Managing and supporting medical students with mental health conditions
- Medical schools should focus on helping students who are receiving treatment to complete the course. They need to make sure that students are able to access the right support and are able to go to support appointments. It is not the medical school's job to treat the student and it must not attempt to do so.
Pastoral support for disabled students at the University of Southampton
The Faculty of Medicine at the University of Southampton has appointed a part-time clinical pastoral tutor to support disabled students. The role includes liaising with the university disability team, the occupational health service and clinical placement providers to try to minimise the impact on the student during the transition from pre-clinical training into the clinical environment. The tutor also participates in various meetings around pastoral support, student progress and disability discrimination.
Examples of areas where the tutor's expertise has been useful include:
- supporting and enabling disabled students to do clinical placements by helping the local trust understand the students' needs and carrying out appropriate risk assessments
- supporting students with mental health conditions through the special considerations and reasonable adjustments process
- supporting students who seem to be struggling with the course by directing them to appropriate help and deciding if they need to suspend their medical degree until they have recovered
- acting as a student advocate
- liaising with all parties around additional examination requirements to improve consistency and fairness
- liaising with others about updating and clarifying process documents for disabled students to improve the student pathway and experience.
The case management model
- Medical schools should think about introducing the case management model of support. In this model, a named person is responsible for coordinating the support that the student receives. They do not need to be a clinician because they do not provide treatment. Their job is to be a central point of contact for the student and to help coordinate support. They also help to make sure the student has access to the support services they need and that they can fit appointments into their study schedule.
Providing confidential support to students at Cardiff University
The Student Support Unit (SSU) at the School of Medicine, Cardiff University, was established in 2010 to provide confidential support for medical students struggling with health conditions, performance, financial or personal issues.
Students are referred to SSU by a tutor or year director, or they self-refer themselves. SSU then refers the student to the appropriate support services and monitors their progress. Typical issues leading to referral include:
- repeatedly failing or nearly failing examinations
- poor attendance
- behavioural issues
- absence due to a health condition
- disability
- fitness to practise issues.
All students referred to SSU are allocated a designated case manager who supports them. In 2011, the referral process was strengthened so that all students who were referred (or who self-referred) were triaged by an occupational psychologist with experience in health conditions and performance issues before being allocated a case manager. Students would be seen for triage within three weeks of referral. The triage appointment would identify the major underlying reasons for the referral and document the major issues and key actions agreed at the meeting with the student.
In September 2012, the medical school introduced a new academic mentoring scheme and launched two services - academic mentoring and SSU - under one umbrella called MEDIC Support. Information about MEDIC Support was disseminated at the beginning of the academic year, and members of MEDIC Support attended lectures for all five-year groups to explain the two services provided and how to access them. During these sessions, a poll was taken to try to understand students' perceptions of support. About 90% of students were not aware where their confidential personal records were held and who had access to them. After the poll, students were told about confidentiality, where confidential records are kept, the different support schemes in place, and the differences between academic and personal support. This information was also sent by email to all students at Cardiff.
Since the introduction of MEDIC Support in September 2012, self-referrals into SSU have increased significantly. In the academic year 2011-12, 19% of all referrals were self-referrals, but this has increased to 68% since September 2012. The reasons for self- referral since 2012 have also shifted from primarily educational reasons to the need for health and personal support.
Substance use disorder (including alcohol)
- The use of illegal substances is normally a fitness to practise issue. Where a student is addicted to a controlled substance, medical schools should offer support to the student alongside the fitness to practise process.
- Substance use disorder often happens alongside other mental health conditions, meaning that the person can face further stigmatisation. Medical schools should train their staff to recognise the common signs that a student is using alcohol or drugs. When they suspect this is the case, they should encourage the student to seek help from their GP, university or medical school support services. In some instances, it will be appropriate to refer the student to an occupational health service.
- If a student has an addiction to alcohol or drugs, the medical school should monitor the student carefully. When a student returns to their course after treatment, they should be encouraged to agree to random testing. This process can be managed through the medical school's occupational health service or through a specialist clinical service.
- Testing gives the medical school reassurance that the student is fit to practise, and it can be used as evidence of abstinence when the student applies for provisional registration with the GMC. Agreeing to testing also shows that the student has an understanding of their condition and is prepared to take steps to reassure the medical school.
- If a student refuses to be monitored for substance use disorder, the medical school could refer them to a student fitness to practise panel. Panels can place conditions on the student's continued participation on the course. They can also enforce and monitor those conditions.
Reasonable adjustments
- Long-term mental health conditions are considered to be disabilities under the Equality Act 2010 (see Appendix). This means that medical schools have a duty to make reasonable adjustments for students with long-term mental health conditions, to help them to study medicine and meet the outcomes in Outcomes for graduates. Even if a student's mental health condition is not covered by the Act, it is still best practice for schools to make reasonable adjustments.
- Occupational health services will be able to give advice on the adjustments that are needed for a student to complete their course. The medical school should then consider whether these adjustments are reasonable, taking into account legislation in this area and the student's future practice as a doctor in the NHS.
- Some common adjustments include:
- time away from studies or placements to go to support appointments
- time away from the course to get treatment for more serious mental health conditions
- placements near to treatment providers or support services
- extra time in written exams.
- Our guidance Welcomed and valued gives advice on reasonable adjustments, which medical schools may wish to refer to.
- Medical students should be aware that they may be entitled to receive Disabled Students' Allowances to help pay towards the reasonable adjustments they need. The university disability service will be able to advise students on whether they are able to receive these allowances.
Student support cards at University College London (UCL)
Requesting time off from a clinical placement or asking for other medical needs to be accommodated can be difficult for a student, particularly if it happens very early in a placement when the student hasn't met the consultant responsible for them. Students can be very embarrassed if they are asked for details about their condition and the adjustments they need in front of other students and staff.
UCL Medical School addressed this problem by introducing the student support card scheme*. Students who have health conditions tell a senior course tutor about their condition and the adjustments they need (for example, going to a weekly psychotherapy appointment). The tutor then issues a wallet-sized laminated card stating that the student has a medical condition and the reasonable adjustments they need. Typical wording would be: 'This student has a health condition which requires regular appointments and I would be grateful for your understanding'. This means that the reasonable adjustment is authorised by the medical school, and the medical school, not the student, is requesting cooperation with making the reasonable adjustment. The name and contact details for the senior tutor are at the bottom of the card should further information be needed.
The student carries the card and shows it whenever they need adjustments, such as time away from a placement. The scheme has been well received by students and no tutors have been asked for further information. The scheme has also been introduced at Barts and The London School of Medicine, which carried out a joint assessment with UCL, showing practical examples of how student support cards can be used**.
* Raven PW, Griffin AE, Hinson JP (2008) Supporting students with disabilities using a 'student support card' scheme Med Educ 42(11): 1142-43
** Cook V, Griffin A, Hayden J, Hinson J, Raven P (2012) Supporting students with disability and health issues: lowering the social barriers Med Educ 46: 564-74
Taking time away from the course
- Medical schools should consider the amount of time that a student is allowed to take away from their studies for health reasons before they are asked to retake the full year of the course.
- Missing a considerable amount of teaching time or placements can make it impossible for a student to catch up on their work. However, this needs to be balanced with the negative effect that retaking a year can have on the student, so decisions should be made on a case-by-case basis.
- Medical schools should think about ways to build flexibility into courses, so that students are able to catch up on the time they have missed.
- If a student needs to temporarily leave the course to get treatment and recover, they could be away for a significant time. They may wish to move away from the medical school to where they can be supported by family and friends more effectively. But they should be able to keep in touch with their medical school and their personal tutor or other member of staff who provides pastoral care. They should also be able to keep in touch with the occupational health service, which will be able to support their return to medical school.
- If a medical school thinks that a medical student should take time away from the course, the school should seek advice from medical practitioners, including the occupational health service. The medical student should be involved in the process - the school should clearly explain to the student why they should take time away and what they are expected to do during that time. At this point, the school should also start to consider how to reintegrate the student into the course when they return and should discuss this with the student. Medical schools must keep records of this decision-making process.
- There will be times when a medical school and a student disagree about whether taking time away from the course is the right thing to do. The school should take reasonable steps to understand the difference of opinion and to develop an appropriate plan with the student. Where this is unsuccessful, the medical school may want to use its fitness to practise procedures to handle this disagreement. This is not to punish the student, but to make sure that the decision is made in a fair and independent way. A fitness to practise panel is impartial and will listen to the point of view of the school and the student before deciding the best course of action.
- Medical schools must be aware that this will be a difficult time for the student, so they should provide a high level of pastoral support.
Student support service at Brighton and Sussex Medical School
Brighton and Sussex Medical School has a dedicated student support service. Students who are struggling to manage their condition are encouraged to seek support from a local GP. But, if this support is not sufficient in the short term, a student will be encouraged to take a period of intermission and return to repeat the full academic year or to pick up where they left the course after a short refresher period. If mental health conditions mean that a student cannot continue with their medical degree, the school will negotiate an exit route to another BSc degree at one of the parent universities.
