Wassim Merzougui, Final year medical student, University of Southampton

Published in JHH16.2 – Faith, hope and love for healthcare

Initially, I was drawn to medicine to have a role in improving the quality of lives in the public, while incorporating my fascination of the human body. It is not only an intellectually stimulating career, but one that is humbling, where vulnerable patients place their trust in doctors to treat them holistically. I’m passionate about medical education and advocacy for both patients and healthcare professionals. During my placements while at medical school, any doubts I had to pursue medicine quickly evaporated, as I witnessed the sheer variety in patient presentations making it a challenging, but rewarding career choice.

Mental health problems are more prevalent among medical students than in other student groups, and medical students are less likely than others to seek help. Doctors face increasing scrutiny, accountability and litigation, which together with the erosion of their former professional status and autonomy make for an uncomfortable professional climate. In addition, doctors are expected to evaluate ever-accumulating research evidence, integrate novel management options into clinical practice, and to be continually appraised and re-validated as accountable, competent professionals. Consequently medical schools face very significant challenges in preparing the next generation of doctors for the uncertain times ahead and the increasingly difficult realities of practice.These winning essays consider medical schools’ duty of care.

The wishful applicant

Mirror, mirror, on the wall, out of all these glossy brochures, which medical school (MS) should I go for? Looking back at my college days (but not too far back), I was at a stage that most teenagers dreaded and that was making a ‘decision’. A decision regarding which course, university and most importantly, which student current account to hide my pennies in. There are 32 medical schools recognised by the General Medical Council (GMC) in the UK, and yet there I was debating whether there were 32 cities in the UK. At this point, you might have pretty much guessed that I desperately needed some career advice (preferably where there were no mirrors around me). My first bit of advice came from my first lifeline ‘phone a friend’, who advised me to base my decision on the metrics of which area offered the cheapest alcohol and simultaneously offered the most fun on a night out. I quickly drew the conclusion that some people should never offer any advice. Although, I was grateful that he considered my financial and social wellbeing. My next chosen lifeline was: ‘ask the audience’ who is also known as my father. He quickly pointed to the six hairs on my chin and stated that the decision was mine, and only mine to make. He too has been added to my list of nonsensical advisors. With 32 medical schools out there, my last option ‘50:50’ left me in no better place.

Well the harsh reality of all of this is, that when I applied, many prospective medical students did not have the luxury of choosing which MS they would like to attend. When applying to MS, the main considerations for prospective students were the grade requirements, finance and location. ‘Beggars can’t be choosers’ so what difference did it make when it came to the duty of care and benefits that the different medical schools had on offer?

Duty of care to the applicant

Before we talk about the duty of care towards medical students, I think it is of paramount importance to consider the duty of care medical schools have towards applicants. In 2016, there were nine applicants fighting for each place on offer and with such high demand comes an even higher rejection rate (Moberly, 2017). Among many of my peers at the time, no feedback was received after the dreaded ‘Unsuccessful’ update on UCAS arrived. Moreover, to add insult to injury, some medical schools had advocated to applicants not to apply again after they had been turned away. This left a few of my peers demoralised and wondering where it all had gone wrong. Surely, the applicant’s next move was to ask for feedback. However, at the time, several medical schools had high[1]lighted that they were unable to deliver feedback due to ‘the sheer load of applications received this year’. But like Bob Dylan said, ‘Times they are a-changin’, and some medical schools are starting to offer places to study medicine through clearing (St George’s, University of London, 2016). Since the imposition of the new junior doctors contract and the media’s attention to the many struggles the NHS is facing, there is an underlying sentiment that being a doctor has lost its sparkle, and so UCAS has reported a drop in medical applications (UCAS, 2016). Medical schools have had to step up their duty of care. Looking through the different MS websites this year, it appears the application process for medical schools has been revised to ensure more support for unsuccessful candidates. Medical schools are offering applicants feedback and the opportunity to re-apply in the future.

Duty of care to the medical student

So, after fulfilling all the medical school’s academic and extracurricular demands, and moonwalking your way through the application process successfully, you now become a medical student. It is time to consider what responsibility and duty of care your MS has towards you. The most obvious duty a school should offer before graduation, is a comprehensive education in line with the GMC’s outcomes and standards of Tomorrow’s Doctors (GMC, 2009). The anticipated outcome is to not only become a doctor, but an accomplished scientist, scholar, practitioner, and a competent professional.

Flexibility

Like Dr Ole Ivar Lovaas said, ‘If they can’t learn the way we teach, we teach the way they learn’. So it is the responsibility of an MS to provide a high standard of teaching, delivered by experts in the subject, employing teaching strategies that vary to cater to students with specific learning methods or to support students with special needs. It is imperative that cancelled lectures/ tutorials are rescheduled or uploaded to ensure there are no gaps in the students’ knowledge.

Consistency

Going through GMC recommendations for the different medical schools during the year 2016/17, it became apparent that several faculties have issues with their Objective Structured Clinical Examination (OSCE) assessment. Among medical students, it became apparent that the OSCE assessment process varies at different placements. There have been issues with OSCE standardisation in medical faculties (GMC, 2017). The faculty has a duty to ensure that all assessors who participate in the assessment process are well equipped with the guidance and training for assessing our future doctors with consistency. Medical students should not feel apprehensive, but reassured they are going to be assessed fairly at any placement.

Usefulness

Most medical students spend their time in various hospital placements and general practices. It is essential that organised placements are safe and that the student receives adequate supervision. There should be clear communication between the faculty and placement regarding the student’s attendance and learning outcomes. Under the guidance of the MS, each placement should provide teaching to develop the student’s clinical knowledge and the opportunity to hone their clinical skills, beyond just pulling curtains and making cups of tea.

Safety and comfort

Living like a vagabond is all part of the university experience. However, the BMA has provided guidance regarding the minimum standards of accommodation (BMA, 2018). It outlines with respect to safety and security, that medical schools should provide adequate accommodation to students undertaking their clinical placement far from their university.

Breadth

To become a well-rounded doctor, medical schools should support students in participating in extracurricular activities, eg attending conferences, performing sport and academic research. The GMC stresses the importance of work-life balance in Tomorrow’s Doctors (2009) [replaced by Promoting Excellence: standards for medical education and training, 2015] and highlights that medical schools should endeavour to protect recreational time.

 Diversity

Medical schools have a duty to support students with disabilities in both applying to MS and during their time in learning to become a doctor. It is a legal requirement that medical schools provide reasonable adjustments to students with a disability that could impact their career. This is highlighted in the GMC ‘Gateways guidance’, which emphasises the various ways medical schools should support students with a disability. Medical schools should facilitate a straightforward application process for students with a disability. We are taught to show empathy towards our patients, but what empathy is shown when we become one?

Wellbeing

Mental health is considered to be a taboo subject in medicine, however according to the student BMJ, over 30% of medical students experience mental health problems, with 80% of them struggling to receive adequate support (Billingsley, 2015). An MS may advertise its mental health services, but many students are reluctant to approach these services, for fear that it will have a negative impact on their future career, that their medical notes will be disclosed or their fitness to practice will be questioned. However, it is important to highlight that the GMC has stated that ‘In almost every case, a mental health condition does not prevent a student from completing his or her course and continuing a career in medicine. If you engage with your medical school and ask for support and follow the advice given, then there will be no need for a fitness to practise committee to be involved’ (Sayburn, 2015). A student BMJ article had described a medical student’s experience on her mental health condition during MS. She had described ‘how there is not always a clear demarcation between MS staff with pastoral roles and those who rule on fitness to practice or disciplinary issues’. This is contrary to GMC guidance, which is clear on the need to separate these two functions. ‘It is important that those providing pastoral support are not in a position to make decisions on academic progression. This separation of function allows students to have a safe environment in which they can raise concerns without worrying that there will be any impact on their academic progression’.

Openness

Medical schools should create an environment where mental health is openly discussed to reduce the stigma around it. It is imperative to explain to students on their induction day, that mental health conditions are very common and that there are services available to support them. They should ensure that they maintain clear confidentiality guidelines with regards to students and their mental health issues. In the same way universities accommodate medical students with physical disabilities, the same should be done for those with mental health issues. For example, a medical student with anxiety had explained how her university had offered her the opportunity to sit an exam in a room with fewer people. ‘That really took the anxiety away from me’ (Sayburn, 2015). A small adaptation, AKA good deed, by the university can go a long way. Just as we give our patients fit notes with a phased return, we should also offer the same to medical students. Some students would prefer their workload to be reduced for a short period of time rather than having taking a year out of training.

The future

So, what lies ahead for the future of medical schools and medical education? For those applying to MS, it could be good news. Jeremy Hunt announced that an extra 1,500 MS places will made available to help tackle the ‘workforce crisis’ that the NHS is facing (McManus, 2016). The recent opening of private medical schools has also been a hot topic of discussion. Private medical schools can accommodate the intake of more students, which in future could support the NHS workforce. It could also encourage competition between medical schools to provide the best care and quality of medical education to prospective students.

It is important to note that here have been some concerns raised regarding private medical schools. Students applying will effectively be paying for their place to attend MS. Since the student is paying outright, does this mean private medical schools have an even greater duty of care to these students, for fear that they might take their business elsewhere? Private medical schools are also business ventures seeking to make a profit. However, could the profit motive have a negative impact on the quality of training medical students receive? With an increase in student intake, there could be a lack of placements available to provide teaching in a clinical setting. Are the pressures that the NHS faces the result of increases in medical admissions, or could it be that the lack of retention of doctors is an underlying cause?

It is with great sadness, that my time as a medical student is drawing to an end. Thankfully, I have more than six hairs on my chin, although some of these hairs have become grey. With more grey hair, comes more wisdom. My experience as a medical student has been fruitful to say the least. I cannot stress the importance of medical schools supporting my peers during their adversities. My peers are resilient, brilliant, but also human. The care that we receive from our medical school translates to the care that our future patients receive. So please be kind to us, for the sake of our future patients!

References

• Billingsley M (2015) More than 80% of medical students with mental health issues feel under-supported, says Student BMJ survey. Student BMJ, 23 [online]. [Internet]. Available at: https://search.proquest.com/ openview/eadd231e88365d67b2f6059650336297/1?pq-origsite= gscholar&cbl=2041875 (accessed 5 June 2019).
• BMA (2018) Minimum standards of accommodation [online]. Available at: www.bma.org.uk/advice/career/studying-medicine/get[1]ready-for-clinical-medicine/minimum-standards-of-accomodation (accessed 5 June 2019).
• GMC (2017) Medical school reports [online]. Available from: www.gmc-uk.org/education/26867.asp (accessed 5 June 2019).
• GMC (2009) Tomorrow’s doctors. [online]. Available at: www.ub.edu/medicina_unitateducaciomedica/documentos/Tomorrows Doctors_2009.pdf (accessed 5 June 2019).
• Lovaas Ole Ivar (1993) In: Hart C. A parent’s guide to autism. New York, NY: Simon and Schuster; pp 260.
• McManus C (2016) Hunt promises 25% more medical students in 2018. BMJ, 355:i5480.
• Moberly T (2017) Sixty seconds on … medical school applications. BMJ, 8, 356: j659.
• St George’s, University of London website. St George’s, University of London offers Medicine through clearing for the first time [online]. Available at: www.sgul.ac.uk/news/news-archive/medicine-clearing-first[1]time (accessed 5 June 2019).
• Sayburn A (2015) Why medical students’ mental health is a taboo subject. Student BMJ, 23 :h722
• UCAS (2015) 2016 cycle applicant figures – October deadline [online]. Available at: hwww.ucas.com/corporate/news-and-key-docu[1]ments/news/2016-cycle-applicant-figures-%E2%80%93-october-deadline (accessed 5 June 2019).

Saleh Jawad, Final year medical student, University of Southampton

I wanted to become a doctor for very selfish reasons. I enjoyed helping people, I enjoyed the intellectual challenge of medicine but also the complexities of interacting with people at their most vulnerable. My time at medical school, however, showed me that not only were the patients vulnerable but also the staff. Doctors, nurses, healthcare assistants, medical students and more, all suffered a burden on their journey to helping people. I wondered why.

I have been taught that honesty and transparency are important cornerstones of medical care. In that spirit, let me be honest. When I sat down to write my personal statement some five years ago, my understanding of what it meant to be a doctor, the vocation as I put it, was naively untried. Saving lives and helping the sick was the dream, and soon it will hopefully become a realisation. What I was not aware of was the toll that fulfilling the dream can take on an individual.

Howe et al (2012) explain that doctors are at risk of suffering ‘moral injury’. They explain that moral injury is the emotional and psychological damage that individuals suffer when they continually experience or take part in acts that go against ordinary moral expectations, much like in the military world. The situations that doctors often find themselves in come with their own moral demands and codes that may run contrary to the norms and expecta[1]tions of society. These situations can be as simple as causing pain to a child in the process of treatment or in a more extreme situation, amputation of a limb to combat disease. It has been suggested that doctors themselves may, in the act of treating a patient, have to refrain from ‘normal’ feelings and morals to provide the best quality of care (Smajdor et al, 2011).

Additionally I learned that medical students experience higher levels of stress and depression compared to their non-medical counterparts and the general population (Dahlin et al, 2005). Interestingly, one study suggested that as medical training progresses the prevalence of depression increases (Quince et al, 2012; Dyrbye and Shanafelt, 2016). It has been shown that stress induced by medical training has more of an impact on students’ depression than any other personal stressor (O’Reilly et al, 2014).

The duties of a medical school

These can be spilt into two categories. The first being the duty to provide society with competent doctors. The second is the duty to its students, not only to train them but also to prepare them for the realities of their vocation. If the military must provide its soldiers with bullet-proof vests, and place them in armour-clad vehicles, we must ensure medical schools are equipping future doctors for the battlefield of medicine. Although these duties can be debated and explored, ‘duty of care’ is a legal concept and I have very little experience in the legal field. On many occasions, however, at medical education conferences my generation have been described as internet- and digitally[1]obsessed. I know that from my use of the internet in writing this essay, I have yet to find a document that clearly outlines the responsibilities a medical school has to its students. The GMC sets out recommendations and standards that aim to support students in their learning but falls short of using the term duty of care (GMC, 2017).

However, it is very easy to find multiple websites and documents that clearly outline the duty of care that doctors must offer to their patients. The duty of care that medical student’s will be legally required to deliver to their patients is made clear on the very first day of medical school. What is also made clear is that ‘no one will hold your hand and unlike your previous schooling, knowledge will not be spoon fed’. It is this culture that I am increasingly questioning, for though I concede that doctors must learn to be independent and lifelong learners, yet I question the culture of isolation and the feeling that I am personally held to a standard that my parent organisation is not.

What cannot be debated is that we have a problem. The problem is clear but the solution less so. In the sad aftermath of 28 doctors committing suicide while under investigation, the GMC released a report with nine recommendations (Horsfall, 2014). One of the nine recommendations made was ‘to make emotional resilience training an integral part of the medical curriculum’. The report stated that ‘it would be helpful to ensure that there is sufficient resilience training or information on how to emotionally handle the transition from student to junior doctor’. The GMC’s guidance to students also stated that ‘you will need to learn early on how to develop emotional resilience’ (GMC, 2016).

The concept of resilience is not new

However, in recent years I have come across it more and more in my life, medical and otherwise. The difficulty of defining resilience is widely recognised, so the proposed solution of resilience training may seem premature. There is no universally accepted way of measuring or quantifying resilience and this to could cause difficulties for medical schools, especially when trying to implement resilience programs that are individual directed. Thus If we would imagine a medical student metaphorically drowning because stress, depression, and anxiety were pulling them down. The medical school suggests that the student should attempt to swim frontstroke or backstroke, or perhaps some version of what dogs do. These different swimming styles represent the individual directed inter[1]ventions found in the literature such as mindfulness based stress reduction, yoga, and stress reduction programmes. Such suggestions might be helpful but in my experience so far, exhortations to boost resilience seem to generate anger with some junior doctors and students if they feel it implies a lack of resilience and this becomes another stick to beat them with when things go wrong. We need to think about resilience in terms of not just of what individual can do to support themselves, but crucially, we must also consider how the system itself must support individuals.

The future of medicine in the UK, depends on the ability of the NHS to retain doctors. This in turn will rely on medical schools’ ability to train resilient doctors who can adapt in healthy ways to the challenges of delivering medical care. In April 2017 a report looking at the longer[1]term sustainability of the NHS stated, ‘Our NHS, our “national religion”, is in crisis and the adult social care system is on the brink of collapse’ (The Lancet, 2017). Organisational changes must occur. A sustainable NHS cannot rely solely on ever-more resilient doctors.

The repeated reorganisation of the NHS has created anxiety and the creation of scapegoats and destructive relationships, where the weakest suffer the most (Balme et al, 2015). Other less than ideal organisational factors include antisocial hours, staff shortages and poor leader[1]ship. They all play a part in preventing the organisation and the individuals within the organisation from delivering safe, effective, and compassionate care (Slavin et al, 2014). Since the problems faced by the NHS and by doctors and medical students are interwoven, and contribute to their overall complexity, should we question whether individual resilience is still a credible solution?

Organisational resilience

Resilience may be a personal trait that medical students can be taught to enhance. However, organisational resilience aims to improve the working environment, which may have negative effects experienced by student during their training. Organisational resilience takes a holistic approach, looking at both the individual and the organisation. In regard to medical education, organisational resilience allows us to critically examine the way we teach students and the environment we teach them in.

Slavin et al (2014) show that through their organisation[1]directed resilience intervention, they were able to address directly the sources of medical student distress within the curriculum. By changing grading systems, reducing contact hours and institutionalising longitudinal electives among other changes, they were able to see a significant decrease in stress, depression and anxiety. These organisational changes were also supplemented with opportunities (individual directed interventions) for students to develop resilience skills to better cope with stressors.

An organisational approach will not just teach students how to swim but will also ensure that the swimming pool is not deep enough to drown in to begin with. It has been suggested that it will be by creating posts and career structures, by working together to improve job satisfaction and by addressing the current bullying culture of shame and blame that staff resilience will be achieved. ‘If we are to create a resilient environment for healthcare staff, there will need to be structural changes from ward to board’ (Balme et al, 2015).

A change in paradigm?

My colleagues and I are the future of medicine, but I question what we will inherit. For, if we are honest, there are many dysfunctional aspects that need to change. What we have before us is an opportunity to shift the paradigm, instead of accepting whatever is thrown at us. Rather than offering resilience seminars and elective courses to mitigate medical student distress, we need to feel empowered to push for changes that address the sources directly. The problem is grave, and the challenges great, but implementing organisational resilience can be effective. Resilience may be poorly defined but this should invite us to develop definitions that include the solutions needed tackling the current and future difficulties that medicine will face.

References

• Balme E, Gerada C, Page L (2015) BMJ Careers – doctors need to be supported, not trained in resilience [online]. Available at: http://careers.bmj.com/careers/advice/Doctors_need_to_be_supported, _not_trained_in_resilience (accessed 5 June 2019)
• Dahlin M, Joneborg N, Runeson B (2005) Stress and depression among medical students: a cross-sectional study. Medical Education, 39(6) 594–604.
• Dyrbye L, Shanafelt T (2016)A narrative review on burnout experienced by medical students and residents. Medical Education, 50(1) 132–49
• GMC (2017) Promoting excellence: standards for medical education and training [online]. Available at www.gmc-uk.org/education/ standards.asp (accessed 5 June 2019).
• GMC (2016). Welcome to medicine 2016 [online]. Available at: www.gmc-uk.org/Welcome_to_medicine_2016_0816.pdf_67466733.pdf (accessed 5 December 2017).
• Horsfall S (2014) Doctors who commit suicide while under GMC fitness to practise investigation. Available at: www.gmc[1]org/Internal_review_into_suicide_in_FTP_processes.pdf_59088696. pdf (accessed 5 June 2019).
• Howe A, Smajdor A, Stockl A (2012) Towards an understanding of resilience and its relevance to medical training. Medical Education, 46(4) 349–56.
• O’Reilly E, McNeill KG, Mavor KI, et al (2014) Looking beyond personal stressors: an examination of how academic stressors contribute to depression in Australian graduate medical students. Teaching and Learning in Medicine, 26(1),56–63.
• Quince TA, Wood DF, Parker RA, et al (2012) Prevalence and persistence of depression among undergraduate medical students: a longitudinal study at one UK medical school. BMJ Open, 2(4) 8.
• Slavin SJ, Schindler DL, Chibnall JT (2014) Medical student mental health 3.0: Improving student wellness through curricular changes. Academic Medicine, 89(4) 573–77.
• Smajdor A, Stockl A, Salter C (2011) The limits of empathy: problems in medical education and practice. Journal of Medical Ethics, 37(6) 380–83.
• The Lancet (2017) The future of the NHS. Editorial The Lancet. [Online] 389(10078)1491. Available at: www.thelancet.com/journals/ lancet/article/PIIS0140-6736(17)30994-7/fulltext (accessed 5 June 2019).