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STATE OF PLAY: A REPORT ON THE SUPPORT AVAILABLE TO MEDICAL STUDENTS WITH SPECIFIC LEARNING DIFFICULTIES

AUTHOR: Duncan Shrewsbury, PGDip Med Ed, Adv Dip Clin Hyp., BMed Sc.

INSTITUTION: Medical School, College of Medical and Dental Sciences, The

University of Birmingham, Edgbaston, Birmingham, B15 2TT.

EMAIL: dhs570@bham.ac.uk / d.shrewsbury@doctors.org.uk

MOBILE: 07875499845

A report to the Higher Education Academy Subject Centre

October 2010

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State of Play: Support available to medical students with specific learning difficulties

INTRODUCTION

Specific learning difficulties (SpLD) are characterised by lifelong deficits in:

attention; concentration; reasoning; understanding; memory; or coordination.

An exact definition is difficult to pin down due to the varied nature of the

symptamology and deficits associated with SpLD. This umbrella term

encompasses conditions such as Dyslexia, Dyscalculia, Dyspraxia, Asperger’s

ABSTRACT: Medical schools in the United Kingdom (UK) implement

“reasonable adjustments” to some aspects of their course delivery and

assessment for students with Specific Learning Difficulties (SpLD). This is a

requirement within UK law, but creates some difficult challenges in medical

education. In order to support further research into the field of SpLD in

medical education, it is necessary to first establish a base line, or the current

‘state of play’, for the implementation of reasonable adjustments in UK

medical education. This study was conducted using structured telephone

interviews to collect data regarding the institutional implementation of

reasonable adjustments in all 32 UK medical schools. Data showed that

schools implement reasonable adjustments at a variable rate across the UK.

Further to this, data collected through the interviews and from the

applications service suggest that there is an increase in numbers of students

with declared SpLD being accepted onto medical degree programmes.

There is a need for more work to be done in investigating the impact that

SpLD have on student welfare and performance in medical education.

Furthermore, little evidence surrounding this issue exists, which must be

addressed for meaningful comparisons to be made and conclusions to be

drawn.

 

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Syndrome and Attention Deficit Hyperactivity Disorder (Wardin & Daniels,

1997; Open, 2006). Dyslexia, often incorrectly used synonymously with SpLD,

is the most common SpLD and is thought to affect an estimated 6% of the

global population (Miles, 2004).

In the UK, students enrolled on higher education (HE) courses in medicine

are given the opportunity to declare a diagnosis of SpLD during the University

and Colleges Admissions Service (UCAS) applications process. Further to

this, all UK HE institutions have a duty to provide support and opportunities for

students to be tested for SpLD, assessed for their education needs and

supported accordingly. Such processes are laid out in legislation in the

Disability Discrimination Act (DDA) (HMSO, 1995) and the Special Educational

Needs and Disability Act (SENDA) (HMSO, 2001). Support available can be

variable, and determined by many factors, such as the course that the student

is enrolled on, the learning environment and the learning needs of the student.

“Reasonable Adjustments” are legally required, and are to be made in order to

afford the students the same opportunity of success and achievement as other

students and aim to minimise the effects of their SpLD (DRC, 2006; DRC,

2007). In medical education this results in concerns and arguments

surrounding patient safety, competence and fitness to practise in later careers.

The General Medical Council (GMC) defines competency standards and

necessary requirements of practising doctors, as well as guidelines on

inclusion of those with disabilities within the profession (GMC, 2008). The true

impact of SpLD on an individual’s experience of medical education, as well as

their performance in the course and later career, remain undefined. However,

it is becoming increasingly accepted that the medical profession needs to

embrace diversity and that the inclusion of people with SpLD and other

disabilities in the education and practice of medicine would add value to the

profession and would not harm public trust or perception of standards (Roberts

et al., 2004).

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AIMS:

The primary objective of this project was to ascertain the level of support

currently available to medical students with SpLD at UK medical schools, in

order to provide baseline information for the implementation of reasonable

adjustments for students with SpLD. In addition, the project also aimed to

source basic data relating to numbers of applications made to undergraduate

courses in medicine and offers made to applicants with declared SpLD from

2004 to 2008.

METHODS

Data regarding the applications and number of acceptances to undergraduate

courses in medicine from 2004 until 2008 were acquired through the UCAS

Statistical Services (www.ucas.ac.uk). Two spokespeople from each of the 32

medical schools in the UK were contacted by telephone. In twenty-five cases,

both spokespeople were from within the medical school. In the remaining

seven, the second spokesperson was from the central University student

support service. Representatives were identified by their involvement in

curriculum support or student development. Where initial contacts were unable

to conduct telephone interviews, suitable alternatives were sought matching

the same criteria. Structured telephone interviews were conducted on an

individual basis, with responses being recorded immediately with expanded

interview notes. Interviews were structured by a set of fifteen questions.

Questions, or elements of questions, were routinely explained and clarified,

and the meaning of responses was consistently checked. For example, the

meaning of ‘Disability Champion’ was detailed to each spokesperson. The

interview protocol focused on three key areas of interest: attitudes regarding

SpLD; adjustments provided; and support available. This protocol (appendix 1)

was developed following background reading into educational support

guidelines and discussions with educational leaders (JCQ, 2009; Jamieson &

Morgan, 2008; DRC, 2006; DRC, 2007). The collected data was entered into a

spreadsheet (Microsoft Excel) and prepared for graphical representation.

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RESULTS

ADMISSIONS

The number of medical schools that actively encouraged the disclosure of a

diagnosis of SpLD was 56% (figure 1). Institutions were considered to actively

encourage disclosure of SpLD if there was written evidence suggesting the

consideration of special requirements that students may have for interview

processes, the provision of information and signposting further information.

Reasons, as reported by

respondents, for not

encouraging this disclosure

varied from logistical

difficulties to actively

avoiding it so as not to

create bias or prejudice

during the admissions

process.

Data provided by the UCAS statistical service suggests that since 2004 the

number of students with SpLD who are applying to study medicine has

increased, from 172 (69 female, 103 male) out of a total of 15,554 applications

in 2004 to 306 (143 female, 163 male) out of 16485 applications in 2008. This

is illustrated in figure 2. The number of students that were accepted onto

courses of medicine has

concurrently increased. In

2004, 54 students (21

female, 33 male), out of

4076 students accepted

onto undergraduate

medical degree

programmes, had a

Figure 1: % of institutions that actively encourage disclosure of a diagnosis of SpLD during the admissions process

Figure 2: UCAS data showing trend in applications to the MBChB 5-year course by students with SpLD. Y-axis shows the number of students (male or female) with a learning difficulty that applied to an undergraduate medical programme.

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declared SpLD. This increased to 116 (66 female, 50 male) out of 6047 in

2008 (figure 3).

ADMINISTRATIVE SUPPORT

Administrative support for staff and students was considered to comprise:

student support services specifically dedicated to medical students, the

appointment of a ‘Disability Champion’ and the provision of specialised training

for academic staff to raise awareness of SpLD in medical education. Of the 32

schools, 65.6% (21) provided a student support service dedicated to the

medical students on their course, 75% (24) had a designated disability

champion and 18.8% (6) provided staff training for dealing with SpLD

specifically in medical education. 44% (14) provided both a dedicated student

support service and had a designated disability champion, 6% (2) of the

medical schools had an appointed disability champion and provided specific

staff training, whilst 1 school provided a dedicated student support service and

specific staff training. A total of 3 of schools provided all three.

WELFARE SUPPORT

Of the 32 medical schools, 87.5% (28) provided a welfare, or personal

tutoring, system dedicated to their medical students. Of the remaining 4, three

medical schools were based at institutions which had collegiate systems with

their own, individual, welfare and support systems in place. One medical

Figure 3: UCAS data showing trend in acceptance to the MBChB 5-year course by students with SpLD. Y-axis shows the number of students (male or female) with a learning difficulty that were accepted on to an undergraduate medical programme.

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school did not have a welfare system in place, but did provide specialised

support through one dedicated individual. Where there were tutors (or mentor),

the mean number of students in each tutor group was 16, with the number

ranging from as few as 5 and as many as 45. The modal average was 10

students per group.

REASONABLE ADJUSTMENTS

Out of a possible 11

reasonable adjustments that

are most commonly

recommended at HE

(Jamieson & Morgan, 2008;

DRC, 2007), 40% of medical

schools provided all,

depending on individual

needs assessments and

educational psychologist

reports. Figure 4 shows the

distribution of compliance with this standard across the 32 medical schools.

Figure 5 illustrates the pattern of how the 11 reasonable adjustments are

implemented, suggesting that assistance with proof reading of written work is

the least employed.

Figure 4: Proportion of medical schools providing all (11) or as few as 5 reasonable adjustments (RAs)

Figure 5: The pattern of provision of the 11 reasonable adjustments in all 32 medical schools. Y-axis show % of schools providing the specific reasonable adjustments.

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Five medical schools currently implement, or are experimenting with, the

implementation of reasonable adjustments in clinical placements and exams,

such as Objective Structured Clinical Exams (OSCE). Experimental

adjustments varied between the institutions. Examples include: providing extra

rest time between OSCE stations; and printing scenarios on a different

coloured paper with extra reading time during OSCE.

DISCUSSION

STRENGTHS & WEAKNESSES OF STUDY

This is the first study in the field of medical education to take a look at the

implementation of reasonable adjustments across a whole country. All medical

schools in the UK were included in this enquiry. This provides some baseline

evidence for an increasingly important debate, and can guide further work in

the area of student support in medical education.

However, whilst this study includes all UK medical schools, it is only a

preliminary investigation into what support is offered, and quite how SpLD

impact on medical education. Interpretation of the findings is limited due to the

lack of comparison with other countries, and previous studies. As the

evidence-base around the area of SpLD in medical education increases, more

such data will be available to draw upon and make such comparisons.

ADMISSIONS

As these data lack comparison with rates of diagnosis, it is not possible to infer

whether this means that more students with SpLD are actually applying and

being accepted, as it could simply mean that either the number of people with

a diagnosis of SpLD, or the rate of initial disclosure, has increased over the

last four years (figure 2). However, the data suggest that there are a greater

number of students entering medical course with a recognised and declared

diagnosis of SpLD. It would be useful to compare this to rates of diagnosis and

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declaration once enrolled on the course. This increase could reflect changes in

attitudes surrounding, and perceptions of, SpLD in the Health Care profession

and an increased trust in equality throughout admissions procedures (Morris &

Turnbull, 2007; Miller et al., 2009).

Active encouragement of disclosure occurred in 56% of medical schools.

However, this figure is open to interpretation. During the interviews, the

meaning of the statement was specified as an active attempt at providing

information and encouraging the confidential disclosure of a diagnosis.

Concerns were raised about the nature of such encouragement, with

representatives stating that they specifically avoided encouraging disclosure

so as to prevent “positive discrimination”. This suggests that there is still some

work to be done on refining the admissions process in terms of how and when

disclosure is sought, and the nature of the security of this information in

relation to the application process.

ADMINISTRATIVE SUPPORT

Seventy-five percent of UK medical schools had a designated member of staff

acting as a “Disability Champion”. The purpose of such a title and role is to

promote awareness of issues surrounding disability in students and staff within

their institution. This could mean that the individual is responsible for

coordinating Impact Assessments (DRC, 2006; DRC, 2007). The title ascribed

to this role was queried, with concerns raised about how it “doesn’t sound

right” and how it may have unhelpful connotations associated with it.

Institutional use of the actual term “Disability Champion” differed, with some

preferring to use the title Disability Liaison Officer or similar. The function of

the role was apparently consistent regardless of the title. However, some

individuals accepted extra responsibilities, linked to welfare and study skills

support.

Six out of the 32 schools provided specialised training for staff involved in

curriculum development and delivery, regarding students with SpLD. This

figure reflects the logistical difficulties in providing such training, and making it

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available and accessible to clinicians and academics, as well as others

involved in medical course. Many schools (21) provided this training on a

voluntary basis through central services. Such training was not specific to the

context of medical education, and the popularity and success of such courses

is unquantified.

WELFARE SUPPORT

Twenty-eight of the 32 UK medical schools provided a welfare support system

specifically dedicated to their medical students. Mental illness is over-

represented in medical student populations, and the study of medicine is

associated with a great number of stressors and demands (Dyrbye et al.,

2006). This highlights the need for a support system specifically tailored to the

demographic of medical students, as well as the course. Medical students with

SpLD often struggle with specific elements of the course or assessment that

overwhelm their coping strategies. Such events can prove to be highly

stressful, and deleterious to students’ welfare (Rosebraugh, 2000; Takakuwa,

1998). Further work need to be done in this area before significant

recommendations can be inferred, however it may be beneficial for those

involved in the welfare support of medical students to be able to integrate

insight into and support of SpLD with this role.

REASONABLE ADJUSTMENTS

As there is a lack of significant evidence supporting or refuting the use of

reasonable adjustments in medical education, it is impossible to comment on

how the varied institutional implementation of the 11, commonly considered

standard, adjustments relates to performance. The provision of specific

support, in the form of extra time granted in written assessments, or allowance

for the use of recording equipment is dependant on a Learning Needs

Assessment. Such assessments are conducted through University, usually

centralised, services and require a formal diagnosis of a disability or SpLD to

be initiated. Resultant reports may recommend specific adjustments to the

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delivery of course material, support of learning and allowance in assessments.

However, effective implementation relies heavily on logistics and practicalities

dictated by reality and specific factors associated with the course. In medicine,

for example, it would be impractical to have assistance in note taking whilst on

clinical placement.

The only conclusions that can be drawn from these results are that the

implementation of reasonable adjustments are variable across the country, but

that there are certain adjustments that are very well implemented, such as

allowing the use of audio recording equipment in lectures and the provision of

Virtual Learning Environment facilities and support. An adjustment that was

not well implemented was the facility for students to have help with proof

reading work. This may be due to the impracticalities, due to the high volume

of written work associated with the course. However, through the interviews, it

became apparent that medical students are often subject to expectations that

are incongruent with the provision of some adjustments.

RECOMMENDATIONS

This investigation highlights the need for greater communication and sharing

of examples of good practice. It would be wise to encourage an open forum for

discussion and sharing of experiences among staff and students, so as to

establish a good base of knowledge and evidence, even if anecdotal,

regarding the support of SpLD in medical education.

FURTHER WORK

Having established a baseline for support available in medical education in the

UK, it would be useful to compare this to global standards, sharing examples

of good practice and ascertaining a wider evidence and knowledge base for

the true impact of, and help required for, SpLD in medical education. There

are yet further landmarks to be achieved in defining and identifying SpLD in

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medical education as well as the impact that they have on performance as a

student and as a practicing clinician.

CONCLUSION

Of the 32 medical schools, 60% do not currently implement the 11 basic

reasonable adjustments investigated. Forty-four percent do not actively

encourage disclosure of a diagnosis of SpLD during the admissions process.

This demonstrates a varied following of current guidelines. However, without

an evidence base supporting the various arguments surrounding the

institutional decisions, or a comparison between this level of performance and

the effect on student’s educational experience it is not possible to suggest

whether these results reflect positively or a negatively. It became clear,

throughout the investigations, that there is still a degree of tension surrounding

the issue of SpLD in medical education and implementing adjustments for

students. Overall, institutions remain positive, encouraging diversity and

supporting students in various ways, which is exemplified by the experimental

implementation of reasonable adjustments in OSCE by 5 of the medical

schools in this study. In order to optimise student performance and to dispel

stigma and related issues surrounding SpLD and the provision of related

supporting measures, it is clear that there is much work to be done in

qualifying and quantifying the use, drawbacks and positive effects of SpLD

and reasonable adjustments in medical education.

KEY POINTS

1. Forty percent of UK medical schools provide all 11 ‘core’ reasonable adjustments.

2. The number of students, with a disclosed diagnosis of SpLD, entering medical degree programmes has increased.

3. Little evidence exists detailing the benefits and costs of reasonable adjustments in medical education.

4. Further investigation into this field should be supported, to ensure meaningful comparison.

 

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NOTES ON AUTHOR

Duncan Shrewsbury is a 5th year medical student at the University of

Birmingham and is concurrently completing a Masters in medical education at

Staffordshire University.

ACKNOWLEDGEMENTS

Many thanks are owed to Professor John Skelton, who was immensely helpful

in the preparation of this report.

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Do the Duty.

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Disability Rights Commission. 2007.

Code of practice (revised) for post-16 education.

The Higher Education Academy: Medicine, Dentistry and Veterinary

Accessed on 21/2/2010 via:

http://www.equalityhumanrights.com/advice-and-guidance/information-for-

advisers/codes-of-practice/

Dyrbye LN, Thomas MR, Shanafelt TD. 2006.

Systematic review of depression, anxiety, and other indicators of psychological

distress among U.S. and Canadian medical students.

Academic Medicine. 81:354e73.

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(GMC) General Medical Council and The Department for Innovation,

Universities and Skills. 2008.

Gateways to the Professions: advising medical schools, encouraging disabled

students.

General Medical Council, London.

Jamieson C and Morgan E. 2008.

Managing Dyslexia at University.

Routledge, Oxford.

(JCQ) Joint Council for Qualifications. 2007.

Access arrangements, reasonable adjustments and special consideration:

general and vocational qualifications. With effect from 01/09/2009.

Miles TR. 2004.

Some problems in determining the prevalence of dyslexia.

The Electronic Journal for Research in Educational Psychology, 2: 5-12.

Miller S, Ross S and Cleland J. 2009.

Medical students’ attitudes towards disability and support for disability in

medicine.

Medical Teacher, 31: e272-e377.

Morris DK Turnbull PA. 2007.

The disclosure of dyslexia in clinical practice: Experiences of student nurses in

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Nurse Education Today, 27: 35-42.

(Open) Open University. 2006.

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Accessed on 1/2/2010 via:

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awareness/what-are-specific-learning-difficulties.php

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Roberts TE, Butler A and Bouriscot KAM. 2004.

Disabled students, disabled doctors – time for a change? A study of different

societal views of disabled people’s inclusion to the study and practice of

medicine.

Higher Education Academy Subject Centre for Medicine, Dentistry and

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APPENDIX 1

Interview Protocol:

Questions asked over the phone, of all UK Medical Schools, as directed by initial contact through general enquiry telephone numbers.

UNIVERISTY: ___________________________________

1. Do you actively encourage people to disclose diagnosis of SLD during

admissions process?

2. Do you / University provide screening for SLD?

i. Is this free, or do the students have to pay?

3. Do you provide a student support service dedicated to Medical

Students?

4. Are there dedicated staff within the Medical School that are designated

as ‘Disability Champions’?

5. Is there training or an incentive to raise awareness of dyslexia within

Medical Education within your institution?

6. Do you have a Student Welfare / Tutoring system dedicated to your

Medical Students?

7. How many students does each tutor look after?

8. Are these tutors trained in helping with study skills?

9. Is there provision for study skills workshops or training at your:

• Medical School, specific to Medical Education ☐

• University, specific to Medical Education ☐

• University, not specific to Medical Education? ☐

10. Do your dyslexic students currently get:

a. Extra 25% time in written exams?

i. If not- why

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ii. If more- detail

b. Advice on DSA?

c. Study Skills Support?

d. Reasonable adjustments?

(Detail.....................................................)

List of ‘Standard’ reasonable adjustments:

• Assistive Technologies ☐

• Handouts (24hs in advance?) ☐

• Virtual Learning Environment ☐

• Accessibility technology ☐

• Extended library loans ☐

• Access to dyslexia tutor ☐

• Photocopying ☐

• Printing ☐

• IT training ☐

• Note taking assistance ☐

• Dictaphone ☐

• Help with proof read ☐