Research Proposal (What factors affect the experiences of assessment and
achievement at medical school from the perspective of UK-originating BME
undergraduate medical students?) and Critical Commentary (Risk factors at medical
school for subsequent professional misconduct: multicentre retrospective casecontrol study)
Critical Commentary
Risk factors at medical school for subsequent professional misconduct:
multicentre retrospective case-control study1
The question to be addressed is clearly outlined in the first line of the abstract,
allowing the reader to establish quickly what the issue is: are there risk factors in a
doctor’s time at medical school that are associated with subsequent professional
misconduct?
At this point it is worth identifying the target audience, the kind of reader the text is
addressing. It is clearly aimed at the scientific community, and with a leaning towards
those engaged in quantitative empirical research. It is not an easy paper to
understand and it required at least three readings in order to be able to grasp fully
what the authors were driving at. This presents a difficulty when it comes to making
an assessment of the believability of the findings, particularly when having to judge
the transparency of the research process and the sufficiency of the information
provided.
Background and rationale for the study
From the abstract the paper develops the objective and its importance: public
interest issues and, separately, public concern regarding doctors who fail to maintain
professional standards. There is a slight danger of being accused of sensationalism in
the initial justification for the study when it is noted that the authors highlight the
public awareness of and concern for high profile cases such as Shipman and the
Bristol paediatric cardiac surgery case. None of the doctors involved in either
example have histories which bear any relevance to the area under study and indeed
Shipman himself (had he been anonymously selected) would have been a “control”
rather than a “case”.
The study authors note that prior to 2010 there had been no mechanism to track and
evaluate doctors’ performance following graduation whereas there was at least
speculation that some of those doctors who experienced professional difficulties may
have had problems at medical school which might have acted as pointers as to the
course of future events. There had, at the time, been no published research in the UK
which had attempted to link students’ course records with subsequent proceedings
for professional misconduct. As such this was a motivational driver for the research
and also meant that this could be seen as entirely original work.
The study
The fundamental design was a retrospective matched case-control study looking at a
sample of doctors who had graduated from UK medical schools 1958 – 1997 and had
a proven finding of serious professional misconduct in GMC proceedings 1999 –
2004.
These were the “cases”, and both they and the “controls” were selected by the GMC’s
research and development advisory board and all were fully anonymised before
being sent to the study authors for data entry and analysis, thus ensuring total
confidentiality and data protection compliance.
The cases were matched using systematic sampling from matching graduation
cohorts in the ratio 1 case to 4 matches. The controls were doctors who had
graduated from the same university in the same year and were fully registered,
currently practising, and had never been under investigation. There was some
difficulty in providing exact control matches because of variations in time spent at
medical school due to academic delay, intercalated years and transfers-in from other
medical schools. 90 of the controls showed a mismatch of up to two years with their
“case”.
The number of cases examined was fairly small at 59, with 236 controls, but the
criteria for inclusion as part of the research sample were specific and consequently
any argument that potential participants had been overlooked ought normally to be
approached with caution.
One might perhaps question the fact that only 8 medical schools were included (out
of a potential 33). The authors make clear that these eight were chosen because they
“retained student records indefinitely and expressed an interest in participating in the
research”. It does imply however that other medical schools could have been
included.
For all cases “all available data” were extracted and entered onto a customised
database. However this “all” is qualified to mean “sociodemographic factors” and
course progress and, as far as can be seen or inferred from the paper
“sociodemographic factors” is further qualified only to mean estimating social class
from the parental occupation of the father using three independent reviewers and
the registrar general’s scheme3, and later condensing the five classes therein into two
– higher or lower. This may not be the correct interpretation but it is certainly how it
reads.
The authors concede being unable to investigate the possible effects of ethnicity as
“these data were not available”. This is somewhat surprising given that race and
ethnicity have been at the forefront of the British national debate certainly over the
period of time addressed in this study, and especially as the authors note that “ethnic
minority status is known to influence performance at medical school and future
attainment”4,5,6, and merits further study.
This is a glaring gap and inconsistency in the rationale. It is not enough to say that
findings linked to sociodemographic factors are “sensitive” whilst at the same time
overlooking arguably the single most relevant and contentious sociodemographic
factor relating to professional and career progression and, even prior to that, entry
itself into a UK medical school.
Having identified the sociodemographic characteristics to be used (Sex (M/F),
domicile (UK/ overseas), age (< or > 21) estimated social class (higher/ lower),
negative comments on UCCA/ UCAS reference (relevant comments/ no relevant
comments), the paper appears to be weak in describing the methodology.
This statement “all available data were entered onto a customised database” has
already been highlighted but it sits in contrast to the description of data analysis the
authors state “was done firstly as a univariate analysis, then a multivariate analysis
initially including all explanatory variables then consecutively dropping the least
significant one until all included variables were significant at p<0.05”. Despite this the
paper does not identify what other explanatory variables were initially considered (in
other words whether there were more identified in the “all available data” statement).
Results
The broad findings were that cases were more likely to be young men from lower
social class groups. The presence or absence of negative comments on the medical
school reference was largely irrelevant. Cases were more likely to have struggled
through the course, particularly in the early (preclinical) years. Cases were less likely
to have achieved consultant status or be on the general practice register.
Interpretation
There are a number of ways one could look at the results, most of which require the
filling in of gaps in knowledge left unanswered by the study.
It is silent on whether allowance has been made for student intake proportions from
a time when male students vastly outnumbered female.
The authors are right to point out that the findings in relation to social class
grouping may be a reflection of social influences operating at the time, up to nearly
50 years ago. It has been identified as a “sensitive” finding, although it is the least
significant statistically of the explanatory variables in the study. Although the authors
offer no explanation for the finding, it is not entirely untoward to link it to the social
class make-up of a medical school intake at the time when most of the cases were
medical students.
The authors concede two important points which go to the limitation of their
findings: the first is that social class is difficult to define and subject to frequent reevaluation, and the second is that in the context of this study, estimated social class
may have been acting as a proxy for some other influence which has not been
explicitly examined, for example race or ethnicity.
The authors, in this regard, allude (but only go that far) to the phenomenon of
stereotype threat, and also mention negative role-modelling, workplace bullying and
harassment particularly to doctors from ethnic minorities.
Gender-based differences in personality and consulting styles have previously been
suggested as a contributory reason for an increase in complaints against male
doctors7 8, as might social biases and the assumption that men were more likely to be
aggressive or commit sexual misconduct. The authors have rightly negated this
consideration by focussing only on proven misconduct, relying in doing so on the
expected robustness of the GMC’s enquiry and investigative operation.
The authors conclude that further work is needed with larger cohorts and a longer
timespan. They also raise the possibility of investigating harassment or bullying, but
it ought to be said that this is an area which the paper did not set out to look into
and only raised as a potential explanation for substandard performance in the
workplace, after graduation, and therefore not something which could be called a
medical school risk factor.
Impression
In terms of the research process itself, a degree of transparency had to be sacrificed
in order to preserve anonymity and data protection compliance.
As to believability, there is a difficulty in insufficient information being sought for
analysis and presented in results. It is difficult to come away with the impression that
anything of significance has been added to the general discourse of what was
already known in this area. On that particular point, the authors remind the reader
that a tentative link has already been made in American studies of unprofessional
behaviour at medical school and subsequent professional misconduct (in and of
itself, unsurprising) but no comparable evidence exists from the UK. It would have
been a valid exercise to look at this phenomenon from a UK perspective but it was
overlooked, possibly in the quest for originality.
However, what the authors attempted to write up as their headline finding, that of
the link between social class and professional misconduct, turned out to be the least
sturdy of their findings, for which they could offer no explanation beyond suggesting
that it may not mean anything in and of itself and may in fact signify something else
which was not looked at.
To its credit the paper did not make any claim at the outset that such risk factors as it
sought to find actually existed. It did not set out to convince any sceptics, though it
did not need to as the results were already largely known or could easily be deduced
from other information sources.
In conclusion the major drawback in reading this paper was the feeling that it did not
go far enough. It lacked ambition. What it highlighted as areas for further research
should have been the leading questions upon which the research was founded.
1. Yates J, James D. Risk factors at medical school for subsequent professional
misconduct: multicentre retrospective case-control study. BMJ. 2010;340:c2040.
doi:10.1136/bmj.c2040
2. Garfield E. The history and meaning of the Journal Impact Factor. J Am Med Assoc.
2006;295(1):2006-2009.
3. Rose D. Official social classifications in the UK. In: University of Surrey; 1995.
4. Yates J, James D. Predicting the “strugglers”: a case-control study of students at
Nottingham University Medical School. Bmj. 2006;332(7548):1009-1013.
doi:10.1136/bmj.38730.678310.63
5. Yates J, James D. Risk factors for poor performance on the undergraduate medical
course: Cohort study at Nottingham University. Med Educ. 2007;41(1):65-73.
doi:10.1111/j.1365-2929.2006.02648.x
6. Liddell MJ, Koritsas S. Effect of medical students’ ethnicity on their attitudes
towards consultation skills and final year examination performance. Med Educ.
2004;38(2):187-198. doi:10.1111/j.1365-2923.2004.01753.x
7. Firth-Cozens J. Effects of gender on performance in medicine. Bmj.
2008;336(7647):731-732.
8. Kinnersley, P; Edwards A. Complaints Against Doctors. Bmj. 2008;336:841-842.
doi:10.1136/bmj.3.5876.407-b