Every year, a small number of undergraduate students at the University of Nottingham Medical School fail to make satisfactory progress on the course. Some have problems at all stages, others have sporadic difficulties, and a proportion fail to graduate at all, either leaving voluntarily or having their course terminated. In an earlier study we found that 10-15% of the annual intake were affected to some degree . There is often a combination of causative factors, including difficulty in coping with the academic workload, health problems, and social issues such as not settling at university or having adverse personal or family circumstances. Some students may have applied for medicine as a result of family pressures rather than personal choice and may therefore lack motivation, or have unrealistic expectations.
Failure to thrive on the course, or 'struggling' in the case of the worst-affected, is a cause for concern. Firstly it is a concern for the student, who may suffer considerable personal distress as a result of exam failures or poor health, with possible financial hardship if their course has to be extended, and perhaps stigma or shame after total failure. Secondly there is an increased load on the Faculty and the university, with a disproportionate amount of time spent on meeting and advising the struggling students, setting additional exams, and in some cases dealing with Fitness to Practise hearings or Appeals against termination. Thirdly, there is a societal cost attached to the student who drops out after receiving public funding. There is evidence that some poor students may become poor doctors, subsequently failing in professional life [2–4]. Strenuous attempts are therefore made to support and advise students in difficulty.
The admissions process at Nottingham has been developed and refined over the years in order to select those whom we feel have the best chances of becoming good doctors and to de-select those who are felt to be unsuitable candidates. To this end, there is a 4-part process: screening of UCAS forms for a minimum academic standard; an online, computer-marked questionnaire to explore the candidate's extra-curricular activities and aptitudes; screening of the personal statement by experienced Faculty staff, to check for factors such as work experience; and finally a semi-structured interview which enquires about motivation, empathy, and communication skills. Despite these measures, problems still occur, ranging from the students who decide within weeks that they do not want to study medicine after all, to those who battle on through an extended course of six, seven or occasionally eight years.
All medical students at Nottingham have the benefit of a comprehensive pastoral care system. They each have a personal tutor who heads a 'Medical Family' of two to four students from each year group. The student will have a 'parent' within the Medical Family, a student in the year above them, to provide close peer support. The tutor and student meet formally at pre-arranged intervals to monitor overall progress and discuss any problems in confidence, and the student may also contact the tutor at other times for informal discussions. Further advice and support can be sought from the Senior Tutors, or Associate Dean for Medical Education. Those who fail exams will be seen at the Academic Progress Committee for support, or can be referred, or self-refer, to the Clinical Sub-Deans for personal mentoring. Students can also be directed towards sources such as the Occupational Health Service or University Counselling Service, and of course their GP or other external agencies. They are regularly reminded to seek help earlier rather than later, to submit extenuating circumstances forms in the event of acute events which might affect exam performance, and that they must take responsibility for their own conduct and performance [5, 6]. However, failure to engage with these supportive mechanisms still occurs and may well contribute to failure to thrive. Reluctance to seek help from medical professionals has been attributed to concerns about confidentiality and the potential longer-term effects on career and reputation [7–10]. Students who lack insight into their own shortcomings may decline to accept feedback and help [11–13] and have the potential to become irremediable doctors .
Although academic achievement is known to predict later performance [15–17] and is the easiest to monitor, many other factors are important. Medical students are known to suffer high rates of stress and depression, especially at the start of the course [18, 19], and our own research has suggested a high incidence of depressive-type illness in struggling students . Another significant aspect of underperformance is unprofessional behaviour, which is increasingly important for both medical students and practising doctors [6, 21]. Although difficult to measure, there is evidence that lapses in behaviour as a student may be associated with poorer performance [22, 23] and with deficiencies in later professional life . A low threshold for detecting unprofessional behaviour, and clear strategies for dealing with it, are recommended [24, 25]. At Nottingham we have recently introduced a 'Concerns Form' which may be used by students or staff to report unsatisfactory behaviour (see Additional file 1).
It is obviously better for all concerned if difficulties can be identified as early as possible. This would provide the best chance for remedial help, whether that be advice on study skills, time out for recovery and recuperation after illness, or even gently steering a student towards a more appropriate non-clinical career. (The Nottingham undergraduate course includes the award of an integrated BMedSci degree at the end of the third year. This enables students to leave at this point and move into research or other areas of study if they find, after the first six months of the full-time clinical course, that they are not suited to medicine. In some circumstances they can transfer to a BSc degree in Medical Sciences during the third year, avoiding the start of the clinical course entirely).
With this in mind, we decided to conduct a detailed review of the course progress files of students who had started the course between 2000 and 2004 inclusive and were known to have experienced any difficulties. We recorded any factors that might have a bearing on student's progress - academic, health, or social issues, and incidents of adverse attitude or behaviour - to see if there was any reliable combination during the first two years of study which might constitute a toolkit to identify those most at risk.
Ethical approval was granted by the University of Nottingham Research Ethics Committee, ref B/11/2009.