Fitness-to-practise policies in Australian medical schools — are they fit for purpose?

Students of medicine, unlike those of any other discipline, have certain privileges and responsibilities which necessitate different standards of conduct, behaviour and professionalism.1 In academia, this presents a challenge as it raises the question of whether the rules governing students in other degree courses are sufficient to ensure that medical students have appropriate safeguards to protect both patients and the students themselves. It has been noted that “there is a strong consensus that medical schools must deal effectively with clearly identified extreme cases of poor professional behaviour”.1 This raises questions about how we define poor professional behaviour, how we assess it, and what processes are in place in medical schools to deal with these issues.1,2

Fitness to practise has been defined as encompassing clinical competence, acceptable professional behaviour, and freedom from impairment.2 Given that there is debate about the definition and assessment of these areas in postgraduate education,3 it is not surprising that there is a range of opinions on how to manage these areas in medical student education.1-4

Fitness-to-practise policies (FTPPs) are being increasingly used to address issues of unprofessional medical student conduct and behaviour. We performed an Australia-wide questionnaire-based study on the uptake and effectiveness of FTPPs, as these policies have not been evaluated on a national level before. We aimed to obtain an accurate picture of the current use of FTPPs, identify factors that might affect policies in Australian medical schools, and collect baseline data for future comparisons. We also aimed to define and benchmark FTPP best practice in Australian medical schools.

A review of the national and international literature to define best practice regarding FTPPs for medical students found that the only country with national guidelines on medical student professional conduct was the United Kingdom.5 Our survey questionnaire (available from the authors on request) consisted of sections on medical school demographics, FTPPs, remediation processes, and exclusion of students. It specified key areas of professional conduct and behaviour to reflect best practice in FTPPs, based on eight categories of concern outlined in the UK General Medical Council guidelines (Box 1).5

Details of currently accredited Australian medical schools were obtained from the Australian Medical Council website, and individual university websites were checked for information on their FTPPs or professionalism policies. It was apparent from the university websites that the people responsible for coordinating professional practice in each medical school have variable titles. As such, we selected the deans as the most appropriate staff members to coordinate the distribution of the questionnaire within their schools, as they were in a position to have access to the information requested or to know which member of staff would be privy to this.

The questionnaire was sent to the deans of the 19 Australian medical schools in August 2009, with a covering letter explaining the aims and methods of the study. All documents were standardised and anonymous. To maximise response rates, reminder letters and emails were sent 2 and 4 weeks later.

Descriptive analysis of the data was used to identify any apparent associations between medical school demographics, use of FTPPs (or lack thereof), remediation processes and numbers of medical students excluded. Formal statistical tests were not used because of the small numbers in the survey.

Ethics approval for the survey was provided by the University of Western Australia Human Research Ethics Committee.

Completed questionnaires were returned by 15 of the 19 medical schools that were contacted. The anomymised questionnaires were coded with a letter (A–O) to aid comparisons between medical schools.

In 2005, a strong association between poor professional behaviour in undergraduate education and subsequent disciplinary action by medical boards for “problem” doctors was shown in the United States.6 In Australia, the New South Wales Medical Board reported that, in NSW (where medical students have been registered with the medical board since 1992), 20% of “impaired” students have drug or alcohol problems and 70% have a mental illness.7 This has prompted medical schools to develop measures to address these issues in undergraduate education; however, a literature search that we performed found no convincing evidence to validate any particular approach. This is the first national study of the experiences of medical schools regarding student professionalism, and the policies and remediation processes that have been implemented in this area.

There were a number of limitations in this study. Not all Australian medical schools were represented. As the survey was anonymous, it was impossible to determine whether there were differences between respondents and non-respondents. Although the deans were the most appropriate staff members to coordinate completion of the questionnaires, this created the potential for observer bias.

The majority of the 15 Australian medical schools surveyed reported using FTPPs in the 5-year period ending August 2009. However, there was little consistency in the criteria used in the FTPPs, and the policies do not appear to be a prerequisite for medical schools having remediation processes. Seven schools had excluded students for professional misconduct over the 5-year period, and the use of an FTPP had no demonstrable association with the numbers of students excluded.

Although the number of students excluded may be a poor marker of FTPP performance, the finding that most students were excluded for FTPP reasons during Years 2 and 3 lends support to medical schools actively assessing students who have difficulties in these areas. The types of remediation processes and efforts to remediate students are also inherently difficult to assess, but, based on our data, most medical schools appear to put significant effort and resources into these processes regardless of whether they have a formal FTPP in place.

It would be appealing to measure a medical school’s FTPP performance based on the number of students excluded. Unfortunately, surrogate outcomes such as this are meaningless. For example, a medical school with a “good” FTPP could have a low rate of student exclusion, reflecting good surveillance and effective remediation for students with difficulties. Conversely, a medical school with a “bad” FTPP might also have a low rate of student exclusion, as there may be no mechanisms in place to detect students with problems, with no onus on the medical school to exclude “rogue” students.

The commonest reason for student exclusion in our study was persistent inappropriate attitude or behaviour. Ironically, persistent poor performance in professional behaviour was the criterion least likely to be used in Australian medical school FTPPs.

At present, individual medical schools leave themselves open to challenge on their FTPPs, remediation processes and exclusion decisions, owing to a lack of evidence that any one process works. As recently noted:

Can these variable policies that lack proven effectiveness be improved by using a nationally consistent framework similar to that in the UK? With no published data to guide practice, the answer is as yet unknown, although a move towards better collaboration and a more consistent approach between medical schools in this area has been given new impetus by the recent National Forum: Assessment of Professional Behaviour of Medical Students (Malcolm Parker, Associate Professor of Medical Ethics, University of Queensland, personal communication). However, it is imperative to evaluate the possible effects of these processes on outcomes if a national approach is to be implemented.