difficulties they may be experiencing and potential solutions.
In some cases, the medical school and the student may not agree on the best course of action. When this happens, the medical school should use its fitness to practise process to make sure that the decision about the student's future is impartial.
Before starting a student's fitness to practise process, the medical school must make sure that it is able to show the support, interventions and reasonable adjustments it has made for the student. It should be able to show that it has made every effort to support the student to complete the course. Also see paragraphs 122-125 from Supporting medical students with mental health conditions.
What support must the school offer?
In the unfortunate scenario where the student was not allowed to graduate, it would be essential to offer the student career advice to consider how they can best utilise their knowledge and skills, and a possible exit route from their medical course.
- BMA Careers (part of the BMA) is a resource for advice and career guidance.
- The 2014 Medical Schools Annual Return (MSAR) summary report (page 18) gives some examples of exit routes that medical schools have established for students who are not able to meet the requirements of the course.
- Also see paragraph 121 from Supporting medical students with mental health conditions.
Regardless of the outcome, it is important that the medical school keeps a record (audit trail) of all relevant evidence and decision-making.
Medical schools and the NHS organisations where the schools send their students for clinical placements should have policies and student and staff support mechanisms in place, to deal with any incidents where patients (or others) are abusive or aggressive to a student during their clinical placement.
What do the GMC standards say?
In Promoting excellence, we set out our expectations from education and training providers in terms of managing the learning environment and supporting their learners. We would highlight in particular:
- S1.1: The learning environment is safe for patients and supportive for learners and educators. The culture is caring, compassionate and provides a good standard of care and experience for patients, carers and families.
- R1.2: Organisations must investigate and take appropriate action locally to make sure concerns are properly dealt with. Concerns affecting the safety of patients or learners must be addressed immediately and effectively.
- R1.13: Organisations must make sure learners have an induction in preparation for each placement that clearly sets out:
- c) how to gain support from senior colleagues
- d) the clinical or medical guidelines and workplace policies they must follow.
- S2.3: The educational governance system makes sure that education and training is fair and is based on principles of equality and diversity.
- R2.19: Organisations must have systems to make sure that education and training comply with all relevant legislation.
- S3.1: Learners receive educational and pastoral support to be able to demonstrate what is expected in Good medical practice and to achieve the learning outcomes required by their curriculum.
- R3.2: Learners must have access to resources to support their health and wellbeing, and to educational and pastoral support, including:
- a) confidential counselling services.
- R3.3: Learners must not be subjected to, or subject others to, behaviour that undermines their professional confidence, performance or self- esteem.
Responsibilities of education providers
When sending medical students to clinical placements, we would expect the school and the host organisation to take steps to ensure that the students are aware of relevant policies and processes that apply within the host organisation, including how students on placement can report any incidents that occur during their time there.
We can't advise on the extent to which a medical student on placement has the same legal rights as an employee to be protected from discrimination, bullying or harassment. However it should be clear the requirements we set, that medical schools and other education and training providers have responsibilities to provide appropriate protection and support for students.
Responsibilities of the student
In terms of what we would expect a student to do, if faced with a challenging or abusive patient, we would refer to the professional standards in Good medical practice and relevant sections of our new student fitness to practise guidance, Achieving good medical practice. See in particular:
- Paragraph 32: As a medical student, both during study and on a placement, you're likely to experience situations that will have an emotional impact on you. At times, you may experience stress and anxiety. This is completely normal and your medical school will support you with safe ways to share and reflect on difficult experiences. But if you are concerned about your levels of anxiety, you should seek help from your general practitioner (GP) and other appropriate sources (for example, helplines) to address any issues at an early stage. This may include making adjustments to your training or practice, if necessary.
- Paragraph 54 All registered doctors must establish and maintain partnerships with patients. This means being polite and considerate and treating patients as individuals. It also means respecting their dignity and privacy and treating patients fairly and with respect, whatever their life choices and beliefs.
- Paragraph 55: As a medical student, you'll learn how to develop a partnership with patients. Therefore you must:
- be polite and considerate at all times
- listen and respond to patients' views and concerns
- respect patients' dignity, confidentiality and privacy
- treat patients fairly and with respect, no matter what your own thoughts are about their life choices or beliefs
- be clear with patients about the role you'll take in their care.
We would stress that, while students have a responsibility to treat patients politely and with respect, it is clearly distressing and unacceptable for medical students to be subject to any abuse. It is essential that any kind of derogatory or aggressive behaviour is reported to both the medical school and the organisation providing the student placement, so that they can tackle it in line with their responsibilities and the requirements of our standards. This is also essential so they can support the student who has been subject to abuse.
Our view is that it is firstly an issue of safety for medical students. There are medical dangers in drugs that are not prescribed via the appropriate channels, and not following the advice of a qualified medical professional. Accessing the drugs by ordering them online also means the student has circumvented the appropriate clinical governance, safe prescription and monitoring of medications consistent with safe medical practice.
Why is this concerning?
Even if drugs were prescribed by a qualified medical professional, it is highly unlikely that the prescribing intent (or licensed indication) would be for 'cognitive enhancement' ahead of examinations, so the student would still be exposing themselves to health risks by abusing prescription-only medications.
Secondly, the behaviour itself, of a medical student being prepared to illicitly source drugs to enhance their performance is extremely concerning. It raises questions about an individual's insight, judgment, appetite for risk-taking and quality of personal decision-making in this dangerous area of practice. This is a dangerous precedent for someone who will in due course, potentially be required to make prescribing decisions for patients under their care (see paragraph 16 of our prescribing guidance in Good medical practice for what is expected of a registered doctor). It also raises concerns about the individual's probity, which is one of the fundamental values we expect of all doctors.
Thirdly, this potentially harmful behaviour on behalf of the student could show a lack of insight into their own health and well-being, which is also a student fitness to practise concern.
How is this addressed in the guidance?
In terms of how this is covered in the new student fitness to practise guidance, the piece addressed to medical students (Achieving good medical practice) outlines key areas of professionalism concern, which might result in student fitness to practise procedures. We should stress that this is not an exhaustive list, but it includes 'Abusing prescription medication', 'Dealing, possessing, supplying or misusing drugs, even if there are no legal proceedings - this may include legal highs', 'Possessing, dealing or supplying illegal drugs' and a few examples under 'health concerns and insight or management of these concerns'. Moreover, Achieving good medical practice:
- highlights that part of professionalism is learning healthy ways to cope with stress and anxiety (taking the challenge of professional excellence)
- tells students they must comply fully with the regulations and other systems or structures provided by their medical school or university (paragraph 4)
- advises students on dealing with stress and anxiety (paragraph 32)
- tells students they should avoid treating themselves or people close to them, and seek independent medical advice (paragraphs 37-38), as well as get support from their medical school (paragraphs 39-41)
- discusses the importance of acting with honesty and integrity (paragraph 72-73).
In conclusion, we believe medical students' taking 'cognitive-enhancing' drugs shows poor personal judgement, is potentially harmful, shows a concerning disregard for their own safety and well-being, as well as setting a worrying precedent for behaviour that we would not expect from future doctors.
We hope the new student fitness to practise guidance will clarify expectations and provide support for students and medical school staff in identifying and dealing with any such concerns.
You and the GMC
All final year students need to complete a fitness to practise declaration when applying for provisional registration to the GMC. This is because, as the professional regulator, we must only register medical graduates who are fit to practise. If we identify that a graduate's fitness to practise is impaired, we have a responsibility to refuse registration until they can demonstrate remediation. This decision is independent from the medical schools' assessment of their graduates.
The GMC does not need to receive information from students about student fitness to practise matters before provisional registration applications open. All student fitness to practise matters are handled by medical schools. If you are a student and you wish to share a student fitness to practise concern, either for yourself or one of your peers, the best thing to do is speak to your medical school, for example to your personal tutor.
We encourage final year students who may have a fitness to practise issue (past or present) to apply well in advance of their foundation year 1 (F1) start date, and as soon as the online application process opens. An early declaration gives us ample time to carry out any investigations needed and reach our decision.
It is important to highlight that we have refused provisional registration in a very small number of cases (30 cases in 2010-16, compared to around 51,000 applications received in the same period). Of these graduates, a substantial number re-applied in the following year and were granted provisional registration.
When applying for provisional registration, students need to answer a series of questions about their fitness to practise, across two sections: conduct and health. The exact questions can be seen online (23 questions as of 2015).
Our Registration team processes all applications - if they are satisfied the applicant is fit to practise from their declaration responses, we will not need any further information.
If the Registration team is not immediately satisfied with the declaration responses, they will investigate.
On the declaration of fitness to practise pages we give some examples of documentation that may be requested from the applicant to facilitate this. We may also speak to their medical school to request documentation from the school's student fitness to practise procedures for the specific student.
The processes for assessing fitness to practise issues declared by UK students and graduates are set out in the diagram below:
Not disclosing information is extremely concerning, as honesty is one of the key professional values we expect from all doctors. Whatever the applicant has not disclosed is likely to emerge during the application process, and would mean the case was automatically referred for investigation.
Insight into an applicant's actions and remediation are vital when making a decision about granting provisional registration, so a case involving non-disclosure is more likely to have a negative outcome. Furthermore, if something that was not disclosed at the provisional registration stage becomes known later on, this would have fitness to practise implications for the doctor who concealed it.
Your fitness to practise
The implications of student fitness to practise for a student's career depend on circumstances of the individual case. In the overwhelming majority of cases, this will not be a barrier to qualifying as a doctor, as long as the student cooperates with their medical school's fitness to practise processes.
In our professionalism guidance (jointly developed with the Medical Schools Council), we state that student fitness to practise can be a positive process, that can enable students to get the support they need in order to in order to successfully complete their course, remediate and gain provisional registration.
Medical schools must only graduate medical students who they deem fit to practise and who have met our published Outcomes for graduates. In rare occasions, the medical school may decide that the student's behaviour is fundamentally incompatible with being a doctor, and decide to remove them from the course.
The criteria where this would be applicable are also in our guidance - Outcomes of an investigation or fitness to practise committee or panel. To give an example for how rare this is, self-reported data submitted to the GMC from medical schools show students being expelled because of fitness to practise concerns related to behaviour in eight cases (out of over 40,000 medical students in the UK).
As mentioned, the GMC decision to register is independent to the schools', and provisional registration has been refused to a very small number of UK graduates. A brief description of each case where provisional registration was refused is included in our annual report - you can see the most recent cases on pages 21-23 of the 2015 report.
Also see our question above on this page: "What advice do you have for students who might not meet our published outcomes for graduates?"
The key point is that a health condition alone is not a fitness to practise issue. As we say in Achieving good medical practice, in most cases, health conditions and disabilities do not affect a medical student's fitness to practise, as long as the student:
- demonstrates appropriate insight
- seeks appropriate medical advice
- complies with treatment.
The issue escalates into fitness to practise when a student doesn't demonstrate insight into their condition, or compromises patient safety by not following medical advice.
Showing insight into health issues
Part of showing insight into their condition is the student being open and honest with their medical school, and seeking appropriate support / medical advice. This is also outlined in the guidance under the key areas of professionalism concern in Achieving good medical practice, showing reasons for impaired fitness to practise in medical students (under 'Health concerns and insight or management of these').
The main thing for students to do is to share information with their medical school and see what support they can access. We and medical schools understand that students may go through difficult periods with physical or mental health issues during their time at university. Everyone's aim is for the students to excel in their studies, and the medical school / university has a lot of support systems in place to help students as much as possible, whatever the issue they are facing. These include personal tutors, student health services, occupational health, student advice centre, confidential counselling etc.
We hope the practical advice on health is helpful for medical students, and we have also developed a case study on personal health as an additional resource.
Fitness to study
On a separate note, when a student has a medical problem, it's important for medical schools to consider their fitness to study - whether they are well enough to participate and engage in their programme. The Higher Education Occupational Physicians group publishes fitness to train standards for medical students on its website.
Removing a student from the course on health grounds
In exceptional circumstances, medical schools can remove students from the course if they if they consistently fail to manage their health condition, have a lack of insight into the impact their health has on others, or consistently fail to follow the advice of their treating physician. It is important to note that in this case it is not the health condition that leads to exclusion but rather the student's behaviour in relation to their health condition that would lead to exclusion.
Medical schools can also remove students from the course if they have a health condition or disability that means they will not be able to meet the outcomes of undergraduate medical education set out in Outcomes for graduates. This is a different situation from the management of the condition, and the views of occupational health physicians and other specialists will be crucial in supporting medical schools to make this decision.
This is not the same as erasing someone from the register, as it does not prevent a student from being able to apply to re-join another medical course in the future. The guidance has a section dedicated to the exceptionally rare occasion where a student is expelled on health grounds (see "Expelling students on health grounds" in Professional behaviour and fitness to practise).
For medical schools
Paragraph 9 of Professional behaviour and fitness to practise says:
Staff members who have significant roles in the student fitness to practise process, such as investigators, panellists or committee members and other relevant decision makers, must understand and receive training in the legal requirements and good practice of equality and diversity specific to their role.
At the moment the GMC does not provide equality and diversity training, but there is a range of providers for medical schools to consider. The GMC Equality and Diversity team have provided the following framework for the training to ensure student fitness to practise procedures are fair and compliant. Their feedback is that the training should deliver the learning outcomes set out below.
An understanding of:
- the principles of equality, diversity, fairness, and how these apply in the context of SFTP procedures
- the principles for fair decision-making, and the safeguards in place to ensure that decision-making and outcomes are fair
- some of the E&D issues/scenarios that may arise in this context
- the relevant provisions of Equality Act 2010 (eg the equality duty), and what this means for their role as decision-makers
- how bias can influence their decisions, and how to manage this
- their role in making sure student fitness to practise procedures are fair and compliant.
A session outline might look like this:
- Introductions, overview of the session
- Defining the key principles
- E&D the standards and guidance for student fitness to practise
- The legal framework
- Principles of unlawful discrimination
- The public sector equality duty
- Reasonable adjustments
- Making fair decisions
- Understanding and managing bias
- Principles for making fair decisions
- Professional behaviours and conduct.
Your role in making sure student fitness to practise procedures are fair and compliant.
Paragraph 7 of Professional behaviour and fitness to practise says:
"Medical schools' procedures for managing concerns about professionalism and fitness to practise should clearly explain how they make sure their processes are fair. Procedures should outline schools' responsibilities under the Equality Act 2010 and should make sure they don't unfairly discriminate on the basis of lifestyle, culture, or social or economic status. This includes characteristics protected by legislation, that apply to further and higher education establishments:
- gender reassignment
- pregnancy and maternity
- religion or belief
- sexual orientation."
We believe this would be relatively straightforward. A medical school's procedures can:
- acknowledge they are aware of your responsibilities with regard to the Equality Act 2010
- signpost different places students can get support
- state how student fitness to practise panellists are trained to handle E&D issues (this links to the previous question)
- state if the medical school takes any other steps for diversity, for example making sure student fitness to practise panels are mixed.
Most of this would be covered by existing university regulations and processes such as the student fitness to practise committee constitutions or related diversity/inclusion policies.