Once support needs raised
It is a matter for each school or university to assess how they approach each case. It is important to have a process for balanced and fair decision making that will apply across all cases. One approach we encourage medical schools to consider as good practice is the case management model.
Case management is defined as: 'A collaborative process that assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet […] health and human services' needs. It is characterised by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes.' As an approach, it has similarities to multidisciplinary teams in medicine.
Schools can use a stepwise process (see figure below) to develop an action plan for supporting each student. The same process can be applied for students who disclose a long-term health condition or disability later on in the course, as well as students who acquire a long-term health condition or disability during their studies. This process gives an overview of what can be done; not all steps will be appropriate for all students, but it can be adapted to each individual case at the discretion of the medical school.
Process map for supporting disabled medical students
This process gives an overview of what can be done; not all steps will be appropriate for all students, but it can be adapted to each individual case at the discretion of the medical school.
Step 1: Form support group
Medical schools may have a lead or a team that deals with support arrangements for incoming disabled students. The particular role or job title will differ between schools, but it would be helpful for a designated person or people to have the responsibility for supporting disabled learners.
The lead can communicate with other medical school and university teams to decide who ought to be involved in exploring support arrangements for the incoming students. The core group for support may include:
- a representative from the medical school with knowledge of the academic and clinical components of the course. It would be useful to include someone with a clinical background and an understanding of the specifics of teaching within the course and of clinical placements
- representatives from student support or pastoral services
- representatives from occupational health services
- representatives from disability services
- any other appropriate role within the school's system, for example patient or lay representatives.
The lead can coordinate with the parties that want to be involved to arrange conversations with the medical student going forward.
Step 2: Decide key contacts
After agreeing which parties would like to be involved, the lead can decide the key contacts moving forward.
- Primary contacts for the student: ideally, this would be one named person that can communicate with the student for anything they need in relation to their health condition or disability and an intermediate to other services. The primary contact could be the lead or another member of the support group, and not involved in the student's progression. The lead can give their contact details, availability (e.g. specific working days/hours) and an alternative contact for when they are not available.
- Key internal contacts: The key contact for each of the services that will be involved in exploring support arrangements for the students going forward.
Step 3: Confidentiality arrangements
When handling information relating to individuals, organisations must make sure they do so lawfully. Medical schools must provide students with material on how their information will be used and their rights in respect of that information.
This will help to make sure any information shared by the student is not misused. It will also give students confidence in providing such information to schools. The Information Commissioner's Office provides guidance on the information to include, including a checklist (in Panel A10 of the Appendix). The Information Commissioner's Office sometimes offer free advisory visits to organisations to give them practical advice on how to improve their data protection practice.
A school might want to consider the following when collecting information from students about their health.
- Keeping a clear audit trail of decision making for supporting disabled learners as this is likely to help schools make sure they have taken appropriate steps to provide reasonable adjustments.
- Keeping a record of all conversations between the support group and student. It is good practice to agree the method of recording such conversations and for the student to see a draft record of any discussions.
- Creating a separate file with different access arrangements for confidential information related to health outside of the general student record.
Step 4: Case conference/joint meeting
The lead can organise a meeting between the student and the support group.
The support group may also consider having regular meetings with just its members present as an opportunity to discuss progress and evaluate cases, especially if they are handling several cases at once. The group let the student know about the meetings and give them an opportunity to attend if appropriate.
General things the group might cover are:
- an outline of the student's health condition or disability - to help understand the effect on their studies. It is not necessary to discuss specific medical details or symptoms.
- considering how the student might be affected by the demands of the course, taking their health condition or disability into account.
Working together with the student to reach a shared decision is best practice:
- The student is the best person to explain how their health condition or disability affects them day to day.
- The support group members are best placed to explain what the student will need to do day to day while at medical school.
The discussion could cover the different parts of student life while at medical school:
- Logistics, accommodation and transport: The student's living arrangements, travel to the university teaching locations, access to university locations and services (eg library, student's union). Existing university policies are likely to cover much of this.
- Academic part: What the student will need to do day-to-day to engage with the course. This includes effectively following teaching activities (eg lectures, seminars, tutorials), having access to teaching materials in an appropriate format, studying or study skills support, and completing assignments
- Laboratory part: A medical course involves sessions in a laboratory or skills lab, where students will uses specific equipment and chemicals. The discussions may include what the student will need to attend, use equipment appropriately and complete tasks.
A simulation or a tour of the skills lab (if possible) can help the student have a more realistic picture of what they will need to do.
4. Clinical part:
- The group can discuss several things about clinical placements:
- Accommodation while on placements
- Transport to and from placement sites
- Navigating the clinical facilities eg accessibility of buildings
- Typical tasks requested of students on placement (eg administrative and clerical tasks, simple examinations, other clinical tasks)
- Schedule while on clinical placements
- Use of equipment, chemicals and pharmaceuticals (e.g. gloves, needles, injectors, cannulas)
- Use of assistive tools
- Communication with patients and their families/carers
A simulation or tour of the clinical placement sites (if possible) can help the student understand what have they will have to do.
5. Assessment part: The written and practical assessments medical students take to progress through different stages of the course.
The group can discuss the format of the assessments including the timing and equipment used. An assessment trial run or simulation can help the student understand what they will have to do. It is also good practice to organise a review after the first assessment a student takes.
6. Care arrangements: The student might need ongoing appointments with health services to make sure their health condition or disability is managed. The group can:
- ask the student how frequently they will need to attend health appointments and at what locations
- agree on arrangements in advance, for example what leave the student will need during the academic year
- encourage the student to register with local services, so they can easily access health professionals as and when they need to for treatment and ongoing management
Other pastoral care or financial support needed for the student to manage their health condition or disability.
Step 5: Decision on whether student can be supported to meet the Outcomes for graduates
Medical schools must use Outcomes for graduates as the ultimate benchmark when deciding if a student can be supported through the course or not.
All graduates from UK medical schools must meet the same competence standard, as described in the Outcomes for graduates. But importantly you can make reasonable adjustments in relation to how those outcomes are assessed, except where the method of performance is part of the competence to be attained.
To decide if a student can be supported to meet the Outcomes for graduates, the support group can:
- go through all the skills and procedures listed in the Outcomes for graduates and ask if the student would be in a position to meet them with appropriate support in place
- explore parts the student might struggle with: Ask the student 'how might you address this?'; 'can you see any problems with this?'; 'what coping strategies might you put in place?'; and 'how can we help with this?'
The discussions can be led by an accredited occupational health physician with experience in physician health. The occupational health physician can complete an assessment and take advice from other specialist organisations if needed; and give their view to the group on whether the student can be supported to meet the Outcomes.
Schools can consider any requests from a student for a second opinion or a referral to another occupational health service.
If the school decides the student can be supported to meet the Outcomes for graduates, the support group can formulate an action plan for the course. The group can also formulate an action plan with appropriate exit arrangements if after thorough consideration they believe the student will not be able to meet the Outcomes despite support (see Step 6).
Note: Medical students don't need to perform exposure prone procedures (EPPs) to achieve the outcomes of undergraduate medical education. Students with blood-borne viruses can study medicine, but they may not be able to perform EPPs and may have restrictions on their clinical placements.
Panel 12: Deciding whether to provide support
In their Good Practice Framework for supporting disabled students, the Office of the Independ Adjudicator (OIA) recommends asking the following questions when applying policies and procedures.
- Is the student disabled?
- If so, what provisions (for example, policies and procedures) are we now applying to them?
- Do these provisions place them at a disadvantage?
- What could be done to prevent that disadvantage?
- Would it be reasonable for us to take those steps?
Based on the guidance from the Equality and Human Rights Commission, the medical school can ask the following questions:
- Have we considered this case individually, about the specific student and their unique circumstances?
- Have we explored treating the student better or 'more favourably' than non-disabled people as a part of the solution?
- Is / are the proposed adjustment(s) effective in removing or reducing any disadvantage the disabled student is facing? Have we considered other adjustments or changes that can contribute?
- How easy or practical is this adjustment?
- How much does this adjustment cost?
- Is there advice or support available? Have we explored getting expert advice to support balanced decision making? Could we contact specialist organisations?
- Do we believe this / these adjustment(s) would increase the risks to the health and safety of anybody (the student, other students, staff, patients etc.)? If yes, have we done a proper, documented assessment of the potential risks?
An adjustment could not be reasonable if there is a risk to safety. But the conclusion there is a risk or potential risk must be based on a proper, documented assessment rather than any assumptions, as we want to reassure learners that an objective decision-making process will be followed for their cases.
Step 6: Action plan
Once a decision has been made on whether the student can be supported to meet the Outcomes for graduates, the group can formulate an action plan with the student.
If the school decides the student can be supported to meet the Outcomes for graduates:
- Draft an action plan for support and reasonable adjustments, for the student to engage with each part of the course.
- Draft with input from the student if possible.
- Incorporate any recommendations provided by the occupational health physician. If there are concerns about feasibility, the group can discuss to reach an agreement on what would be possible.
- Consider financial support for putting the plan in place
If the school decides the student cannot be supported to meet the Outcomes for graduates:
- Good practice to meet with the student and explain decision in person.
- Decision can be explained in the context of Outcomes for graduates and Promoting excellence, which says it is not possible for learners to progress if they cannot meet the required learning outcomes (R3.15)
- Encourage the student to consider alternative options, including gaining an alternative degree from the university and other career advice
- Some suggestions for having difficult conversations are in the appendix of the guide (panel A3).
Step 7: Monitoring and review
Once the action plan has been agreed, the school can appoint someone responsible for its implementation. Implementing the action plan is a shared responsibility between the medical school and the student.
- The key contact and the student can meet regularly to monitor progress for example through a termly or annual review. The school can also give a contact for the student to raise issues in case they are not happy with the support provided.
- The student has to engage with the support process and contribute to the implementation of the action plan. If the student fails to comply with measures and adjustments designed to enable them to complete the course that may become a student fitness to practise issue (paragraph 81, Professional behaviour and fitness to practise).
Note: The school is likely to have clearly identifiable individuals or teams in the school for expert careers advice. The school can also point the student to external careers advice, for example by BMA Careers and Medical Success, Alternative medical careers advice for doctors available online.