supporting struggling medical students

Supporting strugglingmedical studentsMichael Ford, George Masterton, Helen Cameron and Fanney Kristmundsdottir,College of Medicine and Veterinary Medicine, University of Edinburgh, UK

INTRODUCTION

Not all doctors are happy intheir professional lives.Should medical schools try

to select students who will behappier and more effectivedoctors by routinely assessingpersonality profiles and learningstyles before medical schoolentry?1 Successful progressionthrough medical school is relatedto factors such as prior academicability, personality, gender andlearning styles. Prior academicperformance is traditionallyemphasised but accounts for nomore than 23 per cent of thevariance in undergraduate perfor-mance and only six per cent of thevariance in postgraduate perfor-mance.1,2 Although the moreacademic medical students tendto take intercalated BSc degrees

and demonstrate higher deep andstrategic learning scores, they donot necessarily perform better infinal clinical examinations thantheir peers (Box 1).3–6

Modern personality theorysuggests that five key factors (the‘big 5’) underlie normal personal-ity: ‘emotional stability’, ‘extro-version’, ‘openness to experience’,‘agreeableness’ and ‘conscien-tiousness’.7–9 Conscientiousnessis a powerful, positive predictor ofpreclinical performance; incontrast, state but not traitanxiety is a weak negative pre-dictor of medical undergraduateperformance.1,9 Women consis-tently outperform men as medicalundergraduates and also tend todo better in clinical assess-ments.1,6 Learning styles, encom-passing both the process by which

students approach the task oflearning and the degree of moti-vation, have modest effects onundergraduate performance.Learning styles correlate withpersonality measures in medicalschool.6,9,10 Deep learning ishighest in extroverts who areopen to experience, and strategiclearning is highest in conscien-tious students with low openness.Although the effects of deep andsuperficial learning styles areinconsistent, strategic and‘convergent’ learning stylescorrelate positively with perfor-mance in the final examina-tions.1,6 Longitudinal datasuggest that personality andlearning style are not merelycorrelates of approaches to workand career satisfaction but areclosely associated with stress anddissatisfaction.10

Should medicalschools try to

select studentswho will behappier and

move effectivedoctors?

Supportingmedicalstudents

232 � Blackwell Publishing Ltd 2008. THE CLINICAL TEACHER 2008; 5: 232–238

Until the key predictors ofeffective personal and profes-sional development in undergrad-uates are better understood,medical teachers will continue tostruggle to identify poorly per-forming medical students. Thesestudents experience a higherincidence of stress-related prob-lems and exhibit both academicand emotional difficulties that arelikely to undermine their effec-tiveness. Depression is a seriousmental health risk in studentpopulations; those at greatest riskare medical students, particularlywomen.11 Stress, burnout and jobsatisfaction in junior doctorscorrelate with personality traits ofneuroticism and introversion atmedical school entry, in the finalyear of medical school and 5 yearsafter registration in workingdoctors.10 In summary, poorlyperforming medical students areliable to become poorly perform-ing junior doctors, with all theattendant problems andunhappiness that this brings.

Under the direction of theGeneral Medical Council (GMC), allBritish medical schools have pro-cedures in place to ensure fitnessto practise and to decide whetherhealth or behavioural disordersare likely to interfere with safe,effective clinical practice. Peers,medical colleagues and studentsrarely report to such committeesbecause of the threat to astudent’s livelihood. As

fitness-to-practise committeesprovide the legislative functiongoverning the appropriateness ofstudents remaining on the medi-cal undergraduate course, there isa need for a supportive pastoralmechanism to identify, track andassist students experiencing dif-ficulties with emotional, academicor physical disorders. Most medi-cal schools track student perfor-mance continuously throughoutthe undergraduate years to iden-tify and support the ‘strug-glers’.12–14 This paper describesthe introduction and evolution ofa paternalistic model of pastoralcare to identify and support stu-dents with persistent difficultiesin the University of EdinburghMedical School.

STRUCTURE OF PASTORALSUPPORT

The College of Medicine andVeterinary Medicine at EdinburghUniversity has a well-developedsystem of Directors of Studies(DOSs) who are asked to contacttheir students at least twiceyearly and, if problems arise,report to the Director of StudentAffairs. This tutorial systemprovides support and mentoringof students and helps identifystudents who are having difficul-ties in relation to both academicand non-academic performance.The Director of Student Affairs hasan onerous, personal responsibil-

ity for the support of a largeundergraduate school with over1200 students. In addition to thepersonal mentorship provided bythe DOS system, there is a guid-ance team dedicated to supportthe small number of students fromunder-represented, non-tradi-tional, medical school entrybackgrounds as a core componentof Edinburgh University’s strategyof ‘widening participation’ tohigher education.

When students have exhaustedthe facilities available to theDirector of Student Affairs andtheir DOSs, and academic under-performance is persistent orrecurrent, decisions aboutwhether a student should con-tinue on the course are referred tothe appropriate year director.

Pastoral role of the ProfessionalDevelopment CommitteeBy 2002, the breadth, depth andvolume of pastoral care requiredreappraisal. We identified theneed for a specialist studentsupport group to facilitate thepastoral care of students experi-encing severe or persistent diffi-culties. The primary aim of theProfessional Development Com-mittee (PDC) is the pastoral wel-fare of ‘struggling’ students.Students with poor personal orprofessional development assess-ments, and students experiencingpersistent emotional or physicalill health or academic problems,are referred so that they can beassessed, supported and trackedmore appropriately and moreeffectively. The PDC also providessupport and advice to DOSs, theDirector of Student Affairs, theyear director for each year of the5-year curriculum and the Curric-ulum Executive Committee. Moststudents are referred to the PDCeither by a year director or theirDOS; however, any member of theteaching staff or any fellow stu-dent may refer a student if otherpastoral support has proved inef-fective. Although students areencouraged to self-refer, to date

Box 1. Known predictors of undergraduateperformance

• ‘Big 5’ personality factors

emotional stability

extroversion

openness to experience

agreeableness

conscientiousness

• Prior academic performance

• Female gender

• Strategic and ‘convergent’ learning

• State not trait anxiety (negative effect)

Poorlyperfomingmedicalstudents areliable tobecome poorlyperformingjunior doctors

There is a needfor a supportivepastoralmechanism toidentify, trackand assiststudentsexperiencingdifficulties

� Blackwell Publishing Ltd 2008. THE CLINICAL TEACHER 2008; 5: 232–238 233

none has done so. When seriousprofessional misconduct such ascheating or criminal behaviouroccurs, students are referreddirect to the Fitness-to-Practise(FTP) Committee. There is noroute of onward referral from thePDC to the FTP Committee; yeardirectors who refer students withserious unprofessional conduct tothe PDC are requested to refer thestudent direct to the FTPCommittee. Students who remainon the course after FTP Committeehearings may be referred to thePDC for additional support, adviceand tracking.

Students who decline to meetthe group or who refuse to act onits advice are referred back to theYear Committee. If major attitu-dinal or behavioural problemsthreaten a student continuing oncourse, the Year Committee isasked to consider the issuesbefore onward referral to the FTPCommittee if appropriate. Tomaintain confidentiality, onlydetails of how effectively thestudent has followed the advice ofthe PDC are disclosed to either theUniversity Exclusion AppealsCommittee or the FTP Committee.Although the PDC does notrefer students to the FTP

Committee, it can recommend thisto the Year Committee if it wasaware that a student’s behaviourposed a significant risk topatients. The primary pastoralrole of the PDC is maintained,allowing the PDC to liaise withcommittees responsible fordecisions on students’ progress,without deterring students orstaff from referring students inneed of guidance or support(Figure 1).

Composition and work of thePDCThe PDC team comprises fourexperienced members of theteaching staff who have a majorinterest in and demonstratedcommitment to student supportover many years; they include apsychiatrist experienced in thecare of students, a generalphysician (Professor of StudentLearning), a palliative carephysician and medical educator(Director of the Medical TeachingOrganisation), and the anatomycourse director (Director ofStudent Affairs). Committeemeetings are supported by anexperienced administrativeofficer, who organises meetings,schedules appointments andmakes a detailed record of the

key issues discussed withstudents.

Students invited to attend thepastoral group are informedbeforehand about the composi-tion of the group, and its role,remit and commitment to strictconfidentiality. Students areinvited to attend either alone oraccompanied by a fellow studentor DOS. Before attending, they areasked to write a brief, reflectiveaccount of the problems that theyhave experienced, their insightsand interpretations of events,why they believe that they haveexperienced the difficultiesencountered and possiblesolutions likely to improve theiracademic progress.

Interviews with students aresemi-structured and designed toexplore the academic, interper-sonal and health issues relevantto their situation; approximately45 minutes are allotted to theirfirst interview and 15 minutes tosubsequent interviews. Details ofstudents’ professional develop-ment including academic perfor-mance, attendance, timeliness ofsubmissions of course work andin-course assessments of profes-sionalism during course modulesare available before eachinterview. Records of interviewsincluding contexts, contents andconclusions are kept. The guid-ance, advice and recommenda-tions of the PDC remainconfidential but are retainedwithin the students’ records and,with the students’ permission,communicated to their DOS and, ifappropriate, the year director.Written permission from studentsis sought before any informationis requested from the generalpractitioner, physician or psychia-trist involved in their care.Students, their DOS and thereferring year director areinformed of the recommendationsand outcomes. Students are senta confidential record of theguidance, advice and sources ofadditional support unique to their

Figure 1. Pathway of referral.

The primary aimof the

ProfessionalDevelopment

Committee(PDC) is the

pastoral welfareof ‘struggling’

students


situation, tailored to their needsand designed to address theirparticular difficulties. Subsequenttracking of student performance iselectronic, using the electroniccurriculum, email, written corre-spondence and follow-up inter-views.

RESULTS

The College of Medicine and Vet-erinary Medicine at the Universityof Edinburgh currently hasapproximately 1200 medicalstudents on the course (M:F ratio2:3), of whom 13 per cent are ofnon-white ethnicity. The PDC meton 45 occasions over the last6 years and interviewed 61students on 91 occasions duringthe period September 2002 toApril 2008. Of the 61 ‘strugglers’,39 were male (64%) and 22female (36%); 21 were of non-white ethnicity (34%, 15M:6F).Significantly, male gender andnon-white ethnicity wereover-represented among ‘strug-gling’ students, a finding thatothers have also found15

(Table 1). Yates’ v2: gender 11.8,p = 0.0006; ethnicity 23.8, p< 0.0001.

Most students referred to thePDC were interviewed on only oneor two occasions; 10 studentswere interviewed on three or moreoccasions because of continuingconcerns. The majority of ‘strug-gling’ students had experiencedproblems within the first 2 yearsof entry to medical school. Only15 (25%) of the 61 students hadsuccessfully negotiated the first2 years of medical schooluneventfully. Attendance prob-lems, delayed submission ofcourse work, ineffective learningstyles and study skills, and a lackof conscientiousness and motiva-tion were commonly associatedwith examination failures in thefirst 2 years of the course. Poorcommunication skills, psychiatricillness, and attitudinal andbehavioural problems were morecommon among students who hadcompleted the first 2 yearsuneventfully before starting tostruggle (Table 2).

Factors associated with‘struggling’ medical studentsBoth academic and non-academicfactors contribute to persistentunder-performance. Attributingthe major underlying problem toeither a specific personal or aprofessional difficulty is oftendifficult and invariably unhelpful.However, it is important to iden-tify the key factors at play foreach and every student referred tothe PDC (see Table 1). Careerambivalence and poor motivationcontribute significantly in thosestudents who continued to strug-gle, yet adverse life events anddifficulties such as parentalillness or the death of a closefamily member are not majorfactors. In contrast, psychiatricillness and personality andbehavioural problems play animportant role in the under-per-formance of both male and femalemedical students.

Academic factorsMany students experience diffi-culties in moving effectively fromsecondary school to universitybecause of maladaptive learningstyles and poor study skills.Common problems include timemanagement, prioritising aca-demic topics and adopting regularpatterns of study time or studyskills. Poor organisational skills,unhelpful attitudes to peers or theworking environment, and poorattendance all contribute to un-der-performance and examinationfailures.

Non-academic factorsPsychiatric illness, particularlyeating disorders, depression andpersonality problems, are commonand often coupled with poorself-esteem. Surprisingly, alcohol

Table 1. Factors associated with ‘struggling’ medical students attending the PDC

GenderNon-whiteethnicity

Poor courseattendance Depression

Personalityfactor

Motivationproblem

Socialfactor

Males (39) 15 20 9 10 6 7

Females (22) 6 11 12 5 5 5

The majority of‘struggling’students hadexperiencedproblems withinthe first twoyears of entry tomedical school

Many studentsexperiencedifficulties inmovingeffectively fromsecondaryschool touniversity


or drug misuse rarely featuredespite the high prevalence ofalcohol abuse among medicalstudents.16,17 Poor commitmentand motivation are closely linkedand often associated with ambiv-alence in career choice and areluctance to take decisive actionand change university course.Poor social skills resulting inisolation, alienation anddistancing from fellow studentscontribute to the erosion ofmotivation in some students.Ethnic and cultural difficultiessignificantly contribute to poorlydeveloped skills of self-awarenessand self-knowledge, whichundermine students’ ability torelate to fellow students. Manymental health problems antedatedadmission to medical school; inaddition to mood and eatingdisorders, individuals withpersonality problems, dyslexiaand high-functioning autism wereidentified that were either notapparent or undeclared atthe time of medical schoolapplication.

Intervention, remediation andoutcomeAfter the initial interview, aremedial plan was designedspecifically for the ‘struggling’student. The GP, studenthealth service and mental healthservices, including neuropsycho-logical assessment if indicated,were involved in the remedial planfor students with mental healthproblems. Final year studentsrequiring individualised teachingare attached to clinicians with aparticular interest and expertisein remedial teaching. Studentswith poor study or learning stylesare referred to the UniversityTeaching and Learning Assess-ment Centre for individual sup-port. Students with more complexproblems are reviewed andfollowed up by the PDC, and theacademic performance of allstudents is tracked throughoutthe remainder of their medicalcurriculum. All students attendingthe PDC for the first time aresubsequently invited to completea structured questionnaire to

assess their perception of theusefulness of the interview,discussion, guidance, advice andsupport offered.

Evidence of persistent,irremediable behaviouralproblems was identified in 10 ofthe 61 students who were‘struggling’ students (16%) and,when this became apparent,further intervention and supportby the PDC was discontinued.In total, seven of the 61 students(11%) were either excluded,withdrew from the course or failedto register with the GMC (seeTable 2). Three students werereferred by the year director tothe FTP Committee without theinvolvement of the PDC; allthree subsequently remained oncourse.

DISCUSSION

British medical schools attractover 60 000 applications, ofwhich around 7000 studentssuccessfully gain entry. Thoughacademically gifted, most areyoung and inexperienced andmany find the first 2 years ofmedical school difficult. It isperhaps surprising that moststudents proceed uneventfullythrough medical school, giventhe limitation of current selec-tion methods and the age atwhich students enter medicalschool. On average in the UK,approximately seven per cent ofmedical students fail tograduate as doctors; in contrast,dropout rates of 50 per cent arenot uncommon in someuniversity degree courses in theUK. This is a testimony to thededication, resourcefulness andadaptability of the great

Table 2. Outcomes in ‘struggling’ medical students attending the PDC

GenderMore than twoexam resits

Resit wholeyear

Fitness topractise Exclusion

Persistentproblem

Irremediablefactor

Males (39) 25 20 2 5 16 9

Females (22) 14 9 1 2 10 3

After the initialinterview, a

remedial planwas designed

specifically forthe ‘struggling’

student


majority of students who havechosen medicine as theircareer.

However, this does not comewithout a price; medical studentshave a higher prevalence ofstress-related problems than thegeneral population.11,18–20

Precipitating factors include aca-demic demands, perfectionism,competitiveness, and life anddeath issues.12 Medical studentswho struggle typically have evi-dence of maladaptive learningstyles, career ambivalence,adjustment disorders or majorpsychosocial problems. Researchhas previously identified social,cultural, personal and situationalpressures that may particularlyaffect students from certain eth-nic backgrounds and whichrequire specific proactive inter-vention.21 In addition, languagebarriers resulting from the use ofcolloquial, dialectic Englishmay hamper effectivecommunication in the practice ofmedicine.22

Identifying the ‘strugglers’ isrelatively easy. Identifying theunderlying combination of prob-lems, developing the appropriatesupport mechanisms and achiev-ing effective remediation are,however, much more challengingtasks.23 Support systems forstudents must be non-judgemen-tal and independent while rec-ognising the students’ primaryresponsibility for self-directedlearning to achieve competency.Other medical schools haveadopted less paternalistic modelsof pastoral care to support strug-gling students. In one medicalschool, the development of a‘pastoral pool’ of support staffensured that only the most com-mitted and skilled members of theteaching staff provided the addi-tional pastoral support.12 How-ever, the system relied on themotivation and insight ofstudents to self-refer, the uptakeby students was poor (only 3 percent of students self-referred) and

80 per cent of the pastoral workwas underwritten by just twomembers of staff.12 In our expe-rience, although students areprovided with details of supportresources available and areencouraged to self-refer to thePDC, none has done so; it seemsthat those students who are mostat risk are those least prepared toadmit a problem and seek adviceearly. In another medical school,daily ‘welfare clinics’ provided bya senior member of the teachingstaff were introduced, with thesupport of booking and receptionstaff, extra support tutors andcareers and counselling ser-vices.13 Students self-refer or arereferred by concerned members ofthe teaching staff because ofstudent attendance or perfor-mance problems, and up to 30students a week can be reviewed.No formal evaluation of theservice has been reported.

Given the high prevalence ofdepression and psychiatric illhealth in ‘strugglers’, theresources needed include rapidaccess to counselling services,psychiatric intervention andremedial teaching. However,although a caring medicalprofession should demonstrate itscommitment to nurturing the nextgeneration of doctors, theprofession also has responsibili-ties to future patients and needsto protect them from under-per-forming doctors. Although medi-cal schools are responsible forproducing doctors with the req-uisite skills, knowledge andattitudes to meet the needs of thegeneral public, if we are toopaternalistic we may underminethe professional development ofstudents, rendering them less ableto practise medicine indepen-dently and less able to takepersonal responsibility for theirown life-long learning.14

In those students who con-tinue to struggle due to irreme-diable behavioural problems andprofessional misconduct, the evi-

dence is clear and the outcomepredictable. Unprofessionalbehaviour in medical undergrad-uates is strongly associated withdisciplinary action among prac-tising clinicians, especiallyamong those students demon-strating poor reliability, irrespon-sibility, lack of self-improvement,initiative or motivation.24,25

When serious health or behavio-ural problems prove to beirremediable, decisive interven-tion by the FTP Committee isrequired. Currently the 27 medicalschools in the UK determine theirown procedures to identify stu-dents causing serious concern onconduct or health grounds, toensure that students who are arisk to patients are not allowed tograduate with a medical degree.The GMC has recognised thatconsistency and transparency indecision-making about studentfitness to practise are vital withinand between medical schools, andthat patient safety and publicprotection are paramount whenevaluating student fitness topractise.26,27

We cannot draw many conclu-sions about the efficacy or impactof intervention on outcomes in‘struggling’ medical students.Nevertheless, the adoption of asystematic approach has helpedreassure us that, when a studentwithdraws or is excluded from thecourse, we have made every effortto avert what might be a personaltragedy, and students haveexperienced a fair and supportivesystem. Long-term prospectivestudies are required to monitorconcerns about students raised inthe early years of medical train-ing, referral rates to the PDC andattrition rates from the profes-sion, to understand what worksbest to help struggling medicalstudents survive and prosper.

Solutions are not always eithereasy or obvious but our experi-ence suggests that medicalschools should have in placeseparate and independent

Supportsystems forstudents mustbe non-judgementalandindependent

Those studentswho are most atrisk are thoseleast preparedto admit aproblem


professional development and fit-ness-to-practise committees. Stu-dents should be monitored closelyduring the first 2 years, especiallytheir attendance and timely sub-mission of course work. Rapidaccess to skilled counselling,psychiatric services, learningsupport and remedial teaching isparamount.23,28 When the evi-dence suggests continuing andirremediable under-performanceor persistent career ambivalence,students should be advised andhelped to transfer to more appro-priate degree courses. Whenhealth or behavioural problemsare irremediable, the interventionof the fitness-to-practisecommittee is required if thesafety of patients or students is atrisk.

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Medical schoolsshould have

in placeseparate andindependentprofessionaldevelopmentand fitness-to-practise

committees


supporting struggling medical students

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