How can medical schools apply their duties
Panel A1: Issues and suggestions from medical students
What issues did medical students tell us about?
- Unclear information at admission about help available and impact of studying medicine
- Assumptions that medical students cannot have ill health
- Difficulties accessing support or requests for support dismissed
- Impact of first contact on ongoing relationship between student and services
- No route to take if students are unhappy with support provided
- Sense that students are 'in trouble' if they request support
- Perceived attitudes of medical school staff
- Limited knowledge about what will happen after graduation and concern about GMC registration
- Less support available in clinical placements
What do medical students want?
- More data on support from schools, eg national rankings, annual appraisals, audit data with student experiences
- Ability for students to voice their concerns directly in a safe space
- More signposting to support
- Medical schools picking up on cues to offer support
- More succinct and accessible documents and policies
- Clear statement about ability to study medicine with a health condition or disability
- Role models: 'I've done it so you can do too'
- Forward planning from medical schools about support needed (eg availability of clinical placement locations early on to make transport arrangements)
- Involving students in decisions
- Medical schools following up with students to make sure support is helpful
Panel A2: What barriers are medical students facing?
The barriers listed are from the findings of independent research commissioned by the GMC. Read details of the research and the final report.
- Communication and information barriers
- Not knowing whom to contact
- Communication breaking down
- Physical barriers (not usually an issue for medical students at university)
- Travel to clinical placement locations (eg distance, fatigue)
- Accessibility at clinical placement locations
- Financial barriers (minority of students in research)
- Not able to access financial means to pay for equipment
- Limited staffing resources at medical school
- Cultural barriers
- Culture of perfectionism
- Pressure on performance by students themselves and school
- Expectation that support would not be available in clinical practice
- Awareness of pressure in today's NHS
- Experiences of overt discrimination
- Hearing supervising doctors say that disabled people could not work as doctors or in certain specialties
- Derogatory comments by supervising doctors on health conditions, eg mental health conditions
Panel A3: Having difficult conversations in a supportive manner
This document was prepared by Dr M Bunting & Dr K Ellis, Norwich Medical School, and is an adaptation and amalgamation of the SPIKES model and the Clagary Cambridge model.
Before the session
- Offer the student the opportunity to have someone accompany them
Beginning the session and setting the scene
- Summarise where things have got to, check with the student
- Discover what has happened since last seen
- Calibrate how the student is thinking or feeling
- Negotiate agenda
Being sensitive to the student
- Read and respond to the student's non-verbal cues; face/body language, silences, tears
- Allow for 'shut down' (when student turns off and stops listening) and then give time and space: allow possible denial
- Keep pausing to give student opportunity to ask questions
- Allow student to take breaks if they wish
- Gauge student's need for further information as you go and give more information as requested
- Encourage expression of feelings early, ie 'how does that news leave you feeling', 'I'm sorry that was difficult for you'.
- Respond to student's feelings and predicament with acceptance, empathy and concern
- Specifically elicit all the student's concerns
- Check understanding of information given ('would you like to run through what are you going to tell your parents?')
- Be aware of unshared meanings (ie what intercalation means for the student compared with what it means for the adviser)
Planning and support
- Having identified all the student's specific concerns, offer specific help by breaking down overwhelming feelings into manageable concerns, prioritising and distinguishing the fixable from the unfixable
- Identify a plan for what is to happen next
- Give a broad time frame for what may lie ahead
- Give hope tempered with realism ('preparing for the worst and hoping for the best')
- If appropriate, ally yourself with the student ('I can meet with you again soon to...')
Follow up and closing
- Summarise and check with student for understanding, additional questions
- Don't rush the student to intercalation if appropriate
- Set up early further appointment, offer telephone calls, etc.
- Identify support systems, within university and outside (eg family and friends)
- Offer to see/tell parents
- Follow up with an email confirming plan; ask student to confirm it is an accurate record once they have had an opportunity to digest it
Panel A4: Example of good practice - Medical School A
Four key services are involved in the processes designed to support disabled students, these are: the University-wide Disability and Dyslexia Service (DDS), University-wide occupational health, the University-wide Counselling Service, and a Student Support Service within the school dedicated specifically to medical students. The Head of School has oversight of the processes for supporting disabled students and is the final adjudicator in the rare situations where there are disputes.
Within the Student Support Service unit there are case managers with backgrounds either as GPs or as occupational health specialists as well as a Speech and Language Therapist and some highly trained administrators. Professionals do not work in isolation. Whichever service the student is referred to or indeed self refers to, they will share information as appropriate with the other services.
Students are asked about their support needs before starting the course and reasonable adjustments are organised by DDS and a referral is made to Student Support within the Medical School. The student is then assigned a case manager. This case manager will meet with the student and offer them direct support; but also signpost to other services, make sure reasonable adjustments are implemented, advocate for any more adjustments, liaise with placement providers and provide a listening ear. The case manager will agree with the student how often to meet and this can vary based on the changing needs of the individual.
Enablers of good practice within the school
- The school had invested heavily in this area and clearly valued it. Students were also aware of the value placed on this area and the resulting quality of service.
- The Student Support Service use a traffic light system in the database to indicate the level of need and the corresponding level of contact required.
- There is a focus upon the expertise offered by certain professionals, particularly occupational medical specialists.
- A collaborative approach is employed in complex cases, whereby all the support services detailed above along with the Head of the Medical School and the student themselves come together to discuss barriers and solutions. Similarly, for clinical tasks, a student may be observed by the panel practising a task with the agreed adjustments to assess whether they need more support and what further could be offered.
- Staff felt that the biggest strength was that they had an effective process in place but this did not detract from a highly individualised service. In the interests of transparency everything is recorded and shared and there is a clear appeals and complaints process.
- Staff highlighted the importance of early and effective careers advice in situations where with support, students were unable to fulfil the requirements.
- The staff have developed a project called 'One Act of Kindness' in order to promote good mental health throughout the school. This is a universal provision for all students which raises awareness of mental health issues and also encourages peer support and self-care. The school also uses a buddy system for new students as another universal provision.
- The school has developed a passport system whereby they work with the student to write a statement which they would be happy to share with a placement provider with as much information as the student feels comfortable sharing. This can then be used by the student when on placement to hand to their supervisor to detail support needs. Students valued this as they often pointed to the difficulty in having a confidential discussion with a supervisor, finding the time to do so and having the confidence to speak to a someone they had no previous relationship with about a personal matter.
Panel A5: Tips for induction
- State that disabled learners are welcome to the course and will be supported throughout their studies.
- Make it clear that some students will inevitably suffer from health conditions or disabilities in the duration of the course. The medical school knows this will happen and has services in place to support its students.
- Talk about health conditions and disabilities commonly seen in medical students, for example: anxiety, depression, eating disorders, dyslexia, bowel conditions, back or joint pain and diabetes.
- Invite disabled learners to talk about their experiences from the course.
- Point to the available services with specific contact details.
- Explain the importance of sharing information
- Make it clear that the purpose of asking for this information is to offer the appropriate support for completing their studies, in line with Outcomes for graduates.
- Tell students whom they can speak to about a long-term health condition or disability.
- Point students to this guidance, to Supporting medical students with mental health conditions and to Outcomes for graduates.
Panel A6 Tips for introductory session on clinical placements
- What is being on clinical placement like?
- Facilities within locations
- Distance from university campus, medical school, nearest town and amenities
- Transport arrangements
- Accommodation arrangements
- Accessibility of buildings in placement locations and accommodation
- Description of the physical environment, eg in wards and GP practices
- What's expected of medical students while on placement? To help students understand how this might affect them on a daily basis
- Timetable - hours expected to be on location
- Typical tasks performed by students - eg ward rounds, observing consultations, talking to patients, supervised clinical procedures, attending teaching sessions etc.
- Physical demands - eg hours spent standing on a typical day, available rests and breaks, meal times.
- Mental demands - eg sharing experiences from students in other year groups about the level of tiredness and pressures while on placement.
- What facilities and services will be available to students?
- Services available on location
- How to reach other university or medical school services
- Opening hours and out of hours alternatives
- What contacts will be available to students?
- Key people responsible for them, eg clinical supervisor
- How can students contact their medical school while on placement?
- Who can students talk to if they are having symptoms?
- Who can students talk to if they need to discuss something about their health condition or disability?
- What are the experiences of other disabled learners in the clinical environment?
- If possible, invite students from other year groups to discuss experiences and advice for clinical placements.
Panel A7: Examples of wellbeing campaigns in medical schools
'Birmingham Medical School has the Feel Bright campaign. A few years ago, a medical student created a mental health and wellbeing campaign for medical students, called the 'Feel Bright' campaign. This involves a booklet being given to all Fresher's along with an interactive lecture, then an interactive small group session in 2nd year, hosted by 3rd years. Most students find it a positive experience and are keen to help with sessions in the following year. This is all run by students for students.'
'King's College Medical School has a dedicated welfare team that offers a range of activities. It has the mums and dads scheme, which makes sure every student in first year is mentored by second years who act as medic parents to guide them through their first year of university. The Peer Support service is a confidential service provided by trained students to make sure students can speak to someone without fear of repercussions. Lastly, it has recently organised a Wellbeing OSCE workshop, which substitutes the normal stations in OSCE examinations for meditation, colouring, yoga, and other activities that promote student wellbeing, followed by a pack which contains items aiming to give students some assistance during exam time.'
'Nottingham Medsoc run wellbeing activities like cake decorating sessions, yoga and mindfulness classes and massage workshops. Nottingham's Welfare Facebook page is consistently updated by MedSoc supporters, who provide information and support. There are MedSoc peer supporters in every year group (including F1 doctors for final years) so students never have to feel alone. Similarly, the Tea and Empathy Facebook group and Our Mental Health Matters are online spaces where medical students can feel free to share their stories and support one another'.
'At Warwick Medical School, all cohorts have regularly scheduled Mindfulness Sessions where groups come together to discuss their wellbeing and participate on a voluntary basis in meditation. In first year, these sessions are also used to teach students about mechanisms for coping with stress and anxiety (such as mindfulness, planning and reflective practice).'
Panel A8 Sample form for referral to occupational health
- Student number:
- Contact details: email, telephone, address
- Course details: name, year of entry/ current phase or year
- GP details:
- Referring person
- Contact details: email, telephone, address
- Is the student currently studying? (If no, please clarify why e.g. sick leave, suspension, interruption with dates)
- Are there any support / adjustments in place? (If yes, please clarify)
- Does the student need any support / adjustments for the consultation?
- Have you informed the student of the reason and content of the referral?
- Has referral been shared with student a copy given to them?
- Have they consented to be referred?
- Reason for referral
- Please provide the reasons for referral including as much details as possible
- (use the examples provided below as guidance)
- (attach/ provide link to any relevant documents, see the guidance)
- (provide summary of actions taken already)
- What specific questions you wish the OH to answer?
- (use the examples provided below as guidance)
- What specific advice are you seeking from OH?
- (use the examples provided below as guidance)
Examples of reason for referral
- Conduct/ disciple
- Adverse event
- Physical limitation
- Psychological limitation
- Substance abuse
- Interpersonal difficulty
- Fitness for study
- Academic performance
Example questions to ask from OH
- Is the student medically fit to continue/return to the course?
- Is there an underlying medical condition that can have impact on attendance/capability?
- What is the future course of the medical condition?
- What adjustments does OH suggest?
- How long these adjustments should be in place including permanent?
- Is the Equality Act likely to apply?
- Is the student medically fit to attend meeting/Fitness to Practise panel?
Panel A9: Sample form for report by occupational health
- Name and contact details of the addressee
- Student name
- Student unique identifier
- Student DOB
- Student course
- Student year of training
- Date of the referral
- Where the student was seen?
- When the student was seen?
- Was it face to face or telephone?
- Reference to the consent process
- Summary of the reason for referral/question to be responded to
- Statement of the relevant standard to be met by the student, and its source
- Comment on clinical context (this will give limited clinical information which may include a diagnosis if the student agrees. Give the source of the information, e.g. student, referral form, further medical evidence)
- Physical examination if relevant (within confidentiality)
- Test's results if relevant (e.g. for D&A, within confidentiality)
- Student's perspective
- Comment on the functional impact of health
- Opinion, in the form of a response to the questions on the referral, and a time frame (Focus on what the manager needs to know and give a time frame for the validity of the report and recommendations, e.g. if there needs to be a review.)
- Equality Act, (set out the nature of any functional impairment and its duration. May offer a view as to whether the Act is likely to apply, but qualify that not a legal opinion)
- Information about possible adjustments and length (but not to state or infer whether these might be reasonable or practical as that is a management decision)
- Any liaison with other healthcare professionals and the outcome if available
- Need for functional capability assessment
- Limitation of the report
- Request for update
- Whether student agrees with the suggestions
- Review/ discharge
- Author's name
- Author's title
- Author's qualifications
- Author's job role