How do we safeguard and educate medical students to meet the challenges as a doctor in 2020 and beyond?

Chair:  Colin Elton (Consultant Colorectal Surgeon)

Expert Panel:

Professor Anthony Warrens (Dean of Education, Barts and the London School of Medicine and Dentistry) 

Professor Derek Alderson  (President of the Royal College of Surgeons of England)

Professor Dame Parveen Kumar (President of the Royal Medical Benevolent Fund)

Professor Bijendra Patel  (Professor of Surgery at Queen Mary University of London)

Dr Luke Evans MP  (MP for Hinckley and Bosworth.  Member of the Commons Health Select Committee)

Dr Clare Stephens (GP.  Co-Clinical Director of NCL London Cancer Alliance)

Daren Francis (Consultant Colorectal Surgeon, Royal Free Hospital NHS Trust)

Megan Annetts  (President, Barts and The London Students’ Association and 5th year Medical Student)

Shonnelly Novintan  (Chair of the United Hospitals Medgroup and 5th year Medical Student)

Gurdas Singh  (Co-chair of the BMA’s Medical Student Committee and  4th year Medical Student)

Introduction from Chair:

Good evening and welcome to the second debate of the Society for Healthcare Reform.  My name is Colin Elton and I will be your Chair for this evening’s Webinar and entertainment.

The background to this society is something which is within all of us here tonight, the desire to want to make a positive difference to our patients and the system in which we work.  Doctors care passionately about their profession and there is still a sense of ‘calling’, a vocation.  We deeply care about what we do and that has only been made fully aware and magnified by the current pandemic which has seen so many healthcare professionals put their lives on the line for what they care most about: patients and each other.  

Tonight, we are going to begin where all medical careers begin: in medical school.  The Covid-19 crisis has seen an army of final year medical students working in hospitals, some on the frontline and without being paid.  We are going to debate and discuss: “How Do We Safeguard And Educate Medical Students In 2020 and Beyond.”

Medical students are our future doctors and we all have a responsibility to nurture and educate them.  It has never been more difficult to enter medical school than now.  The medical school requirements are 3 AAA A-Level grades plus a UCAT (UK Clinical Aptitude Test) or a BMAT.  So it takes a great deal of desire, hard work and talent to get into medical school.  

23,710 students applied to study medicine for Sept 2020 (increase of 6% compared to last year); (18,500 applicants from UK (up 5%), 1,680 from EU (up 1%), 3,530 outside EU (up 10%))   

There are 11 or 12 applicants for each place, with 7,500 places available.  This is a very competitive profession.

300-400 students drop out each year out of the total medical student population in the UK, an equivalent to a whole year of students to any medical school.  Think what we could achieve with the vacancies in our current medical workforce if we reduced that significantly.  The cost to train a doctor is around £250,000.

Research from Royal Medical Benevolent Fund found that 60% of medical students have experienced financial pressures with 70% having experienced mental health pressures.  The average debt accrued by a medical student is greater than £100,000.

I’d like to first ask Gurdas Singh, what can be done to relieve the massive financial pressures in Medical School?

Gurdas Singh:  

We should bring the NHS bursary in line with the maintenance loan for the penultimate and final year in medical school.  Loans should not be based on parental financial income.  There needs to be an increase in funding. 

Receiving £450 a month is not enough. 

Brexit is an unwelcome environment to middle/lower class income and international students.  We should recommend the abolishment of charging international students to work here.  There is no guarantee of international students returning after the pandemic. 

Shonnelly Novintan: 

In the 5th year of medical school, the approximate living cost is £15,000. You are given £10,000 leaving a £5000 gap. 

There is a responsibility on students or their parents to make up the difference. 

Students can’t find the time for minimum 12 hour jobs alongside their education. The primary focus should be on studying, with 52 weeks of the year for education. 

Megan Annetts:

Only national students, not international students will receive NHS bursaries for their 5th and 6th year of study.  This grant is dependent on individual incomes. 

Regarding travel expenses, if you can’t cycle or walk to your placement, you have to use public transport.  Travel expenses build up.  I would like to see TfL become responsible for student travel fees.

Chair:

Regarding TfL, a letter was sent to the Mayor of London.  The Transport Team Manager replied: “Although TfL has secured this funding settlement from the Department for Transport (DfT), this only runs until September and the focus of this funding is on ensuring TfL can keep its services running and investment in alternative ways to travel, such as encouraging Londoners to walk and cycle. For the foreseeable future there will not be any significant increase in fares income, so it's vital that a longer-term funding solution is agreed. Government needs to provide TfL with stable, long-term funding either by restoring its operating grant or devolving more powers to London so it can pay for some of the services itself. 

In this context and until an agreement can be reached I'm afraid TfL and the Mayor will not be able to consider any further travel concessions.” 

With regard to the pandemic, the health of the nation is most paramount.  This has been seen by furloughing employees from so many industries and locking down everything but the NHS and essential workers.  Is this therefore a chance to improve the lives of our future doctors?

Luke Evans: 

All careers have been furloughed.

Is it right for non-medical tax payers to provide education for medicine when this should be the responsibility of universities.  

For hardship funding and a need of a wider access to universities, who should this income fall on?

Housing, rental and maintenance expenses are too expensive for the student loan to cover. Students have to work for the remaining amount needed alongside education.

Anthony Warrens: 

Is this sensible to make it their responsibility? Universities are under great financial pressure.  There is increasingly more work with less money available to put into education. 

We need to widen partition, giving time, energy and money to disadvantaged areas.  As many people as possible who have the potential to benefit  should have the option to have this education. 

How can we find a way to cut expenses and broaden representation? 

Gurdas Singh: 

Matt Hancock announced a policy to graduate students early.  Most were then unable to get jobs increasing their financial pressure.

Students already work during their medical degree, making them unique.

Taxes should contribute to education which would then result in saving future lives.

Chain restaurants are being supported but not medical students. 

Luke Evans: 

Small businesses are just as important.   Taxes support the greater community.

A doctor’s salary pays well, but how do we stop the burn out of doctors and medical students?

More support is needed to stop students leaving and changing professions. 

Shonnelly Novintan: 

There is a discrimination based on financial background.  Those without sufficient finances come with a disadvantage.  Support is needed for middle and lower class students.  Students are frightened, not knowing the size of the debt that they will have when they finish their studies.  Transport costs need to be lowered. 

Parveen Kumar: 

The workload for medical students and doctors is increasing, which plays on not just financial pressures but anxiety and mental health. 

There are supporting networks, mentors for clinical years when the pressure is high. 

We need to look after each other with different support networks. 

There is help from online counselling and the BMA.  DocHealth is a confidential service for doctors and can offer help to recover bursaries if students are running out of money. 

We need to access sixth forms to educate and relay realistic experiences so they know what to expect within the medical career. 

Gurdas Singh: 

There are 09:00-17:00 counselling sessions available.  However students are not able to access them during these times due to placements. 

The BMA offers 24/7 support for doctors and medical students 

There is a Practitioner health programme which is available to all throughout the country. 

However, we need this service to continue beyond the pandemic on a permanent basis, providing easy access to support medical students 

Anthony Warrens: 

The pressures on students are huge. 

All students will have pressures and problems but everyone can obtain support at university level.  We need to enable students to cope and provide this support service. 

Derek Alderson: 

In hospitals, medical students feel like outsiders and not part of ‘the team’.  They are not involved clinically as much as they should be.

The NHS is short of workforce with gaps in rotas at all levels right down to junior positions. 

The Final year medical students should have more flexibility, to have the option to choice what work to do rather than to be told. With help and guidance from ‘mentors’, they can be allowed to be more easily integrated into the workforce. 

Students are frightened with the debt they will end up with, more so with those from disadvantaged backgrounds. 

Anthony Warrens:

Senior doctors who mentor students find it hard to find the time to take on other roles.

We need to recruit to roles for those who specifically mentor students, possibly involving junior doctors and their peers who are close in age. 

We need the correct appropriate training, supporting and supporting activities. 

There needs to be a way of freeing up time for doctors to train and mentor. 

Luke Evans: 

Doctors and GPs make a choice to carve out their time as a duty and as a gesture of 

goodwill,  but there is nothing in return for the extra work. 

The industry needs time to breathe.  It’s unsafe for doctors to work overtime constantly. 

Daren Francis:

As a whole they are not seen as part of the family in the medical profession.  It shouldn’t be based on goodwill. 

How are 16 year olds expected to be aware of what it entails to care for others? 

This is not a charity.  This is a place of work. 

Looking at the courses across medical schools, there does not seem to be standardised systems.  One course is 5 years, another 6 years.  Some, within their first years are allowed on the wards, others only have lectures. 

Students are not aware of support systems, such as bursaries. 

We should aim to make first the two years standardised, to then become part of the workforce after year three.  Medical students should be paid for their integration.  This will help their financial pressures. 

Chair: 

A lot of people feel that a doctor is privileged.  There is a romantic view of the role.  Doctors don’t earn as much as people think.  We should concentrate on trying to retain students and doctors as much as possible. 

Anthony Warrens: 

There is still a core of wanting to help people.  There is a belief in the introduction of apprenticeships. Universities are moving in the direction towards the possibility of the final year being much more focused on preparation for practice. 

Bijendra Patel: 

We need to distribute educational needs. 

Machinery and smart intelligence are taking over a lot of the work. 

A large amounts of students drop out.  There is a lot of cost and time to train a doctor. 

Students don’t gain their full potential due to fast tracking. 

Chair: 

What can we do create a more cohesive team structure for students to feel more valued?

Clare Stephens:

Students need more recognition, to introduce academic apprenticeships.

WE should concentrate on getting students into the workforce by year 3, making them feel part and work together as a team.

This can allow them to become more equipped to manage day to day general care. We can provide a firm structure.  We should introduce apprenticeship programmes.

Chair: 

Formal paid apprenticeships like an internship, can this be replicated and financed appropriately? 

Anthony Warrens: 

There are a lot of suggestions and ideas to develop, but where will the money come from?

There is the Government degree apprenticeship scheme. 

The Government expects you to put at least 50% in as the paid role.  We shouldn’t try to double up the amount of years to qualify, but getting it done within an aim of, say, seven years. 

Clare Stephens: 

Could we consider applying students to HCA roles across hospitals? 

These roles would not be full time, allowing them to gain experience, earn money and also learn from their education. 

Megan Annetts: 

Being able to work alongside your studies would help students. 

The offer is attractive to both learning and working, shown by the current pandemic, of having so many students stepping forward to help within hospitals during the coronavirus pandemic. 

This makes students feel useful, feeling part of a group and developing their skills and preparedness for work. 

Derek Alderson:

There is so much dissatisfaction from students performing the mundane job roles.  The burden of administrative and repetitive tasks do not benefit students educationally, making little direct benefit to the patients. 

Parveen Kumar:

Worldwide, we are 100,000 healthcare trainers short. So why don’t we standardise the first year, then from the second year they can split off into more focused courses, making it quicker and cheaper to qualify. 

Is this the time for medical education and government to come together to think of an effective plan?

Luke Evans: 

I would love to have taken part in different roles, to understand a feeling of what the student might want to do.  Being a paid apprentice is one of the best ways to gain recognition. 

There needs to be a firm system, accountability, a way of learning on the job. 

They need to learn to manage risks, knowing what course of action to take for patients. 

Shonnelly Novintan: 

Why should we have apprenticeships? 

Placements shy away from students. COVID has proven that students are willing to do more, learning more than in normal placements. 

So they can develop their practical skills under pressure, training them emotionally. 

Placements need to change, students are able, and they need to be given more responsibility and involvement. 

Luke Evans:

Students are given less roles and practical experience because of fear of patient’s safety. How can placements protect students but also get them more involved with working conditions?  Training for students now is different to what it used to be. 

Derek Alderson: 

It is sad that students are not able to do basic procedures for learning the role of being a doctor.  They are withheld from learning these vital skills.  Students end up being busy doing other non-beneficial roles.  How can members of Parliament help? 

Anthony Warrens: 

Students greatly enjoy practical experiences.   This became clear in the work they undertook during the Covid-19 pandemic.   

We still need the basic medical education that will serve doctors well for the rest of their careers.  However, students nowadays don’t get the practical training and experience that students used to have. 

Chair:

So it seems that we have a consensus that creating apprenticeships or paid internships could improve the education, wellbeing and finances of medical students.  Could we set up a Focus Group outside this forum to take this forward

The GMC are considering adding a further examination at the end of medical school, on top of existing exams.  

Gurdas Singh: 

Having an additional exam is not beneficial.  This will increase mental health issues and pressures.  It could lead to a higher dropout rate.  There seems to be no need for the extra exam. 

Derek Alderson: 

Where is the evidence of poor working doctors? Where is the reasoning behind the creation of an extra examination?  Examinations are not broken so why do they need to be fixed?

Anthony Warrens: 

The extra exam is a political decision. 

Luke Evans: 

With the nature of medicine, things happen.  Mistakes occur and that will not change on the basis of adding more examinations for students.

Chair (Final Remarks)

I’d like to thank all the expert panellists who have been absolutely brilliant and provided you with 

two hours of excellent debate, discussion and bringing together of ideas for positive change.  Thank you to the large audience out there who registered, sat by their screens and got involved.  The majority of you are medical students.  I hope that you felt that we covered those topics that are most important to you and I hope that this debate tonight is not the last of these ideas and plans.  We will be following up all the points raised and a summary of this debate will be available online and hopefully as a published article.  

I ask of you to get involved in your medical school and help those who want to keep improving the profession that we hold so dear.  We will continue to do that for you as well and please feel free to email me directly with any questions or thoughts.