Medicine is also a costly course, both to the student and to society. Students are committed to full-time study for at least five years, requiring substantial funding for living costs and tuition fees. Public funding via the Higher Education Funding Council for England (HEFCE) and the Service Increment for Teaching (SIFT) contributes over £200,000 per medical graduate (personal communication with Faculty staff).

Students who fail to thrive on the course, or leave before graduation, are therefore a cause for concern. For the individual student there may be substantial financial and emotional costs involved with failure or course withdrawal, perhaps including shame or stigma. For the Faculty, the provision of additional services such as increased pastoral support or resit examinations generates an extra workload. Students who fail drastically but go through the Appeals process, or are called before a Fitness to Practise committee, will also require substantial staff time and resources. And finally, there is a financial cost to society if an expensive medical school place does not lead to graduation. This also has relevance to long-term workforce planning in the NHS, which must take account of the expected number of new medical graduates each year [2,3].

Progression on the course at Nottingham is subject to clearly-defined regulations, and requires minimum academic standards to be reached at all stages. The first two years are primarily preclinical and laboratory sciences, with some patient contact and early professional development. Failed summative examinations may be retaken once at a later date, but further failure leads to an automatic notice of termination. The third year consists of an Honours course (research project plus taught courses), and then the start of the clinical course, all of which must be passed for onward progression. In the later, clinical, parts of the course (Years 4 and 5), progression requires satisfactory completion of clinical attachments as well as the passing of written and practical examinations. Students failing one or more clinical sections may be required to repeat all or part of an attachment or to resit examinations, sometimes after course suspension and re-start. Successful progress also requires professional standards of behaviour to be met at all times; deviations from such standards may invoke Fitness to Practise procedures on behavioural or health grounds [4].

Students may bring forward personal extenuating circumstances, such as acute illness or unexpected family problems, for consideration by the Faculty. If these are accepted, students may re-take their exams as ‘first sits’. Students issued with termination notices have a right to appeal within a set time frame, and against requirements set down by the University. All students have personal tutors plus access to more senior staff, and are advised and encouraged to seek help and advice for anxieties and difficulties, whether they be academic or personal in nature. Meetings with personal tutors are structured and mandatory during the first two years, and available on demand subsequently. Despite these supportive mechanisms, a number of students leave unexpectedly or fail to seek help for their problems until it is too late.

Course progress data included progression or attrition during each academic year of the 5-year course, adverse health or social factors, examination failures, course suspensions or repeats, termination recommendations and appeals, and voluntary withdrawals.

Discrete categories of information recorded for the study, for example a yes/no option for health problems, were supplemented by free text entries. This type of data category is variable and may be difficult to interpret, but was judged on the basis of whether it appeared to have a measurable or probable impact on the student’s progression. For example, a one-off acute episode of self-limiting illness would not be categorised as a health issue, whereas recurrent migraines leading to missed attendance would be. In this paper, mental health is used as an umbrella term in order to protect confidentiality. It covers a wide variety of disorders including disabling anxiety, eating disorders, and depression of varying severity.

Each student was allotted a confidential Study ID at the time of data entry and no personal identifiers were retained. Data were analysed by running reports from Access or after transferring the file into SPSS v17.

Of the remaining 73, 61 left the course voluntarily and 12 had their courses terminated in Year 1 or 2 for academic failure. The highest rates of attrition were in the early years of the course, as shown in Figure1.

We examined the patterns and reasons for attrition on a yearly basis. In all cases the year of exit is the academic year of study, regardless of the number of years spent on the course.

The number of students affected is relatively small, yet still significant for each one who has made the major life decision to read medicine, then either finds it is not the right choice or has to suffer the consequences of course failure. Our best efforts in admission and selection procedures do not always succeed, for a multitude of possible reasons; academic ability at school may not be sufficiently adaptable to meet the demands of the medical course; unanticipated health or social problems may derail progress, or the realities of clinical medicine may be overwhelming. This study has also illustrated that family pressure has, in a few cases, resulted in students who do not have enough personal motivation to thrive and succeed, and perhaps this also was an undeclared factor in some of the students who changed their minds within the first year or two. Currently the Faculty does not ask such students about their decision to leave in any depth, and therefore our information is lacking in detail. There were clearly many interacting factors that we could not analyse. We believe that the introduction of a structured exit interview will help us to quantify these issues in future.

The majority of medical students will have been high-achievers at school and have equally high expectations of their future abilities. They may find it hard to accept that they are not coping academically, and thus be reluctant to seek or accept help even when it is evident to tutors that they need to do so [7]. The students in this study who were given a second chance, by repeating Year 1, yet still failed, may have lacked key strategic learning skills; successful remediation may require very specific interventions to address any deficiencies [8], which has resource implications for the Faculty. A study based on individual student appraisal meetings at another UK medical school has suggested that up to 70% of first year students may recognise the need for advice on study skills, but not all will achieve the necessary goals [9]. Our students are asked about academic issues at their regular meetings with personal tutors, but the extent to which study skills are explored and reflected upon may vary between different tutors and not lead to targeted or mandatory interventions.

Medicine requires physical and mental stamina and resilience [10-12], and health issues were often a significant factor in course attrition. Several students who withdrew in the clinical course had clearly been struggling in the face of poor mental health for some years. Medical students may perceive additional difficulties with ill-health because of fears about confidentiality [13-16] . However, looking after one’s own health and well-being is required by the General Medical Council as a pre-requisite for safe medical practice [17,18].

As yet there is no valid and acceptable way to detect psychologically vulnerable students. Research in Australia has demonstrated the impact of dysfunctional tendencies on academic performance, which may therefore contribute to drop-out [19]. Much attention has been given to the development of valid and robust psychological tests which could be used to screen out candidates with extreme personality characteristics [11]. However, a longitudinal study of students in the UK who sat this test has unfortunately been technically unable to report on any association with drop-outs [20].

Can anything more be done to reduce attrition? In the case of students who leave within weeks after a change of heart, probably not; they had managed to convince our interview panels of their suitability and motivation.

Similarly, there was no conclusive evidence within our data that those who failed to complete the course were less academically able on course entry. A recent systematic review of the literature has concluded that a poorer pre-admission academic record may sometimes be associated with dropout [21], but our students almost all arrive with good academic grades. It will be interesting to see whether the UKCAT test, currently used by Nottingham and many other UK medical schools [22], shows any correlation with course performance or failure. Early evidence is equivocal [23,24]. Measurable academic ability may however be compromised by deficient study processes or external personal and social circumstances, requiring individual support and mandatory remediation [25][26]. Although we strive to offer personal academic support at Nottingham, ultimately it is the student’s responsibility to engage. Those who need the most help may be those who decline [27], and there has to be a line drawn between giving appropriate support and raising expectations too high by ‘failing to fail’ [28].

In the clinical years, when our students are based in a variety of different clinical settings, some distant from Nottingham, tutor contact may be less easy. We are therefore reviewing the support mechanisms for our clinical students.

In the case of severe or recurrent health issues, especially mental health, there is perhaps a need for the GMC to develop additional guidance to medical schools. Current documents state that health concerns can be addressed within Fitness to Practise procedures but do not provide the practical advice that may be required [4]. Although the medical school may seek the advice of Occupational Health physicians when a student has needed ‘time out’ for health reasons, their assurance that a student is fit to continue their studies may still leave doubt about fitness for an on-going career. A small number appear to lack insight into their future ability to function as a doctor, so earlier but more decisive action may be required.