Select Committee on Education and Employment Appendices to the Minutes of Evidence


Memorandum from the British Medical Association (HE 131)


  The BMA welcomes the Education Subcommittee's examination of the expenditure, administration and policy of the Department for Education and Employment and the decision to examine issues relating to the retention of students in higher education. More than 12,000 medical students from the 24 UK medical schools choose to join the BMA, and the BMA believes that, given the length, structure and cost of studying medicine at undergraduate level and the direct link between medical students and the future workforce of the NHS, medical students are a unique component of the higher education student population. It is our view, therefore, that issues relating to the retention of medical students are sufficiently distinct to warrant separate consideration.

Retention Of Medical Students

  The generally accepted figure for the rate of attrition amongst medical students is in the region of 10 per cent[41] although some sources suggest figures of between 11.7 per cent and 14 per cent.[42] It is accepted that the majority of students who prematurely exit the course do so for non-academic reasons.[43] Many of the factors influencing the drop out rate will be shared by students of other disciplines although a large number will be unique to, or exacerbated by, the experience of studying medicine at undergraduate level.


Selection for Entry to Medical School

  Given that a degree in medicine entitles graduates to be provisionally registered by the GMC, selection for entry to medical school is taken to mean selection for entry to the medical profession[44] and prospective students are assumed to be making a career choice. For a myriad of reasons, entry to medical school is very competitive, the ratio of applications to acceptance being in the region of 10:1[45] and the required entry grades at A-level are universally high.

  Medical schools select students whom they feel will be academically able to cope with the course, although the overriding objective is to ensure that prospective students are equipped with the necessary skills and attributes for a career in medicine and are sufficiently committed to entering the profession. Prospective students are expected to have very positive reasons for wishing to study medicine and are generally encouraged to undertake work experience in hospitals or other settings in order to gain experience of clinical practice and thereby improve their chances of being selected for medical school. The undergraduate course is primarily viewed by prospective entrants as a route into the medical profession rather than simply an academic discipline. It is arguable that, in spite of efforts by medical schools to ensure that applicants are suited to medicine, a significant factor influencing students' decisions not to complete the course is the realisation that they are not suited to a career in medicine.


  The standard undergraduate medical course is five years long although for students who decide to undertake a research project leading to the award of a BSc, known as an intercalated degree, the length of time between starting medical school and finally graduating can be six or even seven years.

The Undergraduate Curriculum

  The Education Committee of the General Medical Council, which has responsibility for the quality of undergraduate medical education and its assessment[46], conducted an in-depth review of the undergraduate curriculum in 1993.[47] One of the principal recommendations was that the burden of factual information be substantially reduced and a core curriculum be identified in order to facilitate qualitative educational opportunities for medical students. Despite the progress that has been made towards this aim, undergraduate medicine remains an intensive, stressful and academically and emotionally demanding course. Medical students report that the commitments and expectations are often far greater than applicants may have expected and far greater than those on other degree courses with attendance at lectures, practicals and clinical sessions lasting from 9 am until 5 pm, the responsibility to participate in on-call rotas and academic years as long as 50 weeks in the latter stages of the course.[48]

Assessment and Learning Methods

  Many medical schools have introduced substantive measures to improve the academic experience of students with continuous assessment and the rearrangement of final examinations so that they are taken over a period of time rather than all at the end of the academic year, thus reducing periodic pressure. Medical student feedback in response to these changes has been largely positive although some have argued that this has simply spread the pressure throughout the year leading to examination fatigue.

  Most medical schools have made good progress in implementing the core tenets of the GMC's recommendations on the content of the course and learning methods. There has been a reduced emphasis on students being expected to learn factual information in favour of the development of the skills and attitudes needed to become a doctor. The traditional distinction between the pre-clinical and clinical aspects of the course has diminished with most medical students being introduced to clinical practice at a much earlier stage of the course than was previously the case.

The Learning Environment

  The changes to the structure of the curriculum and the introduction of medical students to clinical settings at an earlier stage of the course has resulted in medical students encountering radically different experiences than other students in higher education.

  The provision of education in a variety of settings by a range of tutors makes it difficult for students to develop relationships with their tutors and they may feel less well placed to seek support when faced with difficulties on the course.

  Clinical placements are often arranged at considerable distance from the medical student base. The distances to which students have been sent over the past five years have increased dramatically due to the increase in the number of medical students (students at London medical schools have reported being sent as far as Plymouth on clinical placements). Aside from the costs incurred in travelling such distances, the need to live in hospital accommodation for extended periods can be isolating and has an effect on personal relationships, paid work commitments, support networks and leisure activities.

  The availability of educational resources such as internet access and libraries can vary widely depending on the nature of the establishment to which students are sent. Students undertaking placements in general practice, in which setting an increasing amount of teaching is taking place, are largely unable to gain access to educational resources.

Stress Among Medical Students

  Medical schools have been encouraged to adopt a "problem based learning approach" to teaching in which facts are taught within the framework of real-life clinical scenarios. Medical students are, therefore, exposed to the often-stressful realities of medicine and will have far more emotionally demanding experiences than other undergraduate students. The incidence of stress among medical students has been well documented.[49] Medical students are acknowledged to be prone to suffer stress and psychological disturbance due to direct confrontation with disease, suffering and death, which are endemic in clinical practice and the constant evaluation of their performance by staff and patients. It has been suggested that stress management should be incorporated into the undergraduate course and support mechanisms be put in place, particularly in medical schools, to encourage students encountering emotional difficulties to seek help at an early stage[50].


  Medical students are largely entitled to the same levels of financial support from the government as students of other disciplines. Since the abolition of maintenance grants in 1998, which had a disproportionate effect on the debt burden placed upon medical students, student loans have constituted the main form of financial support. Student loans are currently available at a maximum of £4,480 for students in London and £3,635 for students outside London, but this amount is reduced by £500 during the final year of study. This reduction has a particularly disadvantageous effect on medical students who are often expected to be in attendance for up to 50 weeks during the final year of study, the most intensive part of the course. As a result, the average debt levels among final year medical students has risen by over 10per centsince 1998/99 with 22 per cent of final year students now owing in excess of £15,000.[51]

  The BMA's Medical Students Committee has made repeated representations to the government that medicine is a far longer and more expensive course but that no account is taken of this in the administration of the student loan system. The resulting effect is that medical students are incurring increasing levels of debt and hardship, which impacts on stress levels and ultimately academic performance.

  Medical students incur increased expenditure on books, equipment and ward clothing, and being in attendance for longer periods of the year, are unable to take up work during vacation periods and are more likely to work during term time to support themselves. Many medical schools have expressed concern at the increasing incidence of medical students taking up part time work during term time and the resulting detrimental effect that this has on students' ability to cope with the intensity of work on the course. The BMA's survey of medical students' finances has shown that an average of 19 per centof students have to work for up to 11.9 hours per week during term time due to insufficient financial support[52]. It is widely acknowledged that these figures, which are likely to influence academic failure, are likely to rise in future years.

  There has been a surge in the levels of debt incurred by medical students which is likely to continue as the effects of the changes to the levels of financial support take full effect on the medical student population. The BMA's annual medical students finance survey has revealed a 37 per cent increase in debt levels in first year students and an 81 per centincrease in debt levels among second year students.[53] Debt levels are exacerbated among students from lower-income backgrounds with medical students from semi-skilled and unskilled backgrounds owing 21 per cent more than those from professional or managerial backgrounds.[54] Although this is strictly beyond the remit of this inquiry, we feel that it is likely to have a sufficiently serious impact on medical student retention to warrant being brought to the attention of the committee.


  A number of factors influence continued quality in undergraduate medical education. The BMA's Medical Students Committee and Medical Academic Staff Committee have expressed concern that in the absence of sustained investment in the infrastructure required to support medical education, the increase in medical school places adopted by the government will be at the expense of quality in medical education.


  The most obvious resource required to guarantee the continued quality of undergraduate medical education is the availability of clinical academics as it is essential for students to feel that they are able to access academic and pastoral support throughout the course. There has been a 13 per cent drop in the number of clinical academics between 1993 and 1999, a significant proportion of which has taken place since 1997. The BMA has expressed repeated concern that without an appropriate ratio between tutors and students it will not be possible to guarantee continued high quality of teaching in medical education.

  Recent surveys have shown a worsening crisis in the recruitment and retention of clinical academics[55] which has an impact on both research and clinical teaching. This survey, was intended to act as a follow-up exercise to the findings of the 1997 Richards Report[56], which showed 56 chairs being vacant. The 1999 survey results showed a worsening of the situation, with at least 74 clinical Chairs unfilled. A number of factors have served to worsen the growing crisis in recruitment in academic medicine including the lack of training and career structure, terms of service, the difficulties encountered in fulfilling the tripartite responsibility for teaching, research and clinical work and the pressures of the Research Assessment Exercise.

Career Structure of Clinical Academics

  Due to the lack of a co-ordinated career path for potential academics, doctors considering a career in academic medicine face a minimum of 7 years clinical higher specialist training and a further 2-3 years of training in research. This successfully deters most potential academics and is compounded by the lack of certainty regarding career opportunities following training.

Terms of Service

  Clinical academics are employed by Universities, but they hold honorary contracts with NHS Trusts and are expected to fulfil a maximum of six clinical sessions for the NHS per week. The terms of service of clinical academics are, on the whole, less favourable than those of NHS doctors and serve as a disincentive to potential applicants. Clinical academics are denied the arrangements set in place for NHS doctors for study leave and removal expenses which, given that academics are more likely to move around more frequently than their NHS colleagues, can amount to a significant loss. Also, the lack of uniformity in the entitlement to undertake private practice serves as a further disincentive.

  Universities, being autonomous employers, do not recognise years of service at other universities for the purposes of continuity of service. This results in a loss of maternity benefits for female doctors who constitute more than half of current medical student intake, the underrepresentation of whom in clinical academia has been widely acknowledged.[57]

Teaching, Research and Clinical Responsibilities

  Clinical academics, who are employed under honorary consultant contracts, undertake fixed commitments in NHS Trusts and are expected to combine these with teaching and research functions. The continuing responsibility for the provision of quality patient care, in addition to teaching commitments, has compounded the challenges faced by academics. The lack of co-ordination between Universities and Trusts is having a negative effect on clinical academics who face increasing pressures from the requirements to participate in the Research Assessment Exercise, the Quality Assurance Exercise and clinical governance measures. The rising volume and intensity of workload, increasing medical student numbers and the inability to achieve comparable remuneration packages with their NHS colleagues serve to perpetuate the recruitment and retention crisis in academic medicine which has had a damaging effect on the support available to students.

The Research Assessment Exercise

  The Research Assessment Exercise and the five-year timescale to which research is carried out has encouraged universities to plan only in the short term. This has affected investment in core support and staff development as universities compete to attract experts who have succeeded in publishing work in the five-year period of the exercise.

  The BMA's Medical Academic Staff Committee has been concerned for some time about the replacement of clinical academic staff with non-clinical staff, largely as a consequence of the RAE. The financial pressures forcing universities to obtain high scores in the RAE has led to increased emphasis on research at the expense of teaching and service work. The culture of insecurity and instability within academic medicine has served to perpetuate the crisis in recruitment and retention which has impacted on medical students and the quality of teaching at undergraduate level.


  There are a diverse range of factors influencing the retention of undergraduate medical students in the UK. The structure and content of the undergraduate course and the clinical setting in which medical education is provided are largely unchangeable factors that a majority of students navigate their way around during the five or six years in which they are at medical school. There are, however, some measures which would substantially improve the medical student experience and curtail the levels of wastage at undergraduate level:

    — a commitment to ensure continued investment in the infrastructure and resources underpinning the provision of medical education, in particular, computing equipment and books;

    — provision of financial support which takes account of the particular needs of medical students;

    —the adoption of measures to alleviate the recruitment and retention problems in academic medicine.

British Medical Association

January 2001

41   3rd Report of the Medical Workforce Standing Advisory Committee 1997 Back

42   Parkhouse J. Intake, output and drop out in United Kingdom Medical Schools BMJ 1996; 313:137 Back

43   General Medical Council. Commentary on the second survey of medical education practices in UK Medical Schools 1992 Back

44   Council of Heads of Medical Schools' Guiding Principles for the Admission of Medical Students. Back

45   UCAS Figures: Applications and Acceptances Ratios 1999 Back

46   The Medical Act 1983 section 5. Back

47   Tomorrow's Doctors, Recommendations on Undergraduate Medical Training 1993 Back

48   The Insiders Guide to Medical Schools 2000/2001, BMJ Books Back

49   Supe AN. A study of stress in medical students at Seth G.S. Medical College. J Postgrad Med 1998;44:1-6;.Stewart SM, Betson C, Lam TH, Marshall IB, Lee PW, Wong CM. Predicting stress in first year medical students: a longitudinal study. Med Educ 1997;31:163-8 Back

50   Roache & Guthrie, Student BMJ Editorial July 2000 Back

51   Survey of Medical Students Finances 1999/2000 Back

52   Survey of Medical Students Finances 1999/2000. Back

53   Survey of Medical Students Finances 1999/2000. Back

54   Survey of Medical Students Finances 1999/2000. Back

55   Survey of Vacant Medical Chairs; Medical Academic Staff Committee and Council of Heads of Medical Schools September 1999. Back

56   Clinical Academic Careers: Report Of An Independent Taskforce July 1997 Back

57   Independent Review of Higher Education Pay and Conditions; 1999 Back

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