Medical student rankings of proposed sanction for unprofessional behaviours relating to academic integrity: results from a Scottish medical school

Abstract

The General Medical Council emphasizes the cultivation of professional behaviours among medical students from early undergraduate years. Learning professional behaviours, however, is a progression and is constituted of several developmental stages. Behaving with academic integrity may be the first stage. In an educational setting, academic integrity is represented by a collection of diverse behaviours. Although there is consensus within the medical community that the absence of (or lapses in) academic integrity is unacceptable, the level of sanctions recommended for medical students is controversial. In the main, these punitive decisions over students are taken by teachers and clinicians. What sanctions would students suggest for a colleague who is academically unprofessional? This study reports the sanctions recommended by 375/700 (54%) of the students of one Scottish medical school in relation to lapses in academic integrity.

Keywords

professionalism assessment undergraduate

Introduction

Despite the proliferation of studies relating to professionalism, teaching and learning among undergraduate medical students, there are little data to guide the determination of standards and appropriate sanctions for lapses.^1,2 Van Mook et al.³ have pointed out that:

Opinions vary and evolve about how students and professionals should behave. Medical students are nevertheless expected to demonstrate the currently professionally appropriate and ethical behaviour. Knowing what constitutes this behaviour however, appears to be extremely challenging for students as well as teachers, since context (e.g. time, place and culture) all influence the expected behaviour.

Researchers^4,5 who have tried to develop scenarios relating to professional dilemmas have found it very difficult to agree appropriate responses among ‘expert’ panels, and they are highly culturally specific.⁶ Our goal was to determine a set of agreed sanctions at various levels of medical education and training to guide the development of a consistent approach across UK medical schools.

Methods

We identified approximately 100 unprofessional behaviours related to lack of academic integrity at the initial stage of undergraduate education in a literature review of more than 30 studies of issues related to academic integrity in undergraduate medical and health professions courses. With the assistance of two research assistants, these were reduced after duplications were removed and consolidations were made to 41 items (Table 1).

Table 1

The survey asks you to rate your responses to the following 41 statements

Plagiarizing work from a fellow student or purchasing work from a supplier

Completing work for another student

Getting or giving help for coursework against a teacher's rules (e.g. lending work to another student to look at)

Claiming collaborative work as one's individual effort

Paying a fellow student, or being paid by a fellow student, for completion of coursework

Re-submitting work previously submitted for a separate assignment or earlier degree

Intentionally paraphrasing text in an assignment or copying text directly without acknowledging the source

Failing to correctly acknowledge a source (e.g. copying text directly but only including the source in reference list)

Citing sources that have not in fact been read in full

Altering or manipulating data (e.g. adjusting data to obtain a significant result)

Accessing old exam papers or coursework, which have not been released to the whole class, to assist with study

Removing an assigned reference from a shelf in the library in order to prevent other students from gaining access to the information in it

Sabotaging another student's work

Attempting to use personal relationships, bribes or threats to gain academic advantages

Copying answers from a neighbour or enabling a neighbour to copy your answers during an exam

Exchanging answers by use of a mobile phone during an examination

Receiving information about a paper from students who have already sat the exam or providing information about a paper to students who have yet to sit it

Coercing faculty members into providing copies of papers prior to exam through bribery or intimidation

Taking unauthorized material (e.g. crib sheets) into an exam

Sitting an examination for someone else or having someone else sit an examination for you

Inventing extraneous circumstances to delay sitting an exam

Arranging to pass an exam using private connections or by bribery

Signing attendance sheets for absent friends or asking classmates to sign attendance sheets for you in labs or lectures

Missing lectures frequently

Intentionally falsifying test results or treatment records in order to disguise mistakes

Failing to follow proper infection control procedures

Examining patients without knowledge or consent of supervising clinician

Forging a health-care worker's signature on a piece of work, patient chart, grade sheet or attendance form

Falsifying references or grades on curriculum vitae

Altering grades in the official record

Sexually harassing a university employee or fellow student

Threatening or verbally abusing a university employee or fellow student

Physically assaulting a university employee or fellow student

Engaging in substance misuse (e.g. drugs)

Providing illegal drugs to fellow students

Involvement in paedophilic activities – possession/viewing of child pornography images

Involvement in paedophilic activities – molesting children

Drinking alcohol over lunch and interviewing a patient in the afternoon

Lack of punctuality for classes

Not doing the part assigned to him/her in group work

Damaging public property, e.g. scribbling on desks or chairs

Following Teplitsky⁷ respondents were asked to recommend appropriate sanctions for a one-time infraction with no mitigating circumstances. In addition to Teplitsky's nine sanctions, we added a tenth, report to the professional regulator, i.e. the General Medical Council (Table 2).

Table 2

Sanction options⁷

Sanction level	Description
1	None
2	Reprimand (verbal warning)
3	Reprimand (written warning)
4	Reprimand, plus mandatory counselling
5	Reprimand, counselling, extra work assignment
6	Failure of specific class/remedial work to gain credit
7	Failure of specific year (repetition allowed)
8	Expulsion from college (re-admission after one year possible)
9	Expulsion from college (no chance for re-admission)
10	Report to professional regulatory body

The inventory was developed as a Bristol Online Survey. Permission to administer it to the student population at a Scottish medical school was given by the university's research ethics committee. The Head of the Division and the Dean of the Medical School supported the project, and the Secretary of the Medical School issued it through his office to the approximately 700 medical school students (some of whom were on attachments out of the school and not accessing their email). All respondents were anonymized. Two email reminders were sent to all students at two- and four-week intervals before the closure of the survey after six weeks (Table 3).

Table 3

Median sanctions proposed for each unprofessional behaviour

Unprofessional behaviours	Median sanction
Involvement in paedophilic activities – possession/viewing of child pornography images	10.00
Involvement in paedophilic activities – molesting children	10.00
Sexually harassing a university employee or fellow student	9.00
Physically assaulting a university employee or fellow student	9.00
Providing illegal drugs to fellow students	9.00
Coercing faculty members into providing copies of papers prior to exam through bribery or intimidation	8.00
Sitting an examination for someone else or having someone else sit an examination for you	8.00
Arranging to pass an exam using private connections or by bribery	8.00
Altering grades in the official record	8.00
Threatening or verbally abusing a university employee or fellow student	8.00
Copying answers from a neighbour or enabling a neighbour to copy your answers during an exam	7.00
Exchanging answers by use of a mobile phone during an examination	7.00
Taking unauthorized material (e.g. crib sheets) into an exam	7.00
Sabotaging another student's work	6.00
Attempting to use personal relationships, bribes or threats to gain academic advantages	6.00
Inventing extraneous circumstances to delay sitting an exam	6.00
Falsifying references or grades on curriculum vitae	6.00
Engaging in substance misuse (e.g. drugs)	6.00
Plagiarizing work from a fellow student or purchasing work from a supplier	5.00
Paying a fellow student, or being paid by a fellow student, for completion of coursework	5.00
Receiving information about a paper from students who have already sat the exam or providing information about a paper to students who have yet to sit it	5.00
Intentionally falsifying test results or treatment records in order to disguise mistakes	5.00
Forging a health-care worker's signature on a piece of work, patient chart, grade sheet or attendance form	5.00
Drinking alcohol over lunch and interviewing a patient in the afternoon	4.50
Altering or manipulating data (e.g. adjusting data to obtain a significant result)	4.00
Completing work for another student	3.00
Claiming collaborative work as one's individual effort	3.00
Re-submitting work previously submitted for a separate assignment or earlier degree	3.00
Intentionally paraphrasing text in an assignment, or copying text directly, without acknowledging the source	3.00
Removing an assigned reference from a shelf in the library in order to prevent other students from gaining access to the information in it	3.00
Getting or giving help for coursework, against a teacher's rules (e.g. lending work to another student to look at)	2.00
Failing to correctly acknowledge a source (e.g. copying text directly but only including the source in reference list)	2.00
Accessing old exam papers or coursework, which have not been released to the whole class, to assist with study	2.00
Signing attendance sheets for absent friends, or asking classmates to sign attendance sheets for you in labs or lectures	2.00
Missing lectures frequently	2.00
Failing to follow proper infection control procedures	2.00
Examining patients without knowledge or consent of supervising clinician	2.00
Lack of punctuality for classes	2.00
Not doing the part assigned to him/her in group work	2.00
Damaging public property, e.g. scribbling on desks or chairs	2.00
Citing sources that have not in fact been read in full	1.00

Results

Of the 700 medical students, 375 responded: a response rate of 54%. Forty-two (11%) were first-year students; 82 (22%) second-year; 75 (20%) third-year; 74 (20%) fourth-year; and 102 (27%) fifth-year students. The male-to-female ratio was 1:2, which was typical of the full cohort. A majority (259; 69%) of respondents were in the 20–24 years age group; 66 (18%) were younger than 20 years and 49 (13%) were older than 25 years.

There were several statistically significant gender differences in the recommended sanction as set out in Table 4, but they were not all in one direction.

Table 4

Gender differences in proposing sanctions

Unprofessional behaviours	Median sanctions proposed by females	Median sanctions proposed by males	P
Accessing old exam papers or coursework, which have not been released to the whole class, to assist with study	2.00	1.00	0.004
Sabotaging another student's work	6.00	7.00	0.000
Attempting to use personal relationships, bribes or threats to gain academic advantages	6.00	7.00	0.047
Arranging to pass an exam using private connections or by bribery	8.00	9.00	0.024
Falsifying references or grades on curriculum vitae	6.00	7.00	0.023
Altering grades in the official record	8.00	9.00	0.000
Threatening or verbally abusing a university employee or fellow student	9.00	8.00	0.006
Engaging in substance misuse (e.g. drugs)	7.00	5.00	0.022

There was little difference by age group in the recommended sanctions. However, failing infection control procedures was proposed with stricter sanction by 17–19 age group than by their older counterparts (P = <0.05).

There were several statistically significant differences in the sanctions between the different year groups as shown in Table 5, but there were only two differences of more than one point. The junior years recommended a sanction of 5 (reprimand, counselling, extra work assignment) for ‘intentionally falsifying test results or treatment records in order to disguise mistakes’, whereas the fourth-year respondents proposed sanction 7 (failure of specific year [repetition allowed]) while fifth-year respondents proposed sanction level 6 (failure of specific class/remedial work to gain credit). This result may alert the medical school to a need for clear guidance, especially in the junior years and at the point at which students move into more direct clinical work.

Table 5

Variation of sanctions with the year of study

	Median sanctions
Unprofessional behaviours	Year 1	Year 2	Year 3	Year 4	Year 5	P
Plagiarizing work from a fellow student or purchasing work from a supplier	5.00	5.00	5.00	6.00	5.50	0.000
Completing work for another student	3.00	3.00	3.00	4.00	3.00	0.045
Claiming collaborative work as one's individual effort	3.00	3.00	3.00	3.00	4.00	0.004
Re-submitting work previously submitted for a separate assignment or earlier degree	3.00	3.00	3.00	3.00	2.00	0.021
Missing lectures frequently	2.00	1.00	1.00	2.00	2.00	0.021
Intentionally falsifying test results or treatment records in order to disguise mistakes	5.00	5.00	5.00	7.00	6.00	0.000
Failing to follow proper infection control procedures	3.00	3.00	2.00	2.00	2.00	0.000
Examining patients without knowledge or consent of supervising clinician	3.00	2.00	2.00	1.00	2.00	0.000
Providing illegal drugs to fellow students	9.00	9.00	9.00	8.00	10.00	0.029
Drinking alcohol over lunch and interviewing a patient in the afternoon	5.00	5.00	4.00	4.00	4.00	0.314

Interestingly, the fourth years recommended that ‘examining patients without the knowledge or consent or supervising clinician’ should be ignored, while the other years gave it a relatively low sanction. Here again guidance might be required to clarify this issue as students move into more direct clinical contact with patients.

Discussion

The UK Council for Healthcare Regulatory Excellence in its July 2009 Annual Report called for ‘greater consistency to fitness to practice procedures across UK medical schools’ and the evolution of a ‘common sanction set’ across the health professions. The UK General Medical Council now requires proof of fitness to practice before a graduate can provisionally register as a doctor. Medical schools are expected to have fitness to practice procedures in place. Medical Students: Professional Behaviour and Fitness to Practise was published in 2007. This paper reports a study of medical students’ recommended sanctions for first time offences of poor professionalism with no mitigating circumstances as part of a wider study to benchmark appropriate sanctions for use in UK medical schools and beyond.⁸

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