Professional behaviour and fitness to practise

Medical student fitness to practise

What do we mean by student fitness to practise

  1. 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 they cannot justify the trust placed in them should not continue in unrestricted practice while that remains the case.'

  2. This statement explains what fitness to practise is for a registered doctor. But it is also relevant to medical students. Students are also in a privileged position, and have access to patients who may be vulnerable. Medical schools should not let a student continue their medical studies unrestricted, or let them graduate from medical school, if their conduct suggests they may be a risk to patients or the public.
  3. Students are in a learning environment at the start of their professional career. When a medical school considers the fitness to practise of a student, it is appropriate to reflect on the severity of the behaviour, the maturity of the student and the year of study, as well as the likelihood of repeat behaviour and how well the student will respond to support.
  4. Expectations of students are likely to change over the course of their studies. For example, misdemeanours in the early years of study, when a student has greater scope to demonstrate remediation, may have less of an impact on a student than misdemeanours in the later years of their course when there is less time before they must meet the requirements for graduation.
  5. Medical schools should be aware that when concerns are raised about a student in the final year of study, there may not be sufficient time to resolve them. If a concern about a student's fitness to practise is raised close to the date of graduation, then the medical school should consider the amount of time the student will have to demonstrate remediation. It may be necessary to require a student to repeat all or part of a year, if appropriate. But in cases where there is an outstanding, justifiable concern over a student's fitness to practise, the medical school must not graduate the student.

* The meaning of fitness to practise, GMC policy statement.

The threshold of student fitness to practise

  1. In deciding whether to refer students to fitness to practise procedures, medical schools should consider how a student's behaviour or health might affect patient and public safety, or the public's trust in the medical profession. Investigators and panellists must consider, on a case-by-case basis, whether a student's behaviour or health has crossed the fitness to practise threshold.
  2. The following questions can help when considering this threshold. Medical schools should be mindful that this advice is only illustrative of the sort of concerns about behaviour or health that could call a student's fitness to practise into question and the outcome in all cases will depend on the particular circumstances.
 

** Due to differences in Scottish law, for students based in medical schools in Scotland: receiving a caution cannot lead to student fitness to practise procedures or be a reason for a student's fitness to practise being found to be impaired. This only applies to students based in medical schools in Scotland, and not to Scottish students based in medical schools in England, Wales or Northern Ireland.

Considering fitness to practise on the grounds of health

  1. Medical schools should consider fitness to practise procedures for a student with a health condition (including addiction) in the following circumstances.
    • Where there are significant concerns about the student's fitness to practise or about patient safety. For example, if a student's ill health appears to be uncontrolled or where there is evidence that the student is not following treatment or advice.
    • Where there is a significant risk of relapse or loss of insight, which may be characteristic of a condition, for example addiction or certain mental health conditions.
    • If the student fails to comply with measures and adjustments set by occupational health or others that are designed to enable them to complete the course.
    • If a health condition continues to impact on the student's ability to engage with the course after adjustments have been made.
    • Where there are significant misconduct issues linked with a health condition. For example, where a student is convicted of a misuse of drugs offence.
  2. Medical schools should consider the following factors to decide if intervention is needed.
    • Whether there is risk to patients (now or in the future), staff, fellow students or to public confidence in the profession.
    • Whether the student has insight into their condition.
    • Whether the student is seeking appropriate treatment, following the advice of the people treating them, and adjusting their studies or activities appropriately.

Reasons for impaired fitness to practise in medical students

  1. Table 1 gives examples of the sorts of behaviour that might indicate a student’s fitness to practise is impaired. The examples vary in seriousness. In some cases, the behaviour itself might indicate a need to refer the student directly into fitness to practise procedures.
    Other examples are less serious on their own, but if they happen repeatedly or in combination, or if there are aggravating factors, there may also be grounds for referral to a fitness to practise investigation.
  2. To put these examples of behaviour in context, we’ve organised the table according to the published reasons for impairment for fully or provisionally registered doctors and applicants for registration. These examples are not intended to be an exhaustive list. Medical schools should consider each case individually in light of the specific circumstances the case presents.
  3. Students must meet the outcomes of undergraduate medical education to graduate with a medical degree. There is some overlap between the expected professional behaviour of students and the assessed outcomes of medical education in relation to professionalism. Therefore, medical schools may have a formal means of assessing some of the behaviour outlined in this table.

Referring a student to fitness to practise procedures

  1. If a student’s behaviour suggests they may be a risk to patients or the public, or may bring the profession into disrepute, it is appropriate to consider their fitness to practise through a formal procedure.
  2. The decision to refer to a fitness to practise investigation may be based on evidence considered by a low-level concerns committee or by an individual, depending on the medical school’s process. It could be because of a single significant event or a pattern of behaviour, and may also be the result of educational remediation that has failed to resolve the issue.
  3. In exceptional circumstances, a student may be referred to fitness to practise procedures because of a health condition that is preventing them from meeting the required competencies, even after reasonable adjustments have been made.

What is the role of the investigator?

  1. The medical school or university should appoint an investigator (or investigators) to consider cases that have been referred to fitness to practise procedures. The school may already have informally gathered evidence to help it decide whether to refer a student to fitness to practise procedures.
    The role of the investigator, or investigators, is to gather evidence to inform a decision on whether the student's fitness to practise is impaired. This decision will be made by the fitness to practise panel or committee.
  2. The investigator:
    • should not, as far as possible, be the student's personal tutor or anyone else who is involved in supporting the student or making decisions about their academic progress
    • must be appropriately trained and able to carry out an effective investigation in a proportionate way, considering both the interests of patients and the public and those of the student
    • should keep a full record of the investigation.
  3. It is helpful for the investigator to order the record of the investigation chronologically. To give a balanced account of the facts that the panel or committee will consider, the investigator should include records of complaints, meetings, interviews and statements, and any evidence of positive behaviour in support of the student. After reviewing the evidence, the investigator should make a written report of the results of the investigation, which details all the evidence gathered.
  4. The investigator should present their findings to an investigation committee or individual in an equivalent, decision-making role. Depending on the nature of the issue, the findings may be presented directly to a fitness to practise panel or committee. This may be appropriate for serious misconduct issues or convictions.
  5. If the concerns committee, panel members or relevant decision maker considers the student's behaviour is serious or persistent enough to call into question their fitness to continue on their medical course, or their fitness to practise as a doctor after graduation, they should refer the case to a fitness to practise panel or committee for an independent decision. They should do this even if there are mitigating factors such as health problems.
  6. If the investigation committee or relevant decision maker does not consider there is sufficient evidence to call into question a student's fitness to practise, the school or university should deal with the student's behaviour in another way. For example, it may be appropriate to issue a warning or require the student to undertake educational remediation, such as completion of a piece of reflective writing, or meeting the terms of an educational agreement, while continuing to provide any appropriate support for the student.
  7. In some cases, it may be appropriate to give the student an opportunity to offer an undertaking, rather than referring them to a fitness to practise panel or committee (see Undertakings below).
  8. It is not appropriate for an investigator to be the decision maker, since there may be a conflict of interest if an investigator were called to present the case on behalf of the medical school in a subsequent fitness to practise hearing.

What are the possible outcomes of an investigation?

  1. At the end of an investigation, the investigation committee or relevant decision maker can decide on a number of possible outcomes. It can:
    • conclude the case with no action
    • issue a warning
    • agree undertakings
    • refer the case to a fitness to practise panel or committee.

Warnings

  1. Warnings are appropriate when a student’s behaviour is significantly different from expected standards. Warnings are a formal response intended to maintain professional values and prevent a repeat of the behaviour. Students should be offered adequate support to address any underlying reasons for their behaviour. See Table 2 for factors to consider when deciding on a warning.
  2. The investigation committee or relevant decision maker must make clear to the student what will happen if they repeat the behaviour for which they have received a warning. A breach of a warning may be taken into account by a committee or panel in relation to a future case against a student, or the breach itself may comprise misconduct serious enough to lead to a referral to a fitness to practise investigation. The warning should remain on the student’s record, and the student must be aware of their responsibilities regarding disclosure when completing their STEP form and applying to the GMC for provisional registration.

Undertakings

  1. An undertaking is an agreement between a student and the medical school. Undertakings can be agreed at the investigation stage or by a panel or committee. They can be used in situations where the student's behaviour is consistent with their fitness to practise being impaired but the student acknowledges this impairment, has insight and is seeking ways to address the underlying issues. Undertakings allow medical schools and medical students to come to an agreement as to the best course of action after they have identified a concern.
  2. An undertaking is usually more appropriate in health-related cases where there is impairment of a student's fitness to practise and may be put forward by the student before or instead of a formal fitness to practise hearing or determination.
  3. Undertakings are only appropriate if there is reason to believe the student will comply with them, ie the student has shown genuine insight into their problems and wants to resolve them.
  4. Undertakings may include:
    • compliance with an educational learning agreement associated with enhanced supervision
    • a commitment to undergo medical supervision for a health-related matter
    • complying with remedial teaching or learning experiences.
  5. Undertakings are most likely to be appropriate if the concerns about the student's fitness to practise are such that a period of remedial teaching or supervision, or both, is likely to be the best way to address them.
  6. In some circumstances, such as where a student is already seeking appropriate support and therapy to manage a health condition, it may be appropriate to invite the student to agree undertakings. In these circumstances, medical schools should consider the points in Table 2.
  7. Medical schools should monitor students to make sure they comply with the agreed undertakings. The consequences of not complying with undertakings should be clearly set out to the student in writing when the undertakings are agreed.

Referral to a fitness to practise committee or panel

  1. The role of the fitness to practise committee or panel is to make an independent decision on a student's fitness to practise, based on the evidence gathered and presented to them by the investigator. The committee or panel should take into account the balance between patient and public safety, the interests of the medical student, and the need to maintain trust in the profession.
  2. Committees or panels should consider any guidance set by the GMC and work in accordance with the regulations and procedures of the medical school or university. Procedures should be set out in writing and made available to students.
  3. Committees or panels must consider each case on its own merits and circumstances and make decisions on the balance of probabilities about the facts of the case and use their own judgement to determine whether the student's fitness to practise is impaired.
  4. The committee or panel can find that:
    • the student has sufficiently addressed any concerns relating to health or conduct and poses no risk to patients or the public, nor any risk to undermining the public's trust in the medical profession. The committee or panel should then conclude that the student's fitness to practise is not impaired. An appropriate outcome in such a case may be no warning or no sanction
    • the student's fitness to practise is not impaired, but the committee or panel may issue the student with a warning if their behaviour has significantly departed from expected standards. This warning should give details of the behaviour and the consequences of any similar behaviour (see Warnings above)
    • the student's fitness to practise is impaired, in which case the committee or panel will need to consider any mitigating or aggravating factors when deciding an appropriate outcome or sanction. Any sanction should be proportionate to the student's behaviour and deal effectively with the fitness to practise concern.
  5. The committee or panel should set out in writing the outcome of the hearing (the determination). This document should give detailed reasons about why the committee or panel came to its decision. The determination should include the details of any sanctions imposed, the reasons for them and any relevant timescales and mechanisms for review.
  6. The GMC requires any student who has been through a formal fitness to practise procedure to declare this on their application for provisional registration, regardless of the outcome. The committee or panel should include information about this requirement in the outcome letter. The GMC will also require evidence that any undertakings or conditions have been completed and appropriately monitored and reviewed.
  7. There should be a clear, formal appeals process. Medical schools should make sure students are aware of their right to appeal against decisions of the fitness to practise panel, and of the process for doing this.

Fitness to practise committee or panel

Composition and training

  1. Medical schools’ fitness to practise procedures must describe clearly the composition of the committee or panel.
  2. The committee or panel must include a registered medical practitioner with a licence to practise.
  3. Medical schools should also consider including on panels:
    • someone from outside the medical school
    • someone with legal knowledge
    • a student representative who does not know the student being investigated
    • where the concerns are related to health, a relevant health specialist, for example a psychiatrist or occupational health physician. This person should not be involved in the treatment of the student.
  4. Committee or panel members should have appropriate experience and receive training for their role. There should also be a clear description of the requirements of the role. Panellists must:
    • know and understand the rules and regulations of fitness to practise and disciplinary matters at the medical school
    • know and understand the outcomes of undergraduate medical education and the relevant guidance, such as Achieving good medical practice: guidance for medical students and this guidance
    • be fair-minded and willing to hear the full facts of the case before reaching a decision
    • be prepared to seek appropriate expert advice, especially in cases involving health or impairment issues
    • make sure fitness to practise proceedings are fair and proportionate.

Committee or panel hearings

  1. Medical schools and universities must make sure their proceedings are fair and transparent. Among other things, they should:
    • take steps to establish that there are no conflicts of interest between investigators, panellists and the student
    • set up appropriate procedures without unnecessary delay
    • include in their policy how a hearing may proceed in the absence of the student
    • make sure both the student and the representatives of the school or university have a complete copy of all the information given to the committee or panel
    • make sure all parties have an equal opportunity to present evidence
    • make sure that panellists apply the civil standard of proof - 'on the balance of probabilities' - to their findings of fact
    • be prepared to hold hearings in public if that is what the student wants (except hearings involving health issues, which should be held in private)*
    • make sure that decisions and sanctions are proportionate
    • make sure decisions, and reasons for them, are explained and given in writing
    • consider what to do if there is a split vote. For example, it may be appropriate for the chair to have the casting vote. Alternatively, medical schools may wish to consider having an odd number of panellists to avoid this situation.

Support and representation for medical students at committee or panel hearings

  1. Medical schools should encourage students to have a supporter or legal representative present at fitness to practise hearings. The students' union may also be an important source of advice and support. Medical schools' fitness to practise procedures should set out how support and representation will work in practice.
  2. A student who is subject to fitness to practise procedures should be given written guidance to explain:
    • what will happen at all stages of the process
    • where they can get support
    • guidance to help them put together information for their hearing.

    The medical school should also give the student an indicative timeframe for the process.

Witnesses at committee or panel hearings

  1. If individuals or experts have information the committee or panel should consider, they should be asked to give an account of this information in writing. In certain circumstances, it may be appropriate for medical schools or universities to invite witnesses to be present at a committee or panel hearing to give verbal evidence. This may be required if clarification is needed about information given in a witness's statement or if there are conflicting accounts of information given by two witnesses. The representatives of the medical school or the student should be given the opportunity to ask questions of any witness who is invited to give evidence during a committee or panel hearing.

* This does not mean students and others should have unlimited access to proceedings - medical schools can set rules as to how a public hearing will be held.

What are the outcomes of a fitness to practise committee or panel?

  1. A fitness to practise committee or panel may decide on one of a number of possible outcomes (see Table 2).
    If the student’s fitness to practise is not impaired, the committee or panel can apply:
    • no warning or sanction
    • a warning.
    If the student’s fitness to practise is impaired and requires a sanction (or the agreement of undertakings as an alternative to a sanction), the committee or panel can:
    • agree undertakings
    • apply conditions
    • suspend the student from the medical course
    • expel the student from the medical course.

Warnings or undertakings

  1. A fitness to practise committee or panel may decide to issue a warning to a student as an outcome if there is a significant departure from expected standards, but the student’s fitness to practise is not impaired and does not require a sanction (see Warnings above, and Table 2).
  2. The medical school and student will usually agree undertakings before a case is heard by a fitness to practise committee or panel, if the circumstances are appropriate (see Table 2). But in some cases it may be appropriate for a fitness to practise committee or panel to agree undertakings. In these situations, the medical school or university must have reason to believe the student has insight and will comply with the agreed undertakings. Medical schools should monitor and review undertakings to ensure continued compliance and effectiveness.

Sanctions

  1. The purpose of a sanction (conditions, suspension or expulsion) is to protect patients and the public, to maintain trust in the profession, and to make sure that a student whose fitness to practise is impaired is dealt with effectively. This includes possibly being removed from their medical course. Sanctions are not intended as a punishment for the student and, with the exception of expulsion, should give a student the opportunity to learn from their mistakes.
  2. Committees or panels should consider whether a sanction will protect patients and the public, and maintain professional standards. They should consider sanctions in a stepwise order, starting with the least severe sanction first and progressing to the next if they think a lesser sanction is not appropriate in relation to the circumstances of the case.
  3. It is important that, when a panel or committee decides to impose a sanction, it makes it clear in its determination that it has considered all the available options. It should also give clear reasons for imposing a particular sanction, including any mitigating or aggravating factors it took into account in making its decision. It should also explain the intended purpose of the sanction in the determination.
  4. The determination should include an explanation if a particular length of sanction was considered appropriate and include the date it is effective from.
  5. If a student's fitness to practise will be considered again at a review hearing, for example to determine if any remediation has been successful, the determination should specify when and who will do this. For example, would it be by the same committee or panel?
  6. The panel or committee should outline in its determination letter the student's right to appeal against any sanction. It should also give information about how to appeal and include any associated timings in the determination.
  7. The determination letter should also make clear the requirements for disclosure to the GMC when the student applies for provisional registration and when they complete the STEP form.
  8. 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. If the panel or committee considers it necessary, the sanctions can remain on the medical school's record after the student has applied for provisional registration. The medical school should keep student records until the graduate gets full registration with the GMC.

Conditions

  1. Conditions are appropriate when there is significant concern about the behaviour or health of a student. This sanction should be available after a committee or panel hearing and only if the committee or panel is satisfied that the student might respond positively to remediation and increased supervision, and has displayed insight into their problems. The committee or panel should consider any evidence, such as reports on the student's academic or professional performance, health and behaviour, and any other mitigating or aggravating factors.
  2. The committee or panel should make the objectives of any conditions clear, so a student knows what is expected of them. Conditions should be:
    • specific
    • proportionate
    • workable
    • time bound
    • measurable
    • monitored.
  3. The committee or panel should specify how compliance with the conditions will be measured and who will be responsible for monitoring. It should also make clear to the student the consequences of breaching any conditions.
  4. When reviewing a case where conditions have been imposed, the committee or panel should consider whether the conditions remain appropriate.
  5. Before imposing conditions, the committee or panel should satisfy itself that:
    • the problem can be addressed through conditions
    • the objectives of the conditions are clear
    • the conditions will be appropriately monitored
    • any future assessment will take into account whether the objectives have been achieved, and whether patients are going to be at risk if the conditions are removed.
  6. If a committee or panel has found a student's fitness to practise impaired because of adverse physical or mental health, the conditions should relate to the medical supervision of the student as well as to supervision on clinical placements.
  7. A committee or panel should not impose conditions if it has found that the student's fitness to practise is not impaired.

Suspension from medical course

  1. Medical schools should consider whether the nature of a concern means the student should be temporarily suspended while the concern is investigated. This may be appropriate immediately after the concern has been raised, or in response to evidence that arises during the investigation or fitness to practise hearing. It may also be a proportionate response where a student is charged with a serious criminal offence but has not yet been convicted. Any suspension must be made to protect patients, colleagues, the student in question, or other students. Medical schools should make sure the decision is proportionate, fair, documented and evaluated on a regular basis.
  2. Suspension prevents a student from continuing with their course for a specified period, and from graduating at the expected time. Suspension is appropriate for concerns that are serious, but not so serious as to justify expulsion from the medical school. See Table 2 for points to consider when deciding if it is appropriate to suspend a student.
  3. It's important that medical schools have a process in place to make sure a student who returns from suspension understands the seriousness of the findings that led to their suspension and demonstrates insight. This process should also permit consideration of whether any conditions or remediation work is required. It may be appropriate to convene a student fitness to practise panel or committee, or a lower-level committee, to consider these matters before the student returns from a period of suspension, depending on the medical school's internal procedure.

Expulsion from medical course

  1. The committee or panel can expel a student from medical school if it considers it is the only way to protect patients, carers, relatives, colleagues or the public. The medical school and university should help the student transfer to another course if appropriate. But the nature of the student's behaviour may mean they should not be accepted onto health-professional-related courses or, indeed, on any other course.
  2. Expulsion, the most severe sanction, is appropriate if the medical school or university considers that the student's behaviour is fundamentally incompatible with continuing on a medical course or subsequently practising as a doctor. See Table 2 for points to consider when deciding if it is appropriate to expel a medical student.
  3. Students who are expelled from a medical degree should be added to the excluded student database, which is hosted by the Medical Schools Council. They should be told in writing that they will be added to the database and given a chance to appeal the decision to place them on the database.
  4. Medical schools and universities should review their fitness to practise procedures to include appropriate measures to address a situation where a student with a fitness to practise concern leaves voluntarily before a conclusion is reached. All cases that reach a hearing should come to a formal decision and conclusion, even if the student leaves voluntarily before the hearing has concluded. Medical schools must give the student a full opportunity to participate in the hearing, even if they leave voluntarily.

Reviewing a student's fitness to practise following a sanction

  1. Students who receive a sanction, short of expulsion, should also receive ongoing supervision or monitoring, or both, to satisfy the medical school regarding their continued fitness to practise. They should also be given remedial or pastoral support, or both. If the student is in the early stages of their medical education, it may be valuable to support them to reflect on their fitness to practise at least once a year.

Timescales for fitness to practise procedures

  1. Medical schools and universities should make sure documentation about their fitness to practise procedures includes timescales for the various stages of the procedures. It should include timescales for the investigation and hearing stages, taking into account how long a student may be prevented from continuing their course.
  2. Any time limits imposed under the process should include reasonable notice periods, which will allow a student enough time to prepare for and attend a hearing. It is in everyone’s best interests for defined timescales to be adhered to if possible, but they should be flexible enough to reflect what is reasonable under the circumstances. It should be possible to shorten timeframes if a student presents an immediate, significant risk or to extend them in exceptional cases to make sure the procedure is fair (for instance, to make sure everyone required to attend the meeting is available).

Expelling students on health grounds

In exceptional circumstances, medical schools and universities may expel students on health grounds. This approach is consistent with adverse physical or mental health being a reason for impairment when the GMC applies the test of fitness to practise to applicants for registration and may therefore be a reason for the GMC refusing registration. This differs from the GMC’s fitness to practise processes, as registered doctors cannot be removed from the register on purely health grounds, although they can be suspended indefinitely from the register in certain circumstances. But medical students are not registered doctors – they are training to join a profession and therefore it may be necessary to remove them from the course to protect patients.

The difference in a student fitness to practise context is that it does not involve a decision to erase someone from the medical register and therefore remove their ability to practise the profession. Ultimately, a decision whether to expel a student on health grounds is a matter for the medical school. Such a decision would result in expulsion from a particular medical course and it would only be appropriate where it was deemed by the medical school to be a necessary step to protect the public. It would not prevent a student from being able to apply to re-join another medical course in the future, providing the public protection concerns have been addressed.

 
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 A student can be removed from the course 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. This should be done through a formal fitness to practise process managed in line with the guidance in this document.

In these instances, the medical school must show it has taken steps to support the student to continue on the course and has sought to offer adjustments to allow the student to continue. Medical schools should also seek expert advice from a qualified clinician.

If a student fitness to practise panel or committee believes a student should be expelled on grounds of health, it should consider the following questions.

  • How long has the student been on the course, and what opportunities has the medical school given them to show they are able to manage their condition?
  • Does a pattern of behaviour suggest the student fails to manage their health in certain contexts?
  • Is there a pattern of behaviour that shows a student consistently fails to have insight into the impact their health might have on patients and their peers?
  • Is there a pattern of behaviour that shows the student fails to follow the advice of their treating physician in relation to their health?

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 (see paragraphs 33–50). This is a different situation from the one outlined above and the views of occupational health physicians and other specialists will be crucial in supporting medical schools to make this decision. Medical schools should also consider the ability of the student to meet the outcomes within a reasonable time and the impact of prolonged absences from the course on learning, including the currency of knowledge.

All decisions related to expelling a student on health grounds must be made on a case-by-case basis. There are no health conditions that should automatically lead to expulsion – medical schools must follow guidance, including that set out in this document, to make sure their decisions are fair and proportionate. For further advice on supporting students with mental health conditions, please see the GMC and MSC guidance Supporting medical students with mental health conditions. This advice applies equally to medical students with physical health conditions. Medical schools may also wish to consider the guidance in Welcomed and valued.