When the metric becomes the virtue, trust breaks

Five late marks add up to a “persistent lateness” professionalism complaint – one that, according to the sixth-year student describing the system, carries the same number of points as sexual harassment.

That account is one of hundreds gathered for Broken Trust, the BMA’s new report on medical students’ experiences of professional standards.

It’s built on a survey of 2,573 students across every UK medical school last October, a review of professionalism policies from 30 of them, and freedom of information requests to 47.

The BMA’s UK medical students committee commissioned the work after 18 months of reports about professionalism being used to suppress valid concerns and about “vexatious investigations”, and the survey’s designers seem to have half expected the culture war version of that story.

The pre-coded list of reasons students had been labelled “unprofessional” reads like a civil liberties charge sheet – an item of clothing, an aspect of appearance, cultural expression, language, accent, social media use, political opinions, activism, protest.

All of those turn up in the responses, and some of them – accent especially, which the report says should never be described as unprofessional – are indefensible on their face.

But 43.5 per cent of students who’d been labelled unprofessional ticked “other” and wrote in the real reason, and the majority of those wrote some version of the same thing.

Attendance.

The be all and end all

Just over a third of respondents (36.0 per cent) had been described as unprofessional at least once, and when they explain what for, one thing looms over everything. As one fourth-year in England puts it:

The medical school sees attendance as the be all and end all of professionalism, [whilst] having no options to book leave for events that I would have booked leave for when I was working.

What follows in the free text is a portrait of a system in which presence is a measurable proxy for virtue, the measurement an end in itself.

One student carries a permanent professionalism concern for forgetting to submit a feedback form after a lecture block. Another describes their school treating a failure to scan an attendance QR code as “the height of unprofessionalism” – when the code was the school’s, and it didn’t work.

A student in Northern Ireland, sent home from placement by a supervisor for being unwell, was then called to a disciplinary meeting and told they wouldn’t be signed off for the year, two weeks before their OSCEs.

And then there’s the presenteeism, which in a clinical setting is a patient safety issue all of its own:

Once I called in at 9:05 – as I was vomiting in the toilet for over 10 mins. They forced me to come in to prove I was ill.

Health does badly throughout. 55.6 per cent of respondents said the way their school defines and enforces professionalism doesn’t take appropriate account of mental health, 46.5 per cent said the same of physical health, and 58 per cent said their lives outside medicine aren’t appropriately considered at all.

One of the report’s recommendations says a lot about the state of student finance – attendance and leave policies, it argues, must take into account “the increasing requirement” for students to do significant part-time paid work during their studies.

Students also perceive double standards – schools demanding punctuality and administrative perfection while cancelling teaching at short notice and communicating late – and describe year-wide disciplinary emails, warnings attached to routine communications, and a general sense of being, in the report’s word, infantilised.

Yet when a concern is actually raised about a student, the most common formal outcome (37.2 per cent) is that no action is taken at all, and only 6.8 per cent of cases reach a fitness to practise panel.

Meanwhile 71.2 per cent of those labelled thought the label was unfair, the reported impacts on mental health, confidence and trust in others are extensive, and 39.7 per cent felt “not at all” supported pastorally while it was happening.

The problem is that a disciplinary apparatus whose most frequent product is nothing still manages to do plenty of damage on the way through:

I was asked to attend a placement that was 2 hours away by public transport with no reimbursement, this is against the medical school travel policy. I declined and made an official complaint… My complaint was upheld yet I then received a warning for professionalism. When queried, I had received the warning as my complaint generated a lot of work for school staff and submitting a complaint instead of being ‘willing to give it a go’ was unprofessional.”

Good grief. 45.3 per cent of respondents wouldn’t feel comfortable raising a concern within their medical school, and comfort falls from 72.8 per cent among first and second years to 48.3 per cent from third year onwards – confidence to speak up draining away precisely as students approach a register on which speaking up is a professional duty.

By design

We might be tempted to read all this as a collection of local pathologies – overzealous sub-deaneries, badly drafted policies, the odd jobsworth with a spreadsheet. But the machinery is in the national rulebook.

The joint GMC and Medical Schools Council guidance that governs all of this doesn’t just permit the monitoring of minor lapses, it specifies the examples. Low-level professionalism concerns “such as lateness, not handing in work on time and missing lectures” should be formally reported and monitored, it says, so that schools can address behaviour “before it leads to more-significant fitness to practise issues”.

So when a school builds a points system that converts late marks into escalating interventions, it isn’t misreading the guidance so much as automating it.

The report is scathing about those systems – fixed thresholds imply there’s an acceptable quantum of unprofessionalism, points strip out the context that professionalism judgements actually require, and one third-year notes that plenty of behaviour they’d consider genuinely unprofessional attracts no points at all – and recommendation seven calls for them to be scrapped outright, with even informal findings made contestable.

But the underlying theory, that recording the minor prevents the major, belongs to the regulator, was set out a decade ago, and has never really been stress-tested against what it feels like on the receiving end – or what it then does to a student’s willingness to raise a concern. Broken Trust is the stress test, and the theory fails it.

The same machine

I assume, if you’d got this far down, you’re assuming that medical schools are another world.

The problem is that the rest of the sector is has the same machinery under friendlier names – swipe-card attendance capture and lecture check-in apps, learning analytics that convert VLE logins and library gates into “engagement scores” with escalating intervention workflows, visa compliance regimes that already make monitored attendance a condition of sponsorship for international students, and engagement policies whose staged warnings read like low-level concerns processes with the serial numbers filed off.

The sales pitch for all of it is support – early warning, wraparound, catching the struggling student before they fall. This report is a 35-page account of what goes wrong once the metric becomes the virtue – presence stands in for commitment, monitoring stands in for care, and the students being watched conclude that the institution watching them neither trusts them nor particularly likes them.

Medical schools got there first, because they had a regulator’s imprimatur, a fitness to practise regime to plug into, and a points system to do the maths.

Nobody is counting

All of the above is, as the report itself concedes, self-reported and unverified – the BMA recruited through its own channels, and the aggrieved presumably had more reason than most to fill in a survey. Which is why the FOI exercise matters more than the perceptions data, because you’d hope that a system with this much monitoring in it would have someone monitoring the system.

As if. Of 47 medical schools asked, 29 could provide referral numbers broken down by year. Across 2021/22 to 2025/26, recorded low-level professionalism referrals per school ranged from zero to 2,695 – from nothing at all to roughly 35 per 100 enrolled students over the period – and the report is clear that a school recording zero concerns over five years is probably recording nothing rather than experiencing nothing.

Even after adjusting for cohort size, annual referral rates into formal fitness to practise processes varied sixteen-fold, from 0.17 to 2.74 per 100 students. Some schools confirmed they run a low-level concerns process but couldn’t say how many students had been through it, despite that same 2016 guidance recommending a record of every decision. And whether any of this data reaches the GMC turns out to depend on the school – some submit it annually, some on request, some not at all.

The request that mattered most failed almost completely. The BMA asked for the protected characteristics of students referred, and too few schools could answer for any analysis to be possible – because hardly anyone records it.

Pop that alongside the survey finding that 34.9 per cent of students labelled unprofessional believed bias or discrimination linked to a protected characteristic played a part – higher among BAME respondents, who also reported receiving more formal warnings. The question of whether this regime is discriminatory is, right now, unanswerable – by the BMA, by the GMC, and by the schools operating it.

The BMA’s remedy is to route everything through the regulator – professionalism as a core component of the GMC’s annual quality assurance, mandatory data returns, published numbers audited by protected characteristic – proposals that land just as a government consultation on reforming the GMC’s founding legislation has closed.

Whether a body whose name, the report notes, is routinely invoked in the emails that frighten students is the right one to rebuild their trust is another question for another day.

The recommendation worth exporting beyond medicine, though, is number four – attendance should not be used as a proxy for a student’s overall professional conduct. Swap “professional conduct” for “engagement”, or “commitment”, or whichever word your new monitoring policy prefers, and pin it to the front of the document.

Back in medicine (or teaching, or midwifery, or whatever) in England, all of this is subject to condition E6 on harassment and sexual misconduct, which requires a provider to maintain a “single comprehensive source of information” on the subject, to operate in accordance with it, and – the bit that matters here – to keep provisions on that subject matter out of “any other documents” that could reasonably be considered to contradict, undermine or conflict with it.

I say this with alarming regularity to SUs on the phone, but there’s no carve-out for faculties, and no concept of a medical school running its own parallel regime. A professionalism tariff that scores sexual harassment level with five late marks is the sort of other document the condition contemplates – and it sits awkwardly against a minimum content requirement that investigations and decisions be “credible, fair and otherwise reflect established principles of natural justice”, not least when the BMA finds that even informal professionalism findings often can’t be contested.

That’s not to say that those placements can’t or won’t have professionalism or fitness to practise policies and/or standards. It is to say that the HE provider retains a responsibility to oversee the policies, to make an assessment of whether they’re (for example) chilling harassment complaints, and if so, intervene.

He’s always like that

E6’s harassment definition runs through the Equality Act and the Protection from Harassment Act, so the racism students say goes under-enforced is in scope too, not just the sexual misconduct. The accompanying guidance says compliant reporting arrangements involve removing “any unnecessary actual or perceived barriers” that make students less likely to report – and a culture in which an upheld complaint still earns a professionalism warning for generating work is a perceived barrier by construction.

The condition’s definition of appropriate support explicitly includes academic support on “decisions about attendance, continuation, suspension or cessation of study”, and applies whether or not an incident happened on the provider’s premises – which carries it onto placement. A student missing sessions in the aftermath of harassment should find themselves routed to support, not the professionalism file.

And because providers are expected to understand actual prevalence – OfS explicitly warns that low reporting rates may mean inadequate reporting mechanisms rather than a healthy culture – a professionalism regime that chills reporting doesn’t just harm students, it corrupts the evidence base the condition requires a provider to calibrate its steps against.

An SU officer rattled off a quote from a meeting they were in on E6 a few months ago:

They rolled their eyes and said ‘well, that’s just the way hospitals are.’”

Not a million miles away from “He’s always like that”, is it?

Last November, when it was responding to the BMA’s last report on harassment (largely on placement), the Medical Schools Council said it would work with postgraduate education leaders and NHS partners to develop a more coordinated strategy and ensure clear, effective pathways for action.

A “Short Life Working Group” on sexual misconduct was set up in May. It should get a wriggle on.

Meanwhile it said that the GMC was beginning a comprehensive review of its guidance, to incorporate sanctions and fitness-to-practise procedures. It also should get a wriggle on.