An environment in which students can seek help does not exist
Protecting the public is of key importance; I would hope that people entering the medical profession are doing so, at least in part. It certainly seems to be what potential medical students believe when they apply to study medicine, and are told not to say at interview. It would be naive not to expect that a small proportion of entrants to medical school may not be suited to medicine. Let's not side step the difficult issue here; we are talking about trying to prevent people like Harold Shipman becoming doctors, but I'm not sure how this would be achieved. Let's not confuse this issue with people who have ill health or a disability. Let's not, for that matter, stigmatise people with problems of substance abuse either.
Rubin states that there should be an environment conducive to students seeking help, which is a laudable aim that I wholeheartedly agree with. The same paragraph, however, demonstrates that this environment does not exist, and never will while the General Medical Council asks doctors to breach confidentiality by ratting on students to the medical school. This really is overkill, and I hope that it will not be included in the GMC document Student Health and Conduct, which is currently being revised, as it is already covered in the GMC publication Confidentiality.
In legal terms, and this is not being pedantic, I would also have to take issue with the point Rubin makes by stating that public safety must take priority. In fact, the Human Rights Act states that the right of the individual must be balanced against the rights of the public.
More than that--if we as a profession cannot look after ourselves and create a culture in which all of the medical profession, including students, can seek help in a caring confidential environment then how can we possibly claim to have the ability to look after other people?
Peter Taysum, deputy chairman for welfare, Medical Students Committee, British Medical Association; fourth year medical student, University of Newcastle
Setting the bar from the start
In New York, we attempt to set a standard of professionalism in the first week of the first year of medical school. We ask students to reflect on why they came here, what they expect of fellow doctors, and what makes joining this profession different from others. Substance abuse affects about 10% of those in the profession at one time or another, and to enforce this awareness we invite a doctor in recovery to speak to students first hand about his or her experience. Finally, we give students tools for help and reporting (New York state has strict and specific guidelines). It is our intention to give the message that this is important, a priority, and that they must recognise this from the start.
Sheila Otto, instructor, Albany Medical College, New York, USA
Students' welfare should be as important as the safety of the public
Training to be a doctor is not easy, and medical students are under enormous pressures right from the start. The undergraduate course in medicine is not only one of the longest but possibly one of the most demanding both in terms of the amount of learning required and because of the interactions with people who have physical, psychological, and terminal problems. The health, safety, and welfare of our medical students and the responsibilities of our medical colleges is, and should be, as important as the safety of the public. Or, is it still as was the case when I was training in 1975-80--a case of "If you can't stand the heat, stay out of the kitchen"?
Dil Sen, occupational health physician and honorary lecturer, Universities of Manchester and Liverpool
Students mistrust and misunderstand pastoral care
Our research into new and existing methods of providing pastoral care finds that concern among students surrounding the issue of confidentiality is the single greatest barrier to their involvement.1 Students mistrust and misunderstand the purpose of pastoral care and avoid seeking help for fear of jeopardising their careers. This is perhaps not surprising. Rubin rightly emphasises the need for an environment in which medical students "feel able to help themselves with confidence." He goes on to suggest, however, that pastoral care systems should decide (and inform the medical school) if students are able to continue on their course. Students would have little confidence in admitting their weaknesses and approaching such an influential body for support and guidance. To maximise uptake--and thereby effectiveness--all support systems must have transparent, understandable codes of conduct for both users and providers.
Surely the first step to managing students who go off the rails is not, as suggested, identifying the problem but, in time honoured medical tradition, preventing it emerging in the first place? The key is providing effective, accessible pastoral care for every student, not only for those who are struggling. Pastoral care during medical training is in everyone's best interests and crucial to the educational process itself.25
The stresses of medical school are well documented.59 The prevailing culture needs increased levels of personal robustness from students, thereby placing even more pressure on the psychologically fragile.10 To paraphrase Rubin's laudable call for patient protection, steps should be taken to ensure no medical student is harmed by their participation in training.
