DHS-State of Play    STATE OF PLAY: A REPORT ON THE SUPPORT AVAILABLE TO    MEDICAL STUDENTS WITH SPECIFIC LEARNING DIFFIC...
DHS-State of Play     State of Play: Support available to medical students with specific                             learn...
DHS-State of PlaySyndrome and Attention Deficit Hyperactivity Disorder (Wardin & Daniels,1997; Open, 2006). Dyslexia, ofte...
DHS-State of PlayAIMS:The primary objective of this project was to ascertain the level of supportcurrently available to me...
DHS-State of PlayRESULTSADMISSIONSThe number of medical schools that actively encouraged the disclosure of adiagnosis of S...
DHS-State of Playdeclared SpLD. This increased to 116 (66 female, 50 male) out of 6047 in2008 (figure 3).                 ...
DHS-State of Playschool did not have a welfare system in place, but did provide specialisedsupport through one dedicated i...
DHS-State of PlayFive medical schools currently implement, or are experimenting with, theimplementation of reasonable adju...
DHS-State of Playdeclaration once enrolled on the course. This increase could reflect changes inattitudes surrounding, and...
DHS-State of Playavailable and accessible to clinicians and academics, as well as othersinvolved in medical course. Many s...
DHS-State of Playdelivery of course material, support of learning and allowance in assessments.However, effective implemen...
DHS-State of Playmedical education as well as the impact that they have on performance as astudent and as a practicing cli...
DHS-State of PlayNOTES ON AUTHORDuncan Shrewsbury is a 5th year medical student at the University ofBirmingham and is conc...
DHS-State of Play(GMC) General Medical Council and The Department for Innovation,Universities and Skills. 2008.Gateways to...
DHS-State of PlayRoberts TE, Butler A and Bouriscot KAM. 2004.Disabled students, disabled doctors – time for a change? A s...
DHS-State of PlayAPPENDIX 1Interview Protocol:Questions asked over the phone, of all UK Medical Schools, as directed by in...
DHS-State of Play             ii. If more- detail          b. Advice on DSA?          c. Study Skills Support?          d....
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State Of Play: support available to studnets with SpLD in UK medical schools

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State Of Play: support available to studnets with SpLD in UK medical schools

  1. 1. DHS-State of Play STATE OF PLAY: A REPORT ON THE SUPPORT AVAILABLE TO MEDICAL STUDENTS WITH SPECIFIC LEARNING DIFFICULTIESAUTHOR: Duncan Shrewsbury, PGDip Med Ed, Adv Dip Clin Hyp., BMed Sc.INSTITUTION: Medical School, College of Medical and Dental Sciences, TheUniversity of Birmingham, Edgbaston, Birmingham, B15 2TT.EMAIL: dhs570@bham.ac.uk / d.shrewsbury@doctors.org.ukMOBILE: 07875499845 A report to the Higher Education Academy Subject Centre October 2010 1
  2. 2. DHS-State of Play State of Play: Support available to medical students with specific learning difficulties 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.  INTRODUCTIONSpecific 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 thesymptamology and deficits associated with SpLD. This umbrella termencompasses conditions such as Dyslexia, Dyscalculia, Dyspraxia, Asperger’s 2
  3. 3. DHS-State of PlaySyndrome 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 theglobal population (Miles, 2004).In the UK, students enrolled on higher education (HE) courses in medicineare given the opportunity to declare a diagnosis of SpLD during the Universityand Colleges Admissions Service (UCAS) applications process. Further tothis, all UK HE institutions have a duty to provide support and opportunities forstudents to be tested for SpLD, assessed for their education needs andsupported accordingly. Such processes are laid out in legislation in theDisability Discrimination Act (DDA) (HMSO, 1995) and the Special EducationalNeeds and Disability Act (SENDA) (HMSO, 2001). Support available can bevariable, and determined by many factors, such as the course that the studentis enrolled on, the learning environment and the learning needs of the student.“Reasonable Adjustments” are legally required, and are to be made in order toafford the students the same opportunity of success and achievement as otherstudents and aim to minimise the effects of their SpLD (DRC, 2006; DRC,2007). In medical education this results in concerns and argumentssurrounding patient safety, competence and fitness to practise in later careers.The General Medical Council (GMC) defines competency standards andnecessary requirements of practising doctors, as well as guidelines oninclusion of those with disabilities within the profession (GMC, 2008). The trueimpact of SpLD on an individual’s experience of medical education, as well astheir performance in the course and later career, remain undefined. However,it is becoming increasingly accepted that the medical profession needs toembrace diversity and that the inclusion of people with SpLD and otherdisabilities in the education and practice of medicine would add value to theprofession and would not harm public trust or perception of standards (Robertset al., 2004). 3
  4. 4. DHS-State of PlayAIMS:The primary objective of this project was to ascertain the level of supportcurrently available to medical students with SpLD at UK medical schools, inorder to provide baseline information for the implementation of reasonableadjustments for students with SpLD. In addition, the project also aimed tosource basic data relating to numbers of applications made to undergraduatecourses in medicine and offers made to applicants with declared SpLD from2004 to 2008.METHODSData regarding the applications and number of acceptances to undergraduatecourses in medicine from 2004 until 2008 were acquired through the UCASStatistical Services (www.ucas.ac.uk). Two spokespeople from each of the 32medical schools in the UK were contacted by telephone. In twenty-five cases,both spokespeople were from within the medical school. In the remainingseven, the second spokesperson was from the central University studentsupport service. Representatives were identified by their involvement incurriculum support or student development. Where initial contacts were unableto conduct telephone interviews, suitable alternatives were sought matchingthe same criteria. Structured telephone interviews were conducted on anindividual basis, with responses being recorded immediately with expandedinterview 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, themeaning of ‘Disability Champion’ was detailed to each spokesperson. Theinterview protocol focused on three key areas of interest: attitudes regardingSpLD; adjustments provided; and support available. This protocol (appendix 1)was developed following background reading into educational supportguidelines and discussions with educational leaders (JCQ, 2009; Jamieson &Morgan, 2008; DRC, 2006; DRC, 2007). The collected data was entered into aspreadsheet (Microsoft Excel) and prepared for graphical representation. 4
  5. 5. DHS-State of PlayRESULTSADMISSIONSThe number of medical schools that actively encouraged the disclosure of adiagnosis of SpLD was 56% (figure 1). Institutions were considered to activelyencourage disclosure of SpLD if there was written evidence suggesting theconsideration of special requirements that students may have for interviewprocesses, 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 admissionsFigure 1: % of institutions that actively encouragedisclosure of a diagnosis of SpLD during the admissions process.processData provided by the UCAS statistical service suggests that since 2004 thenumber of students with SpLD who are applying to study medicine hasincreased, from 172 (69 female, 103 male) out of a total of 15,554 applicationsin 2004 to 306 (143 female, 163 male) out of 16485 applications in 2008. Thisis illustrated in figure 2. The number of students that were accepted ontocourses of medicine hasconcurrently increased. In2004, 54 students (21female, 33 male), out of4076 students acceptedonto undergraduatemedical degreeprogrammes, had a 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. 5
  6. 6. DHS-State of Playdeclared SpLD. This increased to 116 (66 female, 50 male) out of 6047 in2008 (figure 3). 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.ADMINISTRATIVE SUPPORTAdministrative support for staff and students was considered to comprise:student support services specifically dedicated to medical students, theappointment of a ‘Disability Champion’ and the provision of specialised trainingfor academic staff to raise awareness of SpLD in medical education. Of the 32schools, 65.6% (21) provided a student support service dedicated to themedical students on their course, 75% (24) had a designated disabilitychampion and 18.8% (6) provided staff training for dealing with SpLDspecifically in medical education. 44% (14) provided both a dedicated studentsupport service and had a designated disability champion, 6% (2) of themedical schools had an appointed disability champion and provided specificstaff training, whilst 1 school provided a dedicated student support service andspecific staff training. A total of 3 of schools provided all three.WELFARE SUPPORTOf the 32 medical schools, 87.5% (28) provided a welfare, or personaltutoring, system dedicated to their medical students. Of the remaining 4, threemedical schools were based at institutions which had collegiate systems withtheir own, individual, welfare and support systems in place. One medical 6
  7. 7. DHS-State of Playschool did not have a welfare system in place, but did provide specialisedsupport through one dedicated individual. Where there were tutors (or mentor),the mean number of students in each tutor group was 16, with the numberranging from as few as 5 and as many as 45. The modal average was 10students per group.REASONABLE ADJUSTMENTSOut of a possible 11reasonable adjustments thatare most commonlyrecommended at HE(Jamieson & Morgan, 2008;DRC, 2007), 40% of medicalschools provided all,depending on individualneeds assessments and Figure 4: Proportion of medical schools providingeducational psychologist all (11) or as few as 5 reasonable adjustments (RAs)reports. Figure 4 shows thedistribution of compliance with this standard across the 32 medical schools.Figure 5 illustrates the pattern of how the 11 reasonable adjustments areimplemented, suggesting that assistance with proof reading of written work isthe least employed. 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. 7
  8. 8. DHS-State of PlayFive medical schools currently implement, or are experimenting with, theimplementation of reasonable adjustments in clinical placements and exams,such as Objective Structured Clinical Exams (OSCE). Experimentaladjustments varied between the institutions. Examples include: providing extrarest time between OSCE stations; and printing scenarios on a differentcoloured paper with extra reading time during OSCE.DISCUSSIONSTRENGTHS & WEAKNESSES OF STUDYThis is the first study in the field of medical education to take a look at theimplementation of reasonable adjustments across a whole country. All medicalschools in the UK were included in this enquiry. This provides some baselineevidence for an increasingly important debate, and can guide further work inthe area of student support in medical education.However, whilst this study includes all UK medical schools, it is only apreliminary investigation into what support is offered, and quite how SpLDimpact on medical education. Interpretation of the findings is limited due to thelack of comparison with other countries, and previous studies. As theevidence-base around the area of SpLD in medical education increases, moresuch data will be available to draw upon and make such comparisons.ADMISSIONSAs these data lack comparison with rates of diagnosis, it is not possible to inferwhether this means that more students with SpLD are actually applying andbeing accepted, as it could simply mean that either the number of people witha diagnosis of SpLD, or the rate of initial disclosure, has increased over thelast four years (figure 2). However, the data suggest that there are a greaternumber of students entering medical course with a recognised and declareddiagnosis of SpLD. It would be useful to compare this to rates of diagnosis and 8
  9. 9. DHS-State of Playdeclaration once enrolled on the course. This increase could reflect changes inattitudes surrounding, and perceptions of, SpLD in the Health Care professionand 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, themeaning of the statement was specified as an active attempt at providinginformation and encouraging the confidential disclosure of a diagnosis.Concerns were raised about the nature of such encouragement, withrepresentatives stating that they specifically avoided encouraging disclosureso as to prevent “positive discrimination”. This suggests that there is still somework to be done on refining the admissions process in terms of how and whendisclosure is sought, and the nature of the security of this information inrelation to the application process.ADMINISTRATIVE SUPPORTSeventy-five percent of UK medical schools had a designated member of staffacting as a “Disability Champion”. The purpose of such a title and role is topromote awareness of issues surrounding disability in students and staff withintheir institution. This could mean that the individual is responsible forcoordinating Impact Assessments (DRC, 2006; DRC, 2007). The title ascribedto this role was queried, with concerns raised about how it “doesn’t soundright” and how it may have unhelpful connotations associated with it.Institutional use of the actual term “Disability Champion” differed, with somepreferring to use the title Disability Liaison Officer or similar. The function ofthe role was apparently consistent regardless of the title. However, someindividuals accepted extra responsibilities, linked to welfare and study skillssupport.Six out of the 32 schools provided specialised training for staff involved incurriculum development and delivery, regarding students with SpLD. Thisfigure reflects the logistical difficulties in providing such training, and making it 9
  10. 10. DHS-State of Playavailable and accessible to clinicians and academics, as well as othersinvolved in medical course. Many schools (21) provided this training on avoluntary basis through central services. Such training was not specific to thecontext of medical education, and the popularity and success of such coursesis unquantified.WELFARE SUPPORTTwenty-eight of the 32 UK medical schools provided a welfare support systemspecifically dedicated to their medical students. Mental illness is over-represented in medical student populations, and the study of medicine isassociated with a great number of stressors and demands (Dyrbye et al.,2006). This highlights the need for a support system specifically tailored to thedemographic of medical students, as well as the course. Medical students withSpLD often struggle with specific elements of the course or assessment thatoverwhelm their coping strategies. Such events can prove to be highlystressful, and deleterious to students’ welfare (Rosebraugh, 2000; Takakuwa,1998). Further work need to be done in this area before significantrecommendations can be inferred, however it may be beneficial for thoseinvolved in the welfare support of medical students to be able to integrateinsight into and support of SpLD with this role.REASONABLE ADJUSTMENTSAs there is a lack of significant evidence supporting or refuting the use ofreasonable adjustments in medical education, it is impossible to comment onhow the varied institutional implementation of the 11, commonly consideredstandard, adjustments relates to performance. The provision of specificsupport, in the form of extra time granted in written assessments, or allowancefor the use of recording equipment is dependant on a Learning NeedsAssessment. Such assessments are conducted through University, usuallycentralised, services and require a formal diagnosis of a disability or SpLD tobe initiated. Resultant reports may recommend specific adjustments to the 10
  11. 11. DHS-State of Playdelivery of course material, support of learning and allowance in assessments.However, effective implementation relies heavily on logistics and practicalitiesdictated by reality and specific factors associated with the course. In medicine,for example, it would be impractical to have assistance in note taking whilst onclinical placement.The only conclusions that can be drawn from these results are that theimplementation of reasonable adjustments are variable across the country, butthat there are certain adjustments that are very well implemented, such asallowing the use of audio recording equipment in lectures and the provision ofVirtual Learning Environment facilities and support. An adjustment that wasnot well implemented was the facility for students to have help with proofreading work. This may be due to the impracticalities, due to the high volumeof written work associated with the course. However, through the interviews, itbecame apparent that medical students are often subject to expectations thatare incongruent with the provision of some adjustments.RECOMMENDATIONSThis investigation highlights the need for greater communication and sharingof examples of good practice. It would be wise to encourage an open forum fordiscussion and sharing of experiences among staff and students, so as toestablish a good base of knowledge and evidence, even if anecdotal,regarding the support of SpLD in medical education.FURTHER WORKHaving established a baseline for support available in medical education in theUK, it would be useful to compare this to global standards, sharing examplesof good practice and ascertaining a wider evidence and knowledge base forthe true impact of, and help required for, SpLD in medical education. Thereare yet further landmarks to be achieved in defining and identifying SpLD in 11
  12. 12. DHS-State of Playmedical education as well as the impact that they have on performance as astudent and as a practicing clinician.CONCLUSIONOf the 32 medical schools, 60% do not currently implement the 11 basicreasonable adjustments investigated. Forty-four percent do not activelyencourage disclosure of a diagnosis of SpLD during the admissions process.This demonstrates a varied following of current guidelines. However, withoutan evidence base supporting the various arguments surrounding theinstitutional decisions, or a comparison between this level of performance andthe effect on student’s educational experience it is not possible to suggestwhether these results reflect positively or a negatively. It became clear,throughout the investigations, that there is still a degree of tension surroundingthe issue of SpLD in medical education and implementing adjustments forstudents. Overall, institutions remain positive, encouraging diversity andsupporting students in various ways, which is exemplified by the experimentalimplementation of reasonable adjustments in OSCE by 5 of the medicalschools in this study. In order to optimise student performance and to dispelstigma and related issues surrounding SpLD and the provision of relatedsupporting measures, it is clear that there is much work to be done inqualifying and quantifying the use, drawbacks and positive effects of SpLDand 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.   12
  13. 13. DHS-State of PlayNOTES ON AUTHORDuncan Shrewsbury is a 5th year medical student at the University ofBirmingham and is concurrently completing a Masters in medical education atStaffordshire University.ACKNOWLEDGEMENTSMany thanks are owed to Professor John Skelton, who was immensely helpfulin the preparation of this report.REFERENCESDisability Discrimination Act, 1995. London: HMSO.(DRC) Disability Rights Commission. 2006.Further and Higher Education Institutions and the Disability Equality Duty.Do the Duty.Accessed on 21/2/2010 via:http://www.dotheduty.org/index.aspDisability Rights Commission. 2007.Code of practice (revised) for post-16 education.The Higher Education Academy: Medicine, Dentistry and VeterinaryAccessed 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 psychologicaldistress among U.S. and Canadian medical students.Academic Medicine. 81:354e73. 13
  14. 14. DHS-State of Play(GMC) General Medical Council and The Department for Innovation,Universities and Skills. 2008.Gateways to the Professions: advising medical schools, encouraging disabledstudents.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 inmedicine.Medical Teacher, 31: e272-e377.Morris DK Turnbull PA. 2007.The disclosure of dyslexia in clinical practice: Experiences of student nurses inthe United Kingdom.Nurse Education Today, 27: 35-42.(Open) Open University. 2006.What are specific learning difficulties?Open University, Milton Keynes.Accessed on 1/2/2010 via:http://www.open.ac.uk/inclusiveteaching/pages/understanding-and-awareness/what-are-specific-learning-difficulties.php 14
  15. 15. DHS-State of PlayRoberts TE, Butler A and Bouriscot KAM. 2004.Disabled students, disabled doctors – time for a change? A study of differentsocietal views of disabled people’s inclusion to the study and practice ofmedicine.Higher Education Academy Subject Centre for Medicine, Dentistry andVeterinary Medicine, Special Report: 4.Special Educational Needs and Disability Act, 2001. London: HMSO.Takakuwa K. 1998.Coping with a Learning Disability in Medical School.Journal of the American Medical Association, 298: 81.Wardin M, Daniels C. 1997.Definition of Specific Learning Disability.Conference Proceedings from the Technology and Persons with DisabilitiesConference.California State University Northridge.Accessed on 25/2/2010 via:http://www.csun.edu/cod/conf/1997/proceedings/120.htm          15
  16. 16. DHS-State of PlayAPPENDIX 1Interview Protocol:Questions asked over the phone, of all UK Medical Schools, as directed by initial contactthrough 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 16
  17. 17. DHS-State of Play 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 ☐  17

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