Clinical competencies achievement profiles - a way forward for students with disabilities?

Abstract

The UK Veterinary Medicine Disability Project (DIVERSE) has recently produced a report (‘Time to Take Stock: Disability and Professional Competence’)1 on issues of disability relating to veterinary undergraduate education and practice. Although this is placed in the veterinary context, much of the material is relevant to medicine, dentistry and the allied health professions. Particularly useful are a variety of practical examples of potential problems and how they might be resolved. Despite its focus on UK legislation, it contains a great deal of value for the world community. In the United Kingdom, the General Medical Council (GMC) has statutory obligations with regard to medical education. It has indicated that it will leave it to individual medical schools to determine whether particular candidates should be admitted. The GMC outlines, but does not specify in detail, the outcomes required for graduation, and can withdraw accreditation from a medical programme as a whole. On qualification from a UK medical school, students are registered automatically for practice without further intervention by the GMC. Admission policies for medical schools in the United Kingdom are therefore more significant than in some other countries. The GMC has stated that: for the GMC the issue is not the health or disability status of the medical student but the ability to achieve all the outcomes in Tomorrow's Doctors… when a medical school awards a primary medical qualification it is confirming to us that the graduate has completed in full a curriculum that meets our guidance and the requirements of the Medical Act.2 Here the key phrases are ‘completed in full’ and ‘achieved all the outcomes’. This suggests clearly that there is little leeway for individual medical schools to accommodate disability. Since the entry into UK law of the Disability Discrimination Acts of 1995 and 2005, and the Special Educational Needs and Disability Act 2001, discrimination against the disabled is illegal. There is therefore an unresolved tension between GMC guidance and the law, which is likely to be explored through the courts rather than by professional decision-making at a national level. This situation is not to anyone's advantage. Individual medical schools are exposed to the possibility of expensive legal action and there is a lack of detailed guidance as to what the GMC considers the essential components of a medical course. There is no question that qualified doctors who become disabled remain fit to practise in areas unaffected by their disability; but the GMC's requirement that students achieve all the outcomes in full means that it regards a complete course as an essential part of medical training. Such a view would close the profession to many people with disabilities. It is also believed widely that the presence of students with disabilities would be beneficial to classmates in enriching their experience of disability, and that doctors with disabilities may be particularly valuable in certain areas of practice after graduation.3 These dilemmas might be resolved by ‘limited licensing’, which limits the practice of graduating medical students with disabilities to certain disciplines. However, this would not take adequate account of technological advances which might extend the capabilities of doctors currently regarded as disabled. An alternative way forward might be the concept of a ‘clinical competencies achievement profile’ (assuming that ‘knowledge’ and ‘attitudes’ should be developed equally in all medical graduates). If the GMC defined ‘day 1 essential competencies’, as does the Royal College of Veterinary Surgeons, it would be possible for medical schools to certify which competencies had been achieved by each medical graduate. Normally, students should achieve all the defined competencies. However, a student with a registered disability could be permitted to graduate by recording those competencies she or he has achieved to date. A potential employer would be able to specify the required clinical competencies for each post, and select for interview in a way in accord with current legislation. This would send a strongly inclusive message to the community as a whole. It would allow, for instance, a severely visually impaired student to explore which competencies they could achieve. It might possibly require the Medical Act to be amended, but the GMC should lead this process rather than allowing individual medical schools to be caught between the Scylla of disability legislation and the Charybdis of a requirement to deliver a ‘full’ course.