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Medicine in the 21st century - Standards for the delivery of undergraduate medical education

September 2005

• Foreword
• Introduction
• Admission and selection
• Student finance
• Medical education
• Student welfare and support
• The professional environment
• Foundation programmes

Foreword
Medicine is a continually evolving subject and innovations in technology and the advancement of evidence bases in disease management and prevention necessitate a modern approach to delivering healthcare.

Medical students are poised to embrace the changes that the 21st century has brought to and will continue to bring to medicine, and are keen to be at the forefront of change through active communication with those providing it. Medicine in the 21st century sends out a clear message; medical students have expectations for their medical education, which they believe are essential for them to emerge confident and knowledgeable doctors, able to care for their patients in the modern health system. This document has been widely consulted upon to ensure that these expectations are realistic and achievable for both those providing medical education and those receiving it. By communicating their aspirations, students aim to increase the dialogue between staff and students in all medical schools.

Medical students are aware of the hard work ahead of them as they enter medical school and prepare for the financial, social and educational challenges that face them. However, from the application stage to graduation they must feel confident that medical school and government policies are fair, equitable and encourage diversity, particularly in their selection procedures. Teaching methods used must be tried and tested, and delivered by those competent to teach. Support must be available should a student suffer personal or financial difficulties. Approaching qualification, the future foundation doctors must feel confident that they are prepared to enter the profession, and that their medical education has fully prepared them for the challenging years ahead.

Much of this document focuses on basic principles of equality and justice and covers issues such as the financial cost of accommodation and the treatment of students with disabilities. It sets out clear challenges which require action from a number of bodies and the BMA is committed to achieving these. Whilst the qualities of a good doctor can be enshrined in the medical degree, time must also be invested in the social and personal development of the student doctor if medical education is to meet the objectives set out in the General Medical Council’s document, Tomorrows Doctors.

The standards herein are considered by the British Medical Association to be the gold standard for medical schools in the UK. We hope that through this document, and by increasing dialogue with students, we can achieve an enhanced medical education to reflect the changes in medicine.

James Johnson, Chairman of BMA Council
Leigh Bissett, Chairman, BMA Medical Students Committee

Introduction
At the very core of good medical education is improvement: change toward practices that best fit the present climate. The 2005 review of Medicine in the
21st century is underpinned by our desire to be a part of the continual process of review and enhancement. Medicine in the 21st century 2005 is the medical students’ response to Tomorrow’s doctors and Principles of Good Medical Education and Training, produced by the General Medical Council (GMC). We broadly welcome these documents but believe their scope needs widening to reflect the policy of the British Medical Association’s Medical Students Committee.

The time spent at medical school should equip students with the knowledge, skills, attitudes and behaviours expected of doctors, in a safe and enjoyable learning environment that is free from discrimination. Medicine in the 21st century considers the financial, welfare and pedagogical aspects of medical education. We have also addressed the need for medical schools to impart advice about career progression and the new foundation programmes.

Our intended audience includes all those involved in the delivery of medical education at both the undergraduate and early foundation programme period, and those involved with the welfare, financial or other support of medical students. The heads of medical schools in particular are invited to incorporate the content of this document into the systems at their own schools. Medical students can reference this document locally as a source of what we believe to be a fair set of national standards for their educational environment.

It is an exciting time for undergraduate medicine, and the passions, beliefs and enthusiasm of those who will embark on a satisfying and challenging career are well placed to positively influence and advance the undergraduate learning environment.

Medical Students Committee
BMA House, London 2005

1. Admission and selection
Competition for places at medical school is high. The large number of applicants demands a system of selection that is duly probing, robust and fair. The process should be structured, transparent, evidence-based and regularly reviewed to ensure that suitable and capable candidates are admitted.

1.1 Process
1.1.1 All candidates should have an equal opportunity to show their suitability for the undergraduate course and entry to the medical profession. Merit alone should be the criterion for selection.

1.1.2 Because the requirements of the course go beyond scientific and academic aptitude, selection procedures should be designed to ensure that due attention is also paid to non-academic attributes that are essential for a career in medicine. These selection procedures should be routinely assessed.

1.1.3 Although the educational background of the applicant must be used as selection criteria, predicted qualification grades should not be used solely as a means of academic assessment and alternatives should be investigated. We concur with a recent review of admissions to higher education1 and believe that medical schools should be looking to implement a post-qualification assessment of applicants.

Once an evidence base exists, other methods of assessment, such as biomedical admissions tests2 should be used as one of the indicators of ability and discern between suitable and unsuitable candidates.

1.1.4 Medical students should possess the appropriate attitudes and behaviours expected of professionals in training. Given that medical students now have access to patients at the earliest stage in the undergraduate course, applicants should not be admitted without being interviewed.

1.1.5 Interviews should be structured, and consistently fair and probing between different candidates and different interviewers. The presence of a university welfare officer for interviews involving applicants with disabilities is mandatory3. A senior medical student should form part of the interviewing panel. All members of the interviewing panels should be properly trained in interviewing techniques and have equal opportunity training.

1.1.6 In accordance with the Data Protection Act 19994 and Freedom of Information Act 2005, notes made contemporaneously at interview should be made available to applicants upon request, regardless of their success in obtaining an offer. We encourage medical schools to offer these notes together with positive feedback.

1.1.7 The right of applicants to choose a medical school best suited to them should be aided by the provision of statistics such as drop-out rates, entry qualification requirements and the employment outcomes of previous cohorts.

1.1.8 Medical schools must provide details of the structure and requirements of the course. Prospectuses and course information should contain details of any proposed changes to the structure, content or financial costs of the course that could affect an applicant’s choice of medical schools. Applicants should be informed of any proposed changes to clinical placement options, especially if this involves changing the distance from the medical school or base hospitals.

1.1.9 Successful applicants should be made aware of the responsibilities and duties of both doctors and medical students, as stipulated by the GMC. Every successful applicant should be directed to the GMC document Good Medical Practice6 at www.gmc-uk.org, before his or her admission.

1.1.10 Medical schools must notify successful applicants of occupational health assessment and Criminal Records Bureau requirements associated with the course before admission, preferably in the prospectus.

1.1.11 Medical students must not bear the cost of fees for additional procedures in the application process required by some medical schools.

1.2 Disability and discrimination
1.2.1 The process of selecting medical students must be transparent and comply with good practice as outlined by the Commission for Racial Equality, the Equal Opportunities Commission, the Disability Rights Commission and all accompanying legislation.

1.2.2 Schools should explicitly affirm their commitment to equal opportunities. They must ensure that staff and students involved in the selection process are properly trained to ensure that no discrimination occurs, particularly on the grounds of:
• age
• blood-borne virus status
• disability
• ethnicity
• gender
• number of dependants
• religion
• sexual orientation
• socioeconomic origin.

1.2.3 In light of the findings of the Stephen Lawrence Inquiry7, medical schools should audit their selection procedures to ensure that there is no intentional discrimination against certain groups; the results of these audits should be freely available.

1.2.4 Successful candidates who are known or found to be carriers of HIV or other blood-borne virus should be made aware of how their status might affect their experience of the clinical elements of the course and any potential limitations on their future career by the medical school.

1.2.5 Medical students should be made aware that their obligations to the patient in regard to their health and conduct is the same as other health professionals.

1.3 Widening access
1.3.1 We recognise the positive experiences and attributes that mature students, graduates, and those students with children can bring to both medical schools and to the medical profession. The introduction of graduate courses and the increasing number of such students on conventional medical courses should be welcomed. These candidates should be encouraged and supported.

1.3.2 We support attempts to encourage applicants to medicine from a wider socioeconomic base and believe that all medical schools should develop mentoring and outreach programmes with local schools and sixth form colleges to encourage suitable applicants that may not traditionally consider a career in medicine. Medical students should be willing participants in such schemes.

1.4 Student contracts and the Medical School Charter
1.4.1 Whilst any measure that leads to increased protection for medical students is to be welcomed, we believe that any ‘student agreements’ that impose duties on students should also impose recognisable duties on the medical school offering the agreements.

1.4.2 We strongly believe that if these agreements or contracts are to be recognised legally they should be drawn up by Council Heads of Medical Schools (CHMS) and the GMC in negotiation with the BMA. The National Medical School Charter should replace individual student contracts.

1.4.3 Any mutually agreed charter should be universally implemented and quality assured through a central mechanism.
1.4.4 Quality assurance of the implementation of the medical school charter should be carried out by the GMC, preferably through the Quality Assurance of Basic Medical Education (QABME) mechanism.

2. Student finance
Undergraduate medical courses in the UK vary from four to six years in length and most have unusually long term times, making it difficult for medical students earn a reasonable income from part-time jobs during holiday periods. Medical students finances have worsened year on year and with the Higher Education Act 20048 heralding the introduction of top-up fees, widening participation and equality of access will be even more difficult to achieve. Groups that are likely to be deterred from applying include mature students, graduates9 and those from lower socioeconomic backgrounds.

We applaud the government’s effort to widen access in higher education through the introduction of access agreements. However, the domination
of medicine by socioeconomic groups 1 and 210 must be addressed, and equality of access should remain the driving force for the introduction of ‘top- up fees’. It is well understood that the huge debt burden placed upon students in the UK deters those from poorer backgrounds from applying to higher education11. Any failure of the government to support the good work already done to widen access to medicine will result in a poor situation becoming worse.

2.1 UK domiciled students
2.1.1 NHS bursaries should be extended to all years of the medical course due to the financial strain being placed upon medical students12. Over 90 per cent of medical students do go on to work for the NHS. As the monopoly employer of newly qualified doctors in the UK it is essential that the government recognises the commitment of medical students to the NHS after qualification.

2.1.2 The bursary concessions introduced on four-year courses are a significant improvement to the funding arrangement of the limited number of medical students who have access to these courses. Due to the increasing number of graduate students on five-year courses it is felt that equality of access to such funding should be extended to all graduate students.

2.1.3 The introduction of top-up fees threatens the good work undertaken to attract mature and graduate students into medicine and, therefore, the government should extend tuition fee support bursary schemes to these groups regardless of the length of course they undertake to maintain that interest and ability to study medicine. Graduates should be able to defer top up tuition fees on all medical courses.

2.1.4 The government should recognise that at age 18 students are financially independent of their parents, not after age 25 as it currently stands. It is strongly recommended that the government reassesses the tie to parental income when considering loan applications.

2.1.5 The government should extend the loan amount available to all students in light of top up fees to ensure that students are not forced to opt for high interest commercial loans. Failure to do so would detract further from the widening participation agenda being pursued by the government. Longer term times and the lack of time available to get a job in vacations strengthen the argument for the ability to take out higher government loans if undertaking a medical degree.

2.2 European Union (EU) and international (non-EU) students
2.2.1 Due to the governing statutes of the EU, all UK medical schools should have open and fair funding for European students.

2.2.2 British students must be afforded similar arrangements in other European states including funding arrangements and hardship funds that are available to home students in the country of study.

2.2.3 Current arrangements make it difficult for international students to open UK bank accounts: this process should be made easier for students entering the UK.

2.2.4 Preferential banking rates should be extended to international students.

2.3 University funding
2.3.1 Universities and medical schools should be held to account for the money they spend. Monies given to any institution by the public through taxation or in the form of tuition fees should be accounted for annually, as with any other large organisation.

2.3.2 Medical schools should publish accounts on an annual basis. This should include articulation of the cost per medical student of the medical degree.

2.3.3 The extra money available to universities in the form of top-up fees must be used
to widen access to medicine, improve the quality of teaching and resources, as well as filling existing funding gaps within higher education. Extra funding should not be used solely for university research. The government should ensure that the money raised is hypothecated to a range of goals.

2.3.4 Undergraduate medical course fees and any supplementary costs imposed by the medical school must be explicitly stated. There should be no hidden course costs.

2.3.5 With the exception of international students, medical schools should limit the level of course fees payable by all graduate medical students, to the standard rate paid by those students undertaking their first degree.

2.4 Hardship funds
2.4.1 Open and transparent access to hardship funds should be available to all students within the university or medical school. Medical students must have equal access to hardship funds.

2.4.2 Adequate levels of hardship funds should be available to students in universities which is proportionate to the population of the university and to the specific needs of their student population. Responsibility of such funds extends to targeting of government money. Hardship money must be used at the individual university level.

2.5 Devolved nations
2.5.1 Medical schools in Scotland should not be disadvantaged by the rise in top-up fees in England and money available for research and teaching should be equal to that of their English counterparts. This money should come directly from the Scottish Executive through public taxation.

2.5.2 Medical schools in Wales should not be disadvantaged by the rise in top-up fees in England and money available for research and teaching should be equal to that of their English counterparts. This money should come directly from the Welsh Assembly through public taxation.

2.5.3 UK domiciled students should not be charged inflated tuition fees in Scotland, Wales or Northern Ireland. They should be treated as any other European student when making application or attending a university in the devolved nations.

3. Medical education
The undergraduate course provided by medical schools should be dynamic and reflect changes in the medical profession and incorporate developments in the learning and research model. Medical students should be one of the driving forces behind any modifications and should have active representation on curriculum development committees. All medical students should understand that they have a responsibility to fully participate in feedback and evaluation processes. Medical schools should collaborate with one another to share successful developments in undergraduate medical education.

3.1 The medical curriculum
3.1.1 We welcome the drive in medical schools for dynamic and relevant learning outcomes which are regularly updated in line with current research and evidence. We note that the GMC does not prescribe the exact content of undergraduate courses. This facilitates the great diversity in the approaches taken by medical schools to educate tomorrow’s doctors and is of great value.

3.1.2 Medical schools should ensure that their students have an understanding of the structure of the NHS, the role of risk management and the use of clinical audit.
The curriculum should also cover the professional aspects of being a doctor in depth including: the duties of a doctor, contractual obligations, law relevant to
the workplace, banding and monitoring.

3.1.3 We believe that the teaching of basic science, such as anatomy, pharmacology and pathology provides an essential background for working as a doctor. Students receiving reduced teaching of the sciences may be disadvantaged in postgraduate exams indicating a possible detriment to the medical profession.

3.1.4 The curriculum should focus on helping medical students become effective doctors who understand patients’ health belief systems. As such, students should be informed about how religious and cultural differences may affect patients’ perceptions of westernised medical practices, particularly in relation to medical treatment, death and dying.

3.1.5 The core curriculum should incorporate cultural awareness and communication skills to enable students to identify with the patients they serve.

3.1.6 There are core practical skills required to fulfil the responsibilities of a foundation doctor. Medical students should be trained and assessed in the practical skills that will enable them to undertake these responsibilities. We welcome the establishment of clinical skill laboratories or equivalent facilities which are properly staffed, resourced and accessible to all students. Medical students should make full use of such facilities.

3.1.7 Medical schools should fully prepare students to tackle the transition from medical student to doctor successfully. This is especially important in the final years of
the course.

3.1.8 Basic life support training (BLS) should be provided prior to students embarking upon clinical attachments and advanced life support training (ALS) prior to graduation. The training should include a formal assessment to enable accreditation to levels approved by the Resuscitation Council (UK)13.

3.1.9 Efficiency in core clinical skills is essential for patient safety and student confidence. Skills such as competency in history taking and examination should be fostered before clinical contact is introduced in the early stages of the curriculum.

3.1.10 Basic understanding of the principles, side effects and interactions between evidence-based complementary therapies and conventional medicine should be integrated into the core curriculum in response to greater NHS involvement and increasing public popularity. Students should gain awareness that complementary and alternative medicines are used by some patients.

3.1.11 Important social issues, such as homelessness and care of the elderly should form part of the undergraduate curriculum.

3.1.12 Students should have the opportunity to learn about factors influencing health and healthcare in today’s global society, including political, socioeconomic, cultural and religious factors.

3.1.13 Students should have the option to study humanities and languages during their time at medical school.

3.1.14 During the medical academic year all medical students should have access to up-to-date learning resources, information technology and email facilities with appropriate training and technical support. IT and internet services should have 24 hour access and there should be access to libraries at all times during the academic year with opening hours suited to students at all stages of the course.

3.1.15 Medical libraries should contain current editions of all course texts in adequate numbers to reflect the size of the student population that would benefit from making use of them.

3.1.16 Student selected components (SSCs) provide opportunities to pursue a wide range of academic interests including non-medical topics. Medical students should be encouraged to design their own SSCs, providing minimum standards are met and sufficient supervision can be provided. In this way SSCs can further promote self-directed learning.

3.1.17 The use of innovative assessment methods such as posters, videos, art work and presentations should be promoted as an acceptable form of evaluation of students competencies.

3.1.18 SSCs based abroad should be encouraged and medical schools should provide help to students wishing to arrange such ventures. Medical students wishing to apply to established exchange programmes should be encouraged and medical schools should provide the educational support required for medical students involved in such schemes.

3.1.19 The medical curriculum should reflect the increasing international nature of medicine and include topics such as tropical medicine.

3.1.20 Where an increase in students occur teaching resources should be increased proportionally to the number of students to prevent compromise in quality.

3.1.21 In response to the increase in ethical dilemmas faced by doctors with advances in medicine, the curriculum should include high quality ethics teaching.

3.1.22 Medical schools should support flexibility and support transfer requests from students, should personal circumstances demand it.

3.2 Intercalated, bachelors, masters and higher degrees in medicine
3.2.1 Medical schools should ensure that intercalated degrees are available to students
as an opportunity to develop their learning skills, as well as providing early exposure to research. Such degrees should be optional and available to all those with a satisfactory academic record.

3.2.2 Intercalated degree options should include a range of medical and non-medical subjects. Efforts should be made to widen the range of science, language and arts subjects offered to expand the experience of the medical profession.

3.2.3 Students should be permitted to undertake intercalated degrees at other institutions.

3.2.4 Intercalating students should have access to introductory courses in statistics and ethical practice in research. Students should therefore have access to advisors in statistics and ethics outside the department hosting their project.

3.2.5 The decision to intercalate or not is often a difficult one. Information on the options available should be outlined in undergraduate prospectuses. Medical students should also be informed as early as possible at key stages of the undergraduate course of the option to intercalate, thus allowing time to make the necessary preparations.

3.2.6 We recognise and welcome the expansion of MB PhD programmes as an exciting development in medical education, and urge all medical schools to provide an
MB PhD programme. The quality of these degrees should meet PhD standards, particularly in regards to support and supervision.

3.2.7 Medical students wishing to leave a medical course prior to completion, or having to leave a medical course for any reason apart from expulsion from their university, should be awarded an exit qualification (eg. BSc) if three or more years have been completed with good academic record. Students should have the opportunity to complete a degree such as a BA or BSc degree. We believe this should be with honours where sufficient time has been spent on the course.

3.3 Teaching
3.3.1 Teaching members of staff both within medical school and at clinical placements should be trained in teaching and assessment techniques and subject to assessments of the quality of their teaching. Those involved in teaching should be made aware of any changes to the course, as well as being informed about the course structure, learning methods and modes of assessment.

3.3.2 Doctors have an active role in the education of medical students. Therefore, all medical educators, including practising physicians and non-academics, should receive core training in educational methods.

3.3.3 The teaching of teaching skills to students should also be a core component of the course.

3.3.4 We strongly support peer-led educational initiatives and urge medical schools to provide a means for such ventures to take place in addition to staff teaching.

3.3.5 There should normally be a maximum of six students at a bedside teaching session; the quality and quantity of teaching can thereby be optimised and respect for the privacy of patients maintained.

3.4 Assessment procedures and feedback
3.4.1 Medical schools should establish mechanisms that promote a consistently high standard of teaching and learning. Medical students should be aware of their obligation to participate fully in assessment and feedback procedures. Teaching members of staff should be responsible for seeking their own feedback and this process should be monitored. Medical students should be informed of the action taken as a result of feedback, thereby closing the feedback loop.

3.4.2 Medical students should be given regular updates on their academic and clinical progress throughout the course. Regular assessment is essential for providing students with the opportunity to improve performance and enables medical schools to identify students encountering difficulties so they can be adequately supported.

3.4.3 Medical schools should specify a maximum period for the marking of examinations and the announcement of results. Students should be aware of what this timeframe is.

3.4.4 Examination papers should, where possible, be double and blind-marked. Medical schools must ensure that marking systems are clear and consistent, and should set in place mechanisms by which medical students can appeal against assessment or examination grades awarded.

3.4.5 Medical students should have access to an appeals procedure in response to both academic failure and the moderation of assessment or examination grades.

3.4.6 Appeals procedures should be clearly publicised in medical schools. This should be transparent and equally accessible to all students. Appellate bodies should be properly constituted and should offer students the opportunity for representation.

3.4.7 Opportunities must exist for medical students to have formative assessment. Meaningful feedback on students’ performance in both formative and summative assessments is vital for the facilitation of reflective practice and future learning, and should be provided by medical schools.

3.4.8 Medical schools should ensure all medical students are aware of the procedures in place for dealing with academic failure.

3.4.9 Medical schools should provide both academic and pastoral support for students after exam failure, and publicise this support to all candidates.

3.4.10 Procedures for awarding individual prizes and bursaries within medical schools should be fair and transparent.

3.4.11 Measures that ensure rigorous quality assurance to maintain educational standards are supported. The General Medical Council’s Quality Assurance of Basic Medical Education provides evidence that the required standards are being met whilst maintaining diversity of assessment.

3.4.12 There is no evidence that medical schools or types of curricula and assessment produce different standards of medical graduates. Concerns are held about the implications of a national exit examination and the effects this may have on the delivery and diversity of undergraduate medical programmes.

3.5 Communication
3.5.1 Medical students must receive adequate notice of the date, location and time of their examinations and assessments. This notice should be in a form that is readily accessible to all students, including those on peripheral attachments.

3.5.2 Medical students have a responsibility to ensure that their school has their current contact details on file to aid communication between the medical school and the
individual student.

3.5.3 Medical schools must ensure that all students have easy access to school messages and information, and that systems are in place to relay this information to students on peripheral attachments when they are unable to reach the medical school office itself.

4. Student welfare and support
In addition to support services that are available to all students, medical schools should provide specific facilities for medical students. This is because medical students often require additional or specialised support due to the specific and additional stresses, career choices, workload and financial difficulties that they face. Occupational health facilities should be easily accessible and there should be adequate services provided for GP registration, with clear guidance on safety and security for themselves and patients before working in the clinical setting.

More than three-quarters of medical students believe that drugs or alcohol have a negative impact on medical student culture14 and we should ensure that medical school is not an environment that fosters unhealthy or unprofessional habits. Support should be available for those who experience problems with alcohol or other substance misuse.

Like any other organisation, medical schools must ensure equality for all its students. Routine reviews of the services and learning opportunities available would enable medical schools to create an environment in which students, regardless of their background or beliefs, are able to thrive. Gone are the days when ‘teaching by humiliation’ was the standard and common practice in medical education and students must be able to speak out freely and anonymously against inappropriate behaviour. Any form of discrimination is unacceptable and medical schools should do all they can to ensure those who bully or harass are brought to account; be they students, teachers, doctors or other health professionals. Students should be equipped with the knowledge and skills to implement these procedures.

Medical schools have a responsibility to provide their students with careers advice that enables them to make choices both for the first few years following graduation and for later in their career.

4.1 Welfare services for medical students
4.1.1 Medical students encountering stress, emotional or academic difficulties during the course should be encouraged to seek help, and directed to the appropriate facilities and agencies within the medical school or university.

4.1.2 Medical students should be allocated tutors to provide continuous academic, career and pastoral support throughout the undergraduate curriculum.

4.1.3 Medical students should have access to separate academic and pastoral tutors. Many medical students do not feel comfortable speaking about their personal problems with people who have control over their academic progress.

4.1.4 Tutors and medical students should meet frequently, forming a more open relationship where the student’s progress, perceptions and ongoing concerns can
be discussed.

4.1.5 Medical students should learn about the principles of stress management and the importance of maintaining both a healthy body and mind to cope with stressful situations.

4.1.6 Medical schools should ensure that their students have easy access to an appropriate and confidential counselling service, which can provide objective support and advice, without fear of any impairment to their future medical career.

4.1.7 Medical schools should ensure that independent sources of support and advice that are available to medical students are made known to their populations. The BMA provides a free and confidential stress counselling service that is open to all medical student members 08459 200169 (24 hours). All calls are charged at local rates.

4.1.8 Medical schools should support the development of student mentoring schemes to allow new entrants to build formal relationships with students at more advanced stages of the course.

4.1.9 Medical students should have the opportunity to suspend their studies in certain circumstances, for example pregnancy, bereavement, and family difficulties.

4.1.10 Medical schools should ensure there is adequate provision of prayer facilities for students of all faiths.

4.1.11 Medical schools should ensure there are sufficient affordable crèche facilities available for medical students with dependent children as there should be for all NHS staff, according to the needs of each group.

4.1.12 Medical schools should provide additional support and advice to those students that become pregnant, whose partners become pregnant or those who have children/dependants.

4.2 Drug and alcohol misuse
4.2.1 Medical schools should have clear policies and guidelines on the misuse of drugs and alcohol. These policies should focus upon providing help, such as treatment and counselling, and support to students involved in substance abuse, while ensuring that there are no risks to patient safety.

4.2.2 Medical students should be made aware of the consequences of drug and alcohol abuse, and the systems in place to support students with such difficulties.

4.2.3 Medical schools have the right to refuse to graduate any student who misuses alcohol or other drugs. However, medical schools should strive to counsel and support such students, hopefully enabling them to graduate in the future.

4.3 Equal opportunities
4.3.1 Medical schools should explicitly affirm their commitment to equal opportunities in the provision of services and learning opportunities to students regardless of:
• age
• blood-borne virus status
• disability
• ethnicity
• gender
• number of dependants
• religion
• sexual orientation
• socioeconomic origin.

4.3.2 Medical schools should monitor the provision of services and learning opportunities open to students and take appropriate action if it appears that their equal opportunity policies are not fully effective.

4.3.3 Medical schools should ensure that appropriate measures are in place to enable students with disabilities, including those suffering from dyslexia, to complete the course. When supporting students with individual needs, medical schools should show flexibility and innovation when determining the process by which curriculum outcomes/learning objectives are met.

4.3.4 Medical schools should aim to show respect for the observance of religious festivals and holidays. Medical students should not be penalised for participation in religious or cultural events.

4.3.5 Medical students should discuss with their medical school any ethical or religious beliefs that might require adjustment to their training. Medical schools should aim to accommodate all students, so long as they still meet the requirements for graduation and provisional registration with the GMC.

4.3.6 Medical students should not be prohibited from wearing religious garments that do not interfere in patient care. Innovation from medical schools and teaching hospitals to allow students to observe their religious freedom, such as ensuring the availability of specially designed scrubs to cover or form religious head-dress in theatre, is encouraged and should be developed further.

4.4 Harassment, bullying and discrimination
4.4.1 In compliance with the relevant legislation, medical schools should provide learning environments in which all forms of harassment, bullying and discrimination are deemed unacceptable. Staff and students should be made aware of this policy and mechanisms should be set in place to ensure that victims of bullying and harassment are able to seek help.

4.4.2 Medical students are under an obligation to challenge unacceptable behaviour whenever they encounter it. In doing so, medical students should be supported by their peers and by the medical school.

4.4.3 Medical schools should ensure that all complaints about harassment, bullying or discriminatory behaviour are taken seriously and handled sensitively and discreetly. Anonymity should be preserved if requested by the medical student. Individuals should be identified within the medical school environment to whom complaints can be made in confidence.

4.4.4 Procedures should be in place to ensure that complaints are investigated swiftly, thoroughly and fairly by an independent panel which provides feedback on its decision(s). Details of procedures for investigations of complaints should be published and widely available in the medical school.

4.5 Health and safety
4.5.1 Medical schools and medical students should jointly take responsibility for students’ occupational health and safety. This should include the provision of clear guidance on safety and security for students undertaking clinical attachments.

4.5.2 Students should only be tested for HIV or Hepatitis C prior to undertaking exposure prone procedures in line with all other health professionals.

4.5.3 Medical schools should ensure that all prospective medical students are aware of the need for hepatitis B immunisation, the time required to complete the course of vaccinations, and the future career consequences of failure to develop full immunity to hepatitis B.

4.5.4 Students who test positive for blood-borne viruses, including hepatitis B, hepatitis C and HIV, or who do not gain immunity to hepatitis B should be allowed to continue to study medicine on the proviso that they do not carry out procedures that pose a risk to patients. Carrying a blood-borne virus does not prevent someone from practising medicine in certain specialities, nor should it prevent them from studying it.

4.5.5 Medical students should be given specific training on current health and safety procedures and infection control procedures, including hand washing and sharps disposal policy, prior to embarking upon any clinical attachments.

4.5.6 Medical students should be made aware of the systems in place to report accidents on clinical placements and in medical schools. Medical students have a responsibility to report accidents.

4.5.7 Medical students should have access to the same occupational health facilities and support as staff in locations at which they are undertaking attachments. This includes access to post-exposure HIV prophylaxis.

4.5.8 Medical students should not take part in procedures they feel untrained to carry out or procedures where they feel they pose a risk to the patient.

4.6 Careers advice and general clinical training
4.6.1 Medical schools should provide formal advice on the structure and content of postgraduate medical education, including any changes and the differences between various parts of the UK.

4.6.2 Medical students should be advised and well informed on the criteria that applications for foundation programmes and subsequent run-through grade are based upon.

4.6.3 All medical students should have access to careers advice throughout the course of their degree. This should include specific careers guidance for medical students who wish to work abroad, join the armed forces, or have decided not to pursue a career in medicine after qualification.

4.6.4 Medical schools should link medical students with a suitable junior doctor mentor, to provide individual support and careers advice.

4.6.5 The composition of the medical workforce is gradually changing, and opportunities for flexible training are now available. We welcome changes that accommodate the flexible needs of those with work-life balances, health requirements or disability15. In light of this, medical schools should make students aware of the range of possibilities available both locally and nationally for flexible postgraduate training.

5. The professional environment
As doctors in training we have a responsibility, not just to the professional bodies, but to other staff and patients, to ensure that our actions and behaviour are of the standard expected of someone within the clinical setting. Many of the rights and responsibilities of the doctor are extended to the student and as such their position is one of privilege. Medical schools should prepare students to work in a professional environment and ensure that they understand their obligations and requirements to practise as the doctors of tomorrow.

UK medical students are privileged to have access to some of the highest quality clinical teaching in the world. However, the medical undergraduate course is both arduous and challenging, placing great demands upon students. They therefore require appropriate support, including adequate learning facilities and accommodation when on placement.

Medical students also have the opportunity to spend time away from their medical school for part of their studies. Many take this opportunity to travel abroad, both to developed and developing countries and this provides a very different perspective on healthcare and global health issues. Some remain in the UK.

Medical schools are required to award degrees only to those students who are fit to practise medicine. As such, disciplinary procedures for medical students are different from those for other students, as professionalism and fitness to practise, not just academic ability, should be considered for graduation. Where the behaviour or actions of a student bring into question their fitness to practise, disciplinary procedures may be invoked.

5.1 The medical student
5.1.1 Medical students need to be aware of the privileged position in which they are able to learn the skills and competencies required in being a doctor. They must meet the standards the GMC has set, as set out in Duties of a Doctor16 and other key GMC documents17. Students should be directed to these on the GMC website,www.gmc-uk.org before they begin the medical undergraduate course and should be familiar with this documentation.

5.1.2 From the earliest stages of the undergraduate course, medical students should understand the importance of confidentiality, a core tenet of the professional relationship between patients and doctors, and the need to respect patient confidentiality at all times.

5.1.3 Medical students must have up-to-date knowledge of the legal situation in relation to matters of confidentiality, for example, the Data Protection Act18. Medical students should understand the legal circumstances under which they practise, and should have medical indemnity insurance.

5.1.4 Medical students must not examine patients, take histories, or undertake any procedure without the prior informed consent of the patient. A badge should be worn whilst in the hospital and the student is responsible for ensuring that consent has been obtained. Students should retain the right to refuse to commence or continue an examination, history or procedure, without fear of harassment, if it is not clear that informed consent has been obtained.

5.1.5 Medical students must in no circumstances initiate, alter, or stop the investigation and treatment of a patient.

5.1.6 As responsible members of the clinical team, medical students must refuse to participate in procedures for which they feel they have not been adequately trained, without fear of harassment. Refusal to perform these procedures is not a disciplinary matter: medical schools should identify the areas in which further training is required.

5.1.7 Medical students, like any member of the clinical team, have not only a moral, but also a professional, obligation to bring to light harmful practices of other members of the clinical team. Before being attached to a clinical team, medical students should be aware of the procedures in place to deal with such circumstances, including anonymised whistle-blowing mechanisms.

5.1.8 As members of the clinical team, medical students should be subject to the same procedures as NHS staff. Medical students should recognise that they have a responsibility to report to the occupational health department any health problems that may affect the care of patients. Any student suffering with a serious communicable disease19 should be given the option of remaining on a suitably adapted course. Adherence to the limitations placed on the student may be a condition of continuation on the course. Failure to comply with limitations may provide grounds for dismissal from medical school.

5.2 The medical school
5.2.1 Medical schools should provide access to high quality facilities and resources required to achieve the academic and professional goals that are set.

5.2.2 The medical school and other relevant organisations should provide an environment that is safe and secure and does not tolerate harassment or discrimination of
any kind.

5.2.3 Medical schools should prepare students for the many professional and ethical issues that they will face in the clinical setting, including legal and ethical dilemmas.

5.2.4 Medical students should be made aware of the conditions under which they are allowed to be present in clinical teaching sessions. This may include dress codes and adherence to codes of practice, particularly with respect to consent and confidentiality. Such codes of conduct should be made explicit.

5.2.5 Medical schools should ensure that the NHS trusts in which students are placed have made patients aware of the possible presence of medical students in consultations or teaching sessions.

5.2.6 Medical students should be issued with clear written guidance on confidentiality and how the principle applies within the context of education.

5.2.7 Medical schools should ensure that their students are fit to practise and do not pose a risk to patients. Medical schools have the right to question students’ behaviour and initiate internal or external disciplinary procedures if they consider this to be necessary.

5.3 Clinical attachments
5.3.1 Medical students should be reimbursed for expenses incurred in travelling to and from clinical attachments.

5.3.2 Medical students on attachment should not feel that their education is limited by where they are placed. As such the educational facilities and resources that are essential for the undergraduate course should be made available to students on all clinical attachments. This should include:
• adequate access to library facilities
• recreational and exercise facilities
• word-processing and email facilities
• access to the internet and university network/intranet
• access to photocopying and overhead projector transparencies.

5.3.3 Medical schools should take into account students social circumstances when allocating peripheral attachments. Students with special circumstances, such as dependants, should be able to request placements nearer to home.

5.3.4 Medical students should have free access to accommodation in clinical placements that are over 45 minutes travel by public transport from their main teaching base. The standard of accommodation provided for medical students should meet with HIMOR standards20, and the standards set out for junior doctors in Health Service Circular 2000/03621.

5.3.5 Medical schools are partly responsible for the safety of medical students while on attachments in the community and in hospitals. Organisers of attachments should acknowledge that the safety of students is an important consideration and take positive steps to ensure potential risks are minimised. Medical schools must be able to assure safe travel to student accommodation at all hours of the day, every day, throughout the year. The accommodation should be both safe and secure.

5.3.6 Medical students should have access to secure storage facilities while on clinical attachments.

5.3.7 Students should be able to make use of the same car parking facilities as other staff. This should be affordable, easily accessible and meet demand. Car parks should be well lit and fitted with CCTV.

5.3.8 Trusts should ensure that security passes are issued and inspected and there should be adequate security at clinical placement sites.

5.3.9 Senior medical students on attachments should be provided with bleeps so that they can be readily contactable by nursing and junior medical staff to maximise learning opportunities.

5.4 Electives
5.4.1 Students travelling overseas, particularly those going to developing countries, should not undertake greater responsibility than that for which they have been trained. Students should not attempt to diagnose, prescribe or administer treatment without close clinical supervision.

5.4.2 Occupational health advice plays a key role in electives. The occupational health of medical students on elective remains the responsibility of their medical schools.

5.4.3 Medical students should, with the aid of their medical school, undertake risk assessments prior to electives. The emphasis of these assessments should not be upon restriction of destinations but upon management of risk.

5.4.4 Risk assessment should include assessment of violence, political instability, natural disasters and serious communicable diseases.

5.4.5 Management of risk should include training, teaching, up-to-date information provision (to include World Health Organisation sources), equipment provision, immunisation and prophylaxis.

5.4.6 Medical students going to areas of high endemicity of HIV should be issued with clear guidance on procedures to be avoided and be given adequate advice on safety measures when taking blood and the disposal of sharps.

5.4.7 Medical students should be provided with latex gloves, medikits and starter-packs for HIV post-exposure prophylaxis prior to embarking upon their electives where required.

5.4.8 Medical schools should issue guidance in procedures to be followed on exposure to infection including procedures for notification both at the overseas hospital and at medical school.

5.4.9 Medical students should be able to contact a member of the medical school 24 hours a day, seven days a week who is able to deal with concerns and difficulties of students on elective. They should be sufficiently resourced to cope with various circumstances that students may find themselves in.

5.5 Fitness to practice
5.5.1 University and/or medical school disciplinary procedures should be readily available to all students.

5.5.2 Students should be made aware of the circumstances in which the procedures may be invoked and what behaviour constitutes gross misconduct.

5.5.3 Medical schools should make students fully aware of the practices, in relation to both assignments and examinations, that constitute cheating and/or plagiarism.

5.5.4 Internal disciplinary procedures must be independent, include an appeals mechanism and students should be entitled to full representation.

5.5.5 We believe the proposed National Medical School Charter22 should be adopted at all medical schools. This charter sets out the rights and responsibilities of medical schools and medical students.

6. Foundation programmes
The publication of Unfinished Business in 2002 highlighted the need for reform to improve medical training23. Modernising Medical Careers outlined radical changes to the way that postgraduate medical training is delivered in an attempt to address the identified shortfalls. The resulting foundation programme is defined as the bridge between undergraduate medical education and specialist/general practice training.

The planned reforms are structured around seven pillars: trainee centred, competency assessed, service based, quality assured, flexible, coached, and structured and streamlined24. If successfully implemented, the foundation programmes will be able to provide graduates with the opportunity to become fully competent, well-trained and motivated doctors. There should be effective communication of changes to the postgraduate education to students so they are aware of how their career will progress and are able to plan ahead.

6.1 Applications
6.1.1 We welcome the suggestion that entry to programmes is through a UK-wide competitive selection process25. This would facilitate greater geographical flexibility for candidates considering the increased time period of foundation programmes compared to the PRHO year.

6.1.2 In the absence of a national matching scheme, regional matching could occur. No barriers should exist to candidates applying from outside the matching scheme area.

6.1.3 Foundation schools should support students in the local area while maintaining opportunities for entry of those outside the foundation school catchment area.

6.1.4 Students should be able to apply to other foundation schools in the country, but their home school must retain responsibility for the qualifying student. In the event that a student’s application is not accepted elsewhere, the home school must find a placement for them in local foundation schools.

6.1.5 Application procedures should be evidence-based and transparent; to quote Modernising Medical Careers: the next steps document, ‘there must be explicit, published entry criteria and selection processes for each Programme’26.

6.1.6 Selection for foundation positions should not be based on purely academic grounds.

6.1.7 Specific regard must be given to those with dependents when applying to foundation programmes.

6.2 F1 year
6.2.1 The F1 year should develop core competencies of communication, assessment of patients and practising evidence-based medicine. This would include at least three months of general surgery and three months of general medicine.

6.2.2 The development of basic F1 programmes in specialties such as primary care, paediatric, psychiatry etc should concentrate on core competencies to ensure candidates are on a level playing field when applying to specialist training.

Editors
Jonathan Beavers, University of Edinburgh
Leigh Bissett, University of East Anglia
David Burke, University of Nottingham
Emily Rigby, University of Bristol

Editorial Assistance: Paul Gadsby, Sally Girgis and Jennifer Innes.

The editors were members of the British Medical Association’s Medical Student’s Committee (MSC) during the 2004-2005 session. The MSC comprises of elected representatives from all UK medical schools. The committee campaigns on all issues affecting medical students. Get more information about its activities here