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Is Academic Attainment or Situational Judgment Test Performance in Medical School Associated With the Likelihood of Disciplinary Action? A National Retrospective Cohort Study

Sam, Amir H. PhD, MBBS1; Bala, Laksha MB BChir, MA2; Westacott, Rachel J. MB ChB3; Brown, Celia PhD4

Author Information
doi: 10.1097/ACM.0000000000004212

Abstract

Problems relating to a physician’s professional performance, misconduct, or adverse physical or mental health 1 can affect patient safety and lead to disciplinary action being imposed on their registration and/or license to practice medicine. Examples of organizations responsible for ensuring that physicians are fit to practice medicine and provide safe care to patients are the state medical boards in the United States and the General Medical Council (GMC) 2 in the United Kingdom. In the United States, state medical boards can impose actions, including revocation or suspension of a medical license, probation, limitations to practice, fines, or mandatory education of the physician. 3 In the United Kingdom, disciplinary action can take the form of erasure, suspension, conditions, undertakings, or warnings. 4

The potential hazard to public safety posed by physicians is of great importance and, therefore, efforts should be made to identify which physicians are most at risk of disciplinary action to help prevent the occurrence of patient harm. Indeed, the earlier these physicians are identified, the sooner interventions can be put in place to remediate physicians and potentially prevent patient harm. Identifying risk factors for future disciplinary action is of global relevance and reflects a common goal to protect the values of the profession, improve the quality of medical care, and promote public safety.

Previous work has identified certain personal risk factors for disciplinary action including being male; being older; lack of board certification; practicing in the specialties of family medicine, psychiatry, or obstetrics and gynecology; being an international medical graduate 5; and increased years in clinical practice. 6,7 Previous academic performance has also been shown to be associated with the risk of future disciplinary action. In the United Kingdom, poor performance on several postgraduate examinations has been linked with an increased risk of disciplinary action. 8,9 There are similar findings for performance on the United States Medical Licensing Examination (USMLE), 10 the Comprehensive Osteopathic Medical Licensing Examination of the United States, 11 and the Medical Council of Canada Qualifying Examinations, 12–14 which are taken at various points as a student progresses through medical school and residency. One case–control study from the United Kingdom also highlights that failing examinations taken in the early years of medical school is an independent predictor of future serious professional misconduct. 15

Despite the significant results of studies focusing on academic performance, this does not preclude the need to identify other possible determinants of professional misconduct. Several high-profile failures in the standards of professionalism expected in U.K. hospitals 16 have led to considerably more emphasis being placed on the importance and assessment of professional attributes. It seems plausible that performance on assessments of professional attributes could be associated with future disciplinary action, but, to date, no studies have looked at data from such assessments. Due to the recent development of a longitudinal national database—the UK Medical Education Database (UKMED)—such a study can now be undertaken.

In the United Kingdom, new medical graduates enter the UK Foundation Programme, a 2-year training program undertaken after graduation and before entering specialty training (similar to the internship year in the United States). While all graduates can enter the UK Foundation Programme if they wish, the allocation of specific training posts is competitive and determined by scores on 2 undergraduate medical assessment components that are used nationally in the United Kingdom: the situational judgment test (SJT) and Educational Performance Measure (EPM). The SJT is worth a minimum of 0 points and a maximum of 50 points. The EPM is worth a minimum of 34 points and a maximum of 50 points.

The SJT is a national written assessment managed by the UK Foundation Programme Office and taken by medical students in their final year. It is designed to test some of the professional attributes expected of a foundation year 1 doctor (equivalent to an intern in the United States), as described in the UK Foundation Programme person specification (a list of essential criteria required of a newly qualified physician). 17 A previous study of first-year physicians found that those with SJT scores in the bottom quintile were almost 5 times more likely to receive remedial action for clinical or nonclinical performance (i.e., one-to-one training or additional learning due to suboptimal performance, as opposed to disciplinary action) compared with those in the top quintile. 18

The EPM score comprises 2 elements: medical school performance and additional educational achievements. Medical school performance involves assigning all students a decile score according to their academic performance within their medical school. Each medical school decides which assessments contribute to the decile score and their respective weightings. Additional educational achievements such as degrees (e.g., PhD) and publications also contribute to the EPM score.

This national retrospective cohort study therefore sought to examine whether there was an association between academic attainment (EPM) or performance on an SJT in medical school and the risk of receiving subsequent disciplinary action within the first 5 years of professional practice as a physician in the United Kingdom.

Method

Study population

We obtained data from the UKMED database (extract UKMEDP107) that contained anonymized data for 44,690 physicians in the United Kingdom on September 20, 2019. Data held by the UKMED that were used in this research were exempt from review by an institutional review board (per the Queen Mary Ethics of Research Committee, January 16, 2017). In accordance with the Higher Education Statistics Agency’s statistical disclosure controls, we rounded all frequencies to the nearest multiple of 5 and suppressed percentages based on fewer than 22.5 individuals, which are denoted as (...). 19

Inclusion criteria.

We analyzed data for 37,425 physicians who were U.K. medical school graduates and started the UK Foundation Programme (i.e., working as interns or first-year physicians) between 2014 and 2018 (inclusive). This provided 1–5 years of exposure during which physicians might be disciplined (up to July 31, 2019).

Exclusion criteria.

We excluded data for graduates from outside the United Kingdom (i.e., for those who did not have EPM and SJT scores), who withdrew their application to the UK Foundation Programme and, therefore, did not start work as a physician, or who had less than 30 days on the medical register (list of qualified physicians). We censored (i.e., removed from the analysis) physicians who chose to leave the register for reasons other than disciplinary action (e.g., moving abroad) at the point when they first left. If these physicians rejoined the register at a later date, we did not reintroduce them into the study. We also excluded physicians missing key data (e.g., no data on SJT score or date of entry onto the medical register) from the study. We included data for 93% of physicians (34,865/37,425) from 33 U.K. medical schools in the final analysis (see Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/B136, which demonstrates the flow of UKMED data included in final analysis).

Data management

We computed a number of summary variables from the UKMED data. Some data were missing for variables we had hoped to include in this analysis (e.g., widening participation index, which measures medical school entry for people from underrepresented groups in the population, such as ethnic minorities or those from lower-income backgrounds). We also undertook data checking to identify any potential erroneous values and to minimize any subsequent bias. Based on the years over which data were available and the extent of missing data, we identified the following control, outcome, and explanatory variables for our analysis.

Control (demographic) variables.

The control variables included UK Foundation Programme start year, medical student fitness to practice concerns (for this variable, we only included those students with action outcomes, i.e., students who had a fitness to practice concern raised in medical school but received a “no action” outcome were excluded), gender, graduate status on entry to medical school (i.e., did an alternative degree first before applying for medical school, which is commonplace in the United States), and ethnicity (White vs Black, Asian, and minority ethnic [BAME]). We did not include medical school attended as it has been shown not to be predictive of disciplinary action among U.K. graduates. 20

Outcome variables.

A binary (1 or 0) outcome variable was created for disciplinary action or no disciplinary action. We then computed time in days from beginning work as a physician (i.e., entering the UK Foundation Programme) to the date of disciplinary action.

Explanatory variables.

The explanatory variables included the SJT score (out of 50) and EPM score (a composite score out of 50 created by combining the decile [based on academic performance], degree, and publication scores) from students’ first application to the UK Foundation Programme (rather than from the year of successful application). We converted these data to normalized deviate values by year of the first UK Foundation Programme application (mean = 0, standard deviation [SD] = 1) to account for our use of SJT and EPM scores from different years. 21 We observed approximate normal distributions of data, thereby enabling parametric analysis.

Data analysis

We used Stata V15 (StataCorp, College Station, Texas) for data management and analysis.

Descriptive analysis.

We analyzed demographic data according to whether physicians received disciplinary action, were censored out (left register for reasons other than disciplinary action), or remained on the register (up to July 31, 2019) without being censored out or receiving disciplinary action.

Univariate analysis.

We performed an analysis comparing physicians who had received disciplinary action to those who did not receive disciplinary action (either censored out or reached July 31, 2019, without being censored out or receiving disciplinary action) for gender, ethnicity, and graduate status on entry to medical school. We undertook chi-square tests and calculated the relative risk reductions to quantify these associations. We compared mean EPM and SJT scores of physicians with and without disciplinary action using an unpaired t test for each explanatory variable. We identified the number of students who had fitness to practice concerns raised during medical school and went on to withdraw their UK Foundation Programme application. We did not analyze student fitness to practice concerns further as no students with a concern went on to receive disciplinary action after they qualified as a physician.

Relationship between EPM and SJT scores and disciplinary action.

We performed an analysis of the relationship between EPM and SJT scores and the probability of disciplinary action by calculating the proportion of physicians receiving disciplinary action within subgroups for each assessment (subgroups were defined by scores, from 34 to 50, for the EPM and by scores measured in units of 0.5 SD from the mean score, from –3.0 to +3.0 SDs, for the SJT). We analyzed trends using an ordinal chi-square test.

Multivariate survival analysis (Cox proportional hazards model).

The risk of disciplinary action increases with time on the medical register and this exposure time (i.e., time between registration and end of study) varied depending on each student’s date of entry onto the medical register. To account for this, we performed a multivariate survival analysis using the EPM and SJT scores as continuous independent variables in a Cox proportional hazards regression model and included appropriate control (demographic) variables as explained above. We did not include year of starting work as a physician as this was already accounted for by the use of survival (time to event) analysis. As a secondary analysis, we separated out the EPM into decile scores and additional educational achievements and undertook a further Cox proportional hazards model. The survival analysis produced a hazard ratio (HR) for each explanatory variable (EPM and SJT score). The HR reflects the relative risk of disciplinary action attributable to a 1-unit change in each variable at any point in time. We tested the proportional hazard assumption using the Schoenfeld test. 22

Statistical power.

We undertook a sample size calculation in Stata V15 (StataCorp, College Station, Texas) using a total sample size of 35,000 physicians (rounded up from 34,865). Based on national data for SJT scores for students across U.K. medical schools, 23 we used a mean score of 41 points and an SD of 3.5 in our calculation. A discipline rate of 0.5% in the first decade after qualification has previously been reported. 8 We analyzed data from 1 to 5 years after qualification and, therefore, assumed a disciplinary action rate of 0.1% for the power calculation. This is around the same as the GMC referral rate (i.e., how many physicians are referred to the GMC due to concerns regarding their fitness to practice medicine) for the first 2 years after qualification. 24 With the 2 explanatory variables (SJT and EPM scores), we used an alpha of 0.025. Our calculation demonstrated a power of 87% to detect a difference of 2 points on the SJT between the groups of physicians who did and did not receive disciplinary action (approximately 0.6 SDs).

Results

Descriptive analysis

Of the 34,865 physicians included in our study, the imposition of disciplinary action on a physician was a rare event (65, 0.19%; Table 1). For physicians who were disciplined, the mean exposure time in days to disciplinary action was just over 2 years (mean = 810 days, SD = 440 days). Twenty-five (0.35%) out of 7,060 physicians starting the UK Foundation Programme in 2014 received disciplinary action, compared with 5 (...) out of 6,865 physicians starting in 2018, confirming that the risk of discipline increases with length of exposure. None of the 125 physicians who had fitness to practice concerns as a student and who entered the UK Foundation Programme went on to face disciplinary action after they had qualified as physicians. Twenty medical students who had fitness to practice concerns raised during medical school subsequently withdrew their application to the UK Foundation Programme. For 5 of these students, withdrawal was due to expulsion from medical school.

Table 1
Table 1:
Demographics of Included Physiciansa From UKMED Databaseb

Univariate analysis

We identified being male and from a BAME background as potential risk factors for receiving disciplinary action as a qualified physician (Table 2). The association between graduate status on entry to medical school and the risk of disciplinary action was not statistically significant. Normalized mean EPM and SJT scores were higher for physicians who had not received disciplinary action compared with those who had (Table 3). We observed a raw mean EPM score of 41 and an SD of 3.8. Accounting for a difference in means of 0.67 for the EPM score (Table 3), our results reflect an approximate difference of 2.5 out of 50 for the EPM score between physicians who were disciplined and those who were not. Similarly, the raw mean SJT score (40) had an SD of 3.7, and we observed a difference in means of 0.53 (Table 3). This can be interpreted as an approximate difference of 2.0 out of 50 for the SJT score between physicians who were disciplined and those who were not.

Table 2
Table 2:
Univariate Analysis of Demographic Variables Against Outcome of Receiving Disciplinary Action for Included Physiciansa From the UKMED Database
Table 3
Table 3:
Univariate Analysis t Test for EPM and SJT Scores Against Outcome of Receiving Disciplinary Action for Included Physiciansa From the UKMED Database

Relationship between EPM and SJT scores and disciplinary action

To consider if there was a relationship between EPM and SJT scores and the probability of disciplinary action, we calculated the percentage of physicians disciplined within the subgroups defined for each assessment (see Method).

As demonstrated in Figure 1, a declining rate of disciplinary action was observed as the EPM score increased (ordered chi square = 32; P < .001). On visual inspection of the graph, there appeared to be a clear decrease in the percentage of physicians receiving disciplinary action when comparing those obtaining EPM scores of 39 and above with those obtaining scores of 38 and below. That is, the discipline rate for those scoring 38 and below was 0.41% (40/9,680), compared with 0.10% (25/25,185) for those scoring 39 and above.

Figure 1
Figure 1:
Relationship between the EPM score and the percentage of physicians with that score who received disciplinary action. EPM scores were extracted from the UKMED database for 34,865 physicians from 33 U.K. medical schools who started the UK Foundation Programme between 2014 and 2018. Abbreviations: EPM, Educational Performance Measure; UKMED, UK Medical Education Database.

As demonstrated in Figure 2, there was also a trend of declining rate of disciplinary action as the SJT score increased (ordered chi square = 13; P < .001). Visual inspection of the graph shows a comparatively high rate of disciplinary action for those in the lowest SJT group (< 2.5 SDs below the mean), but no disciplinary action for those in the next lowest group (between 2 and 2.5 SDs below the mean), a finding that disrupts the overall negative trend.

Figure 2
Figure 2:
Relationship between the SJT score, grouped according to the number of SDs away from the SJT mean score (41 points), and the percentage of physicians with scores in that group who received disciplinary action. SJT scores were extracted from the UKMED database for 34,865 physicians from 33 U.K. medical schools who started the UK Foundation Programme between 2014 and 2018. Abbreviations: SJT, situational judgment test; SDs, standard deviations; UKMED, UK Medical Education Database.

Multivariate survival analysis

For the purposes of the survival analysis, we defined the time to event as time to disciplinary action in days from first entering the medical register. None of the test statistics generated from the Schoenfeld test for the explanatory variables were statistically significant; therefore, the proportional hazards assumption was met and the unit of time was not deemed relevant. 22

The multivariate survival analysis demonstrated that an increase in the EPM score of 1 SD (approximately 3.8 out of 50 points or 7.6 percentage points) reduced the hazard of disciplinary action by approximately 50% (HR = 0.51; 95% confidence interval [CI]: 0.38, 0.69; P < .001). There was not a statistically significant association between the SJT score and the hazard of disciplinary action (HR = 0.84; 95% CI: 0.62, 1.13; P = .24). We observed that for a 1-unit increase in the deciles component of the EPM, the hazard of disciplinary action was reduced by 20% (HR = 0.80; 95% CI: 0.72, 0.90; P < .001), whereas there was no statistically significant association between the additional educational achievements component and the hazard of disciplinary action. The survival analysis also demonstrated that the hazard of disciplinary action was higher for males (HR = 5.34; 95% CI: 2.90, 10.00; P < .001), but the coefficients for ethnicity (HR = 0.70; 95% CI: 0.42, 1.20; P = .18) and graduate status on entry to medical school (HR = 1.70; 95% CI: 0.89, 3.30; P = .11) were not statistically significant.

Discussion

We investigated whether performance on a national SJT or academic attainment (via the EPM) in medical school is significantly associated with the risk of receiving future disciplinary action as physicians.

Disciplinary action is a rare event

Overall, the imposition of disciplinary action on a physician in their first 5 years of practice was a rare event. This may be a testament to the rigor of selection, education, and assessment of medical students in the United Kingdom. However, the potential risk to public safety of any underperforming doctor is substantial. As part of the effort to protect patients and uphold the values of the profession, methods need to be developed to identify physicians most likely to underperform early on in their career and provide an opportunity for remediation.

Higher scores on the EPM were associated with reduced hazard of disciplinary action, but there was no significant association with SJT scores

We observed that an increase in EPM score was significantly associated with a reduced hazard of disciplinary action and identified that higher rates of disciplinary action were associated with lower EPM scores. There was a clear decrease in the percentage of disciplinary action between EPM scores of 38 and under and 39 and above. This could indicate that for the EPM, the bottom 5 deciles could be more of a concern for future disciplinary action while acknowledging that the total number of doctors who are subject to such action is low. This finding is in contrast to findings reported for the Royal College of General Practitioners and Royal College of Physicians membership examinations that found no clear threshold in examination performance for identifying physicians at risk of disciplinary action. 8

In the multivariate survival analysis, the relationship between the SJT score and the hazard of receiving a disciplinary action was not statistically significant. This suggests that there is either no independent impact of SJT scores on the hazard of disciplinary action or that the effect size was too small to have been detected with sufficient statistical precision in our sample. These findings may be of interest to professional bodies considering the introduction of an SJT for assessing the professional attributes of graduating students.

Other work has shown that both EPM and SJT scores are predictive of successful completion of the first 2 years as a practicing physician. 25 Higher EPM and SJT scores have also been associated with reduced odds of students’ conduct-related declarations (e.g., self-reported conduct concerns, such as fixed penalty notices). 26 Attaining low scores on the SJT has also been shown to be associated with poorer supervisor ratings for first-year physicians (the U.K. equivalent of an intern), 18 which is in keeping with the overall observed trend of lower rates of disciplinary action for higher SJT scores.

There are several possible explanations as to why higher scores on the EPM reduce the hazard of disciplinary action to a greater extent than higher scores on the SJT. Previous work has highlighted that examinations requiring demonstration of clinical skill as opposed to knowledge (e.g., the Membership of the Royal College of General Practitioners Clinical Skills Assessment or the Professional and Linguistic Assessments Board Test Part 2 Objective Structured Clinical Examination [the examination international medical graduates must pass before practicing in the United Kingdom]) are particularly predictive of subsequent risk of disciplinary action among physicians. 8,9 This finding could be extended to the comparison between SJT scores (which focus on knowledge of required professional attributes) and EPM scores (which include assessments of applied knowledge and clinical skills).

The EPM score offers a comprehensive assessment of students based on academic attainment throughout medical school and additional achievements, such as degrees. It has been postulated that the attributes required to achieve a high EPM score (e.g., conscientiousness and persistent hard work) are examples of good conduct, which would render a physician less likely to be disciplined. 8 By contrast, being successful in a single written examination testing knowledge of professional attributes (like the SJT) does not necessarily require significant preparation and consistent work to attain, neither does it assess actual behaviors.

Decile scores are associated with the hazard of disciplinary action, but additional educational achievement scores are not

We observed that upon separating the EPM into decile and additional educational achievement scores, the decile score remained independently associated with the hazard of receiving disciplinary action as a physician, but the additional educational achievement score did not. This may be because additional educational achievements are predominantly determined by students’ performance in research activities and outcomes (e.g., publications), which typically do not involve much exposure to patients. Furthermore, students with higher additional educational achievement scores are more likely to have research-focused careers in which fewer instances of behavior leading to disciplinary action may occur (e.g., clinical errors).

Physicians who had fitness to practice concerns as medical students did not receive disciplinary action after qualifying as physicians

While previous work in the United States has shown that being disciplined at medical school is a risk factor for future disciplinary action, 27 we found that out of the 125 physicians in the study who had fitness to practice concerns raised in medical school, none went on to receive disciplinary action after they had qualified as physicians.

This association could be interpreted in several ways. Perhaps the mechanisms through which undergraduate students with fitness to practice concerns are identified are not conducive to identifying those at risk of future disciplinary action. Alternatively, the fitness to practice processes in U.K. medical schools could be highly effective. These students may have been identified early and received sufficient support (e.g., increased monitoring and mentoring) to allow them to remediate and prevent them from being disciplined as physicians or they may have been expelled from medical school or withdrawn their UK Foundation Programme application. Our ability to identify students who would go on to receive disciplinary action as physicians may have also been affected by the small sample size of students receiving fitness to practice concerns and the very low rate of those being disciplined as a qualified physician in the sample.

Risk factors for discipline

In keeping with existing literature, 15,28 we found that being male was a statistically significant risk factor for receiving disciplinary action. When hypothesizing why males are more likely to be disciplined, several theories have been proposed, 28 but the most likely is the increased rate of sexual misconduct. 7,29,30 Another suggestion in the literature is that females have reduced exposure time for being disciplined as they are more likely to work part-time and, therefore, have fewer patient encounters compared with male physicians. 31 Further exploration of the type of offences that led to the imposition of disciplinary action in this cohort of males is required for clarification.

In this cohort of U.K. graduates, we observed that there was no statistically significant increase in risk of disciplinary action among BAME physicians compared with White physicians in the multivariate survival analysis. Similarly, we found no statistically significant increased risk of disciplinary action for graduate compared with undergraduate status on entry to medical school in the multivariate survival analysis.

Strengths and limitations

Strengths.

The strengths of this study include the use of a large national database (the UKMED), which resulted in a large overall sample size of U.K. medical graduates (34,865), which is important when analyzing rare outcomes, such as disciplinary action. A particular strength of our study is the temporal order of the explanatory and outcome variables. That is, because the EPM and SJT scores are always awarded during medical school, the risk of reverse causality is eliminated.

Limitations.

The total number of physicians with disciplinary actions in the study population (65) was small. We focused on disciplinary action imposed on physicians within 5 years of graduating from medical school. This may not have captured all instances of professional misconduct (e.g., misconduct may have gone undetected or unreported during this period of time). While we are able to comment on observed trends from these data, we are cautious of what recommendations we could make based on the data available. Although it would be possible to repeat the analysis once exposure time has increased, the utility of performance measures from medical school is likely to be diluted over time, so this approach may not resolve this limitation.

Due to statistical disclosure controls requiring rounding of frequencies, we were unable to report the precise reason for discipline (i.e., type of disciplinary action imposed or underlying allegation). These data may have shed light on why disciplinary action occurred at increased rates among males or for those with lower EPM scores. Such clarification may lead to more targeted support and influence medical education policy and how medical students are prepared for practice.

We did not reintroduce physicians who left the register for a reason other than being disciplined (e.g., moving abroad) and then reentered the register at a later date into our final analysis. This led to the loss of 455 out of 34,865 physicians from our analysis, as detailed in Table 1. These physicians may have gone on to be disciplined, thus, this could be the main source of bias in this study. However, we believe that the magnitude of this potential bias is minimal because it affected only 1.31% of the dataset.

Another limitation of our analysis is the fact that physicians who are struggling professionally may have chosen to leave the profession before reaching the stage of being disciplined (thereby diluting any effect of the explanatory variables included). Moreover, the effect of the EPM score may have also been diluted given that deciles are based on performance within medical schools and because there is currently no national examination of graduation standards, there may not be equality between medical schools in terms of an individual student’s objective ability and decile placement.

Further research

The risk of receiving disciplinary action as a physician is complex and multifactorial and would be better understood with the inclusion of further potential explanatory variables (e.g., widening participation index, see above).

Interestingly, this study demonstrated that none of the physicians who went on to be disciplined had fitness to practice concerns raised as students. Further research is required to clarify whether physicians who go on to be disciplined can be identified as medical students and if indeed the fitness to practice processes are effective in identifying and appropriately remediating students with fitness to practice concerns.

While we have hypothesized reasons for why the observed associations in this study may exist (e.g., the purpose of the EPM vs SJT and males having higher rates of sexual misconduct), a more detailed evaluation of the reasons for disciplinary action and type of outcome (e.g., erasure from the register vs a formal warning) would likely aid our understanding and ability to explain these observations.

U.S. residency programs vary in their approach to ranking applicants and may include a combination of elements, such as rotation grades, USMLE scores, interviews, letters of recommendation, publications, medical school attended, and a personal statement, when making such determinations. 32 Given the utility of the United Kingdom’s EPM in identifying physicians at risk of receiving disciplinary action early on in their careers, it would be interesting to identify whether residency program ranking algorithms can similarly identify physicians at risk of disciplinary action in the United States.

Conclusions

This study demonstrates that overall academic attainment (EPM), but not performance on a written assessment of professional attributes (SJT), both in medical school, is independently associated with the hazard of future disciplinary action for physicians. Being disciplined as a doctor remains a rare event. Our findings have potentially identified a tool that can help to identify physicians at risk of being disciplined in the first 5 years after graduation. Early identification of increased risk of disciplinary action provides an opportunity to increase monitoring and mentoring of at-risk doctors and, thereby, to protect patients and professional values.

Acknowledgments:

The authors wish to thank Mr. Daniel Smith from the General Medical Council (GMC) for helping with queries.

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