Equal opportunities sexual orientation monitoring

GLADD's position statement on this important area can be downloaded here as a

Medical students with serious communicable diseases

Medical students with serious communicable diseases, such as HIV or Hepatitis B are currently excluded from the undergraduate medical course if these conditions are diagnosed, denying them a career in medicine. They are also afforded less confidentiality with regard to their diagnosis than qualified doctors or members of the general public. Is this fair? GLADD produced a discussion paper in 2000 which attempts to explore the current situation and whether this might be changed. This is shown below.




Medical students affected by serious communicable diseases - a discussion paper

Introduction

The General Medical Council may be in the process of reviewing its policy with regard to medical students who have (or may have) serious communicable diseases. It is therefore timely for GLADD to produce a discussion paper on this issue. This paper has been written by members of GLADD's Executive Committee.

Publication of the paper on GLADD's web pages is intended as a consultation exercise, prior to formal publication in mid-September 2000. Your comments are welcome and encouraged; please see the contacting us page for information about how to send your comments to GLADD.

 

Diagnosis, confidentiality and subsequent management

The term serious communicable disease is defined by the General Medical Council as:

Any disease which may be transmitted from human to human and which may result in death or serious illness. It particularly concerns, but is not limited to, infections, such as Human Immunodeficiency Virus (HIV), tuberculosis, hepatitis B and C.1

 

Qualified doctors are required to seek appropriate medical advice if they think they have a serious medical condition which they might pass on to patients.1,2 Such guidance may include advice regarding appropriate modifications to clinical practice/work patterns. Qualified doctors are entitled to receive this advice in confidence, although part of the advice may involve discussions about the disclosure of any positive diagnoses to colleagues or their employer. Indeed, it is Department of Health policy that confidentiality should be maintained (including the use of media injunctions if necessary) for any health care worker with a serious communicable disease.3,4 If possible, a qualified doctor's work pattern should be modified so that they do not have to perform exposure-prone procedures. If work pattern modification is not possible then the doctor is entitled to re-training in order the practise in a specialty which does not involve performing exposure-prone procedures.3, 4 Entitlement to such re-training may come under the remit of the Disability Discrimination Act 1998.

The GMC health procedures deal with doctors whose own health may put the health of their patients at risk.5 Although this primarily refers to psychiatric illness, and drug and alcohol dependencies, the health procedures can also be applied to doctors with a serious communicable disease. Doctors are required to undergo appropriate medical supervision, as outlined above, and failure to follow this guidance can be deemed to be serious professional misconduct and therefore may be a disciplinary offence.

Patients who may have a serious communicable disease are entitled to receive appropriate counselling regarding the implications of a positive diagnostic test result prior to such diagnostic tests being performed. Such tests should normally only be performed with their consent. Patients are entitled to the results of such tests being treated in confidence.1

Medical students who believe they may be a carrier of a serious communicable disease are required to seek appropriate medical advice and to inform their medical school of their concerns. Doctors treating medical students with serious communicable diseases are required to disclose information regarding the nature of the condition to the medical school authorities as soon as possible.6 Although a student's consent prior to disclosure is considered to be desirable, the GMC Guidance permits the disclosure of information regarding medical students to the medical school whether or not consent has been granted. The GMC also recommends that counsellors and other non-medical advisors, although not bound by GMC regulations, should follow this advice when consulted by medical students.7

The GMC guidance 'Student Health and Conduct' is interpreted by the Council of Heads of Medical Schools, the Committee of Vice-Chancellors and Principals or by each medical school individually, who have their own procedures for the conduct and health of students. In 1994, the Committee of Vice-Chancellors and Principals issued guidance to medical and dental schools, stating that infectious carriers of hepatitis B should be precluded from commencing an undergradute course in medicine or dentistry and, should they have commenced the course, that it should be terminated.8 Beyond this, there have been a variety of interpretations of the guidance regarding serious communicable diseases such that one university's undergraduate prospectus contained a paragraph discouraging students at risk of serious communicable diseases from applying.9 This paragraph has been removed from subsequent editions of the prospectus.

Whereas qualified doctors are entitled to appropriate counselling and retraining in the event of a diagnosis being made of a serious communicable disease, this is not the case for medical students who are likely to find their undergraduate medical course being terminated. The basis for this is that, both in undergraduate medical training and the year of general clinical training (PRHO year), medical students and PRHOs are expected to obtain undifferentiated experience of medicine and surgery and it is the opinion of the GMC Education Committee that this could not easily be sustained if the clinical experience has to be circumscribed in the interest of patient protection:

38. Medical students who may be infectious to patients will not be able to follow a modified curriculum. The medical act of 1983 requires the GMC to prescribe the knowledge and skill which each graduating student must possess and to ensure that the training offered by every UK university with a medical school meets these requirements. The GMC cannot offer a restricted form of provisional registration or full registration to those who cannot safely carry out invasive or exposure-prone procedures on patients.2
39. We recommend that students who are Hepatitis B e-antigen positive should not be allowed to begin or continue with a degree in medicine unless they respond to interferon therapy. They should receive counselling and advice on alternative courses and careers.2

 

The guidance contained in 'Student Health and Conduct' regarding medical students with serious communicable diseases was originally written to apply to students with e-antigen positive Hepatitis B. It has subsequently been extended to include all serious communicable diseases following the case of Dr Ngosa in 1997. This decision has yet to be reviewed and appropriate guidance contained within 'Student Health and Conduct'. Although there are similarities between modes of transmission of HIV and Hepatitis B, the risks of transmission are different (this is reflected in them being classed in different COSHH categories)10 thus it is not necessarily logical to extend the GMC guidance on Hepatitis B to include all other serious communicable diseases.

Modern therapy for Hepatitis B can reduce infectivity to an extent that healthcare workers are able to resume exposure-prone procedures, subject to appropriate monitoring.4 Anti-retroviral therapy for HIV can also reduce the HIV viral load to such a level that the virus is no longer detectable. Indeed such therapy has been demonstrated to reduce the vertical transmission of HIV from infected mother to baby during childbirth.

The threat of course termination may, potentially, discourage medical students who are concerned that they may have a serious communicable disease from seeking appropriate medical advice. This would be to the detriment of their own health as well as potentially to that of any patients that they come into contact with, should they continue to carry out exposure-prone procedures.

Guidance from the Department of Health does not prohibit healthcare workers from carrying out invasive procedures but does limit their participation in exposure-prone procedures.3,4

Exposure-prone procedures

The following definitions of exposure-prone procedures are taken from a Department of Health publication:3

3.2 All breaches of the skin or epithelia by sharp instruments are by definition invasive. Most clinical procedures, including many which are invasive, do not provide an opportunity for the blood of the health care worker to come into contact with the patient's open tissues. Provided the general measures to prevent occupational transmission of blood-borne viruses are scrupulously adhered to at all times most clinical procedures pose no risk of transmission of HIV from an infected health care worker to a patient, and can safely be performed.
3.3 Exposure prone procedures are those invasive procedures where there is a risk that injury to the worker may result in the exposure of the patient's open tissues to the blood of the worker. These include procedures where the worker's gloved hands may be in contact with sharp instruments, needle tips or sharp tissues (e.g. spicules of bone or teeth) inside a patient's open body cavity, wound or confined anatomical space where the hands or fingertips may not be completely visible at all times.
3.5 Procedures where the hands and fingertips of the worker are visible and outside the patient's body at all times, and internal examinations or procedures that do not involve possible injury to the worker's gloved hands from sharp instruments and/or tissues, are considered not to be exposure prone provided routine infection control procedures are adhered to at all times. Examples of such procedures include:
  1. taking blood (venepuncture);
  2. setting up and maintaining IV lines or central lines (provided any skin tunneling procedure used for the latter is performed in a non-exposure prone manner;
  3. minor surface suturing;
  4. the incision of abscesses;
  5. routine vaginal or rectal examinations;
  6. simple endoscopic procedures.
The final decision about the type of work that may be undertaken by an infected health care worker should be made on an individual basis, in conjunction with a specialist occupational physician, taking into account the specific circumstances including working practices of the worker concerned.
3.6 The decision whether an HIV infected worker should continue to perform a procedure which itself is not exposure prone should take into account the risk of complications arising which necessitate the performance of an exposure prone procedure; only reasonably predictable complications need to be considered in this context.
3.8 Those exposure prone procedures most frequently associated with transmission of hepatitis B from infected surgeons to patients are likely to pose a higher risk of HIV transmission to patients when performed by HIV infected health care workers. Such procedures are referred to in this document as higher risk exposure prone procedures. Examples have been open cardiothoracic surgical procedures including sternal opening and closure, and major gynaecological surgical procedures, e.g. caesarian section, hysterectomy. Cardiothoracic and major gynaecological surgery also have relatively high rates of needlestick injury of health care workers which may explain the greater risk of exposure of patients to their blood. Although most such research has been US-based, a small UK study showed similar conclusions.

 

A point of discussion is whether the performing of, taking part in, or first hand experience of any of the above exposure-prone procedures is essential experience in order to graduate from medical school and to perform effectively as a PRHO. It is unlikely that medical students or PRHOs will be performing such exposure-prone procedures, even under emergency circumstances. The use of anatomically correct models for teaching purposes would reduce the need to perform exposure-prone procedures for educational purposes. A recent study surveyed educational supervisors in the Northern Deanery in an attempt to establish a consensus opinion as to which tasks should be considered appropriate to PRHOs.11 None of the practical procedures identified in the consensus would be defined as exposure-prone under the Department of Health definitions.3 The GMC's own guidance, 'Tomorrow's Doctors' does not explicitly contain requirements for medical students to participate in exposure-prone procedures.12

Although the GMC maintains in its current guidance6 that it is not possible to modify an undergraduate course or PRHO year sufficiently to avoid exposure-prone procedures and ensure adequate undifferentiated clinical experience, GLADD has received correspondence from one post-graduate dean's department which believes that this is indeed possible. This is also the opinion of the Medical Students' Committee of the British Medical Association.7 In addition, the Representative Body of the BMA passed the following resolution at the Annual Representatives' Meeting in 1999:

That the prohibition of hepatitis B carriers from gaining entry to medical school or completing their medical degree is grossly unjust and should be reversed, with appropriate modification to the undergraduate course and pre-registration year, given the plethora of medical career options which do not require performing exposure-prone procedures.13

 

It is sometimes suggested that society as a whole should determine whether or not members of the medical workforce should be able to continue with patient contact if they have a serious communicable disease. However, Department of Health guidance exists which aims to reduce to a minimum the possibility of a serious communicable disease being transmitted from healthcare worker to patient. These publications also contain recommendations about modifications to working practices and re-training for healthcare workers with serious communicable diseases.3,4

Disability

It is possible that workplace modifications for those with serious communicable diseases comes under the remit of the Disability Discrimination Act 1998. The Departments of Health state the following with regard to HIV and disability:

5.5 The Disability Discrimination Act 1995 makes it unlawful to discriminate against disabled persons including those with symptomatic AIDS or HIV infection in any area of employment, unless the employer has justification, a material and substantial reason. The restriction of such a worker for the purpose of protecting patients from risk of infection, such as the requirement to refrain from performing exposure prone procedures, would justify discrimination. However the employer who knows that the worker is disabled has a duty to make reasonable adjustment, e.g by moving the worker to a post, if available, where exposure prone procedures could be avoided. Asymptomatic HIV infection does not bring the worker within the protection of the Disability Discrimination Act. The NHS Executive letter EL(96)70 refers to the general implications of the Act for the NHS.3

 

It is possible that the remit of the Disability Discrimination Act will be extended in the near future to include people with asymptomatic HIV infection. This extension of the DDA has been recommended by the Disability Rights Task Force.14 It may be that GLADD, and other organisations, should be considering campaigning for this change to be made to the DDA.

The Disability Discrimination Act is likely to be extended in the Autumn of this year, to include all services provided by education. There may be implications for this with regard to medical students with serious communicable diseases. The Human Rights Act, which is to come into force in October 2000 may also be relevant in this respect.

Much discrimination on the basis of HIV infection begins when the diagnosis is made, rather than when symptoms develop, which can often be many years after contracting the infection. Indeed, discrimination may also occur because somebody is perceived to be at a high risk of contracting HIV.15 There have also been many, well-publicised, cases of employees successfully taking legal action against employers who have discriminated against them on the basis of simply carrying HIV, rather than symptomatic HIV infection preventing the person from working.16

Current clinical practice in HIV management is very much reliant on the results of blood tests (e.g. CD4 count and viral load) to guide therapy rather than pure symptoms and thus HIV+ patients may be experiencing side-effects from the therapy rather than symptoms of the disease. This is another way in which disability begins with diagnosis rather than symptoms.

The very fact of having an HIV infection if you work in the health care professions means that you must change your working practices if you carry out exposure-prone procedures.3,4 Having symptoms of HIV infection does not make any difference to these requirements. Thus the disability (if defined as not being able to carry out your work in the way that you would otherwise do) begins with the diagnosis.

A similar set of arguments might be used for Hepatitis B, which is often asymptomatic and treatment is based on blood results. Presently, it is not clear whether Hepatitis B infection is covered by the DDA in the way that HIV is, though it would be possible to argue for this to be the case, perhaps more so as Hepatitis B is considered to be more contagious than HIV in the event of a needlestick injury.

The Medical Act, 1983, makes provision for the Registration Committee of the GMC to consider applications for the approval of alternative experience in the case of doctors prevented by lasting physical disability from embarking on or completing any period of experience prescribed for the purpose of full registration.6 GLADD has received correspondence from a postgraduate dean's department indicating that undergraduate courses and PRHO years have been modified in the past to accommodate the needs of disabled medical students such as those with broken limbs, paralysis, carcinoma and multiple sclerosis. This was presumably with the consent of the GMC Registration Committee. Although there may be concerns amongst medical school deans and perhaps the GMC about the feasibility of course modification, it has already been achieved. The course modifications required for a medical student or PRHO to avoid carrying out exposure-prone procedures would be relatively modest in comparison to those required to allow a medical student with a physical disability to complete the course. Medical schools are being scrutinised to ensure that their admission criteria select students who reflect, as broadly as possible, the diversity of the population as a whole.17 Demonstrating a willingness to modify courses appropriately for medical students with physical disability might encourage applications from such students.

Although the General Medical Council may state that its decisions are limited by guidance from Parliament and that the GMC is not in a position to seek changes to the guidance issued by Parliament, some members of the GMC are, necessarily, members of the Privy Council and the GMC would have to seek changes to the Medical Act in order, for example, to approve the establishment of a new medical school.

Conclusions

  • Medical students with serious communicable diseases are currently not afforded the same level of confidentiality as either patients or health-care professionals;
  • Whereas qualified doctors with serious communicable diseases are able to continue to work in the medical profession, subject to suitable work pattern modifications or re-training, undergraduate medical students have their course terminated. They may therefore be denied a career in medicine where they have the potential to fulfil a valuable role working in a specialty which does not involve performing exposure-prone procedures;
  • Medical students are treated differently to qualified doctors when there is sometimes only an arbitrary difference between the two which can be only a matter of a few days in terms of time or a piece of paper arriving through the post;
  • This discriminatory treatment of medical students may lead to them not developing appropriate help-seeking behaviour which may be to the detriment of their health and that of their patients;
  • It is doubtful whether the taking part in exposure-prone procedures is an essential part of the undifferentiated clinical experience which medical students and PRHOs are required to undertake. Although the GMC states that course modifications for medical students with disabilities are not possible, such modified courses have already been implemented successfully, presumably with the GMC's approval;
  • The management of health care workers with HIV, whether asymptomatic or not, is likely to fall within the remit of the Disability Discrimination Act. It may be desirable for the DDA remit to include other serious communicable diseases which require a change in working practice from those workers affected by them;
  • Although blood-borne viral infections have similar routes of transmission, their infectivity rates vary considerably. A number of anti-viral therapies currently in use (and others in the future) may also modify the infectivity of viral infections. A review of guidance on serious communicable diseases should take this into account.

References

  1. General Medical Council. Serious Communicable Diseases. London: GMC, October 1997
  2. General Medical Council. Good medical practice. London: GMC, July 1998
  3. UK Departments of Health. AIDS/HIV infected health-care workers: Guidance on the management of infected health care workers and patient notification. London: UK Departments of Health, 1999.
  4. UK Departments of Health. Hepatitis B infected health care workers: Guidance on implementation of Health Service Circular 2000/020. London: UK Departments of Health, 2000.
  5. General Medical Council. Helping doctors who are ill. London: GMC.
  6. General Medical Council. Student health and conduct. London: GMC, 1996.
  7. BMA Medical Students' Committee. Student Health and Conduct: Position paper by the BMA Medical Students' Committee. London: BMA, 1999.
  8. Committee of Vice-Chancellors and Principals of the Universities of the United Kingdom. Guidance on fitness to practise: hepatitis B. London: The Committee, 1994.
  9. University of Cambridge. Undergraduate prospectus for entry 1999-2000. Cambridge, 1998.
  10. UK Departments of Health. Guidance for Clinical Health Care Workers: Protection Against Infection with Blood-borne Viruses. London: UK Departments of Health, 1998.
  11. Stewart, J, O'Halloran, C, Harrigan, P, Spencer, JA, Barton, JR., Singleton, SJ. Identifying appropriate tasks for the pre-registration year: modified Delphi technique. BMJ 1999; 319: 224 - 229.
  12. General Medical Council. Tomorrow's Doctors. London: GMC, December 1993.
  13. British Medical Association. Minutes from Annual Representatives' Meeting 1999. London: BMA, 1999.
  14. Dayal Mistry. Personal communication (e-mail). Leicester: Leicestershire Centre for Integrated Living, 8th July 2000.
  15. Godwin, J. Promoting disabled people's rights: creating a Disability Rights Commission fit for the 21st Century. London: National AIDS Trust, 15th October 1988.
  16. Disability Now. Biggest DDA win in HIV case. London: Disability Now, May 2000.
  17. BMA Board of Medical Education. A report of a BMA conference on selection for medical school. London: British Medical Association, December 1999.