We should be offering GP registrars screening for specific learning differences (SLDs)

Adrian Hucks is a military GPST, the Defence GP Registrar representative at RCGP and an Academic Clinical Fellow in the Academic Department of Military General Practice.

The impact of Specific Learning Differences (SpLDs) is a widely acknowledged and researched element of post-graduate medical training, especially within GP training.^1-5 The impact of dyslexia, one such SpLD, on individual clinicians is unique to them, but differences range across 5 key areas: phonological awareness, short-term memory, processing speed, visuospatial skills and sequencing skills.⁵ It is also acknowledged that increased self-awareness and development of supportive strategies is essential for individual learners, as well as for educators and supervising colleagues.^1,2,5

General Practice speciality training (GPST) in the UK is a 3 year full-time equivalent (FTE) programme, requiring completion of the MRCGP tripos; the Applied Knowledge Test (AKT), the Simulated Consultation Assessment (SCA) and the Work Place Based Assessments (WBPA), with continued professional development demonstrated through a written portfolio.⁶

For both the AKT and SCA exams, reasonable adjustments can be given for individuals with SpLDs(3,4). Due to the nature of SpLDs, individuals may also require additional support when completing their portfolio as well as in their workplace, both through training and beyond.^1,2,5 This workplace-based support is especially important when placing GPST in the context of the highly pressured NHS currently, where over a fifth of trainees are at high risk of burnout, and over half of trainees describe their work as highly emotionally exhausting.⁷

In Good Medical Practice (GMP), the General Medical Council (GMC) highlight the need for a training environment that is fair, free from discrimination and where individuals are respected and valued, as well as highlighting that good doctors work effectively with colleagues and are self-aware.⁸ The RCGP also highlight the need for GP trainees to comply with GMP, manage the factors that influence their performance and maintain an ethical approach, respecting diversity.⁹ The Equality Act (2010) requires examination bodies to monitor candidates with protected characteristics, including SpLDs, performance and ensure they are treated fairly and without disadvantage.⁴

GPST builds on the knowledge base acquired through years of university education and clinical experience. The route to entering GPST can be as short as 2 years after graduating from medical school and completing Foundation Year (FY) training, but paths to entering training vary as much as the individual doctors. As a result, the author acknowledges the role of universities and post-graduate training in detecting and diagnosing SpLDs. However, the heterogeneity of trainees’ backgrounds is vast, with primary medical qualifications in over 112 different countries noted by the RCGP exams team in 2023.¹⁰ As a result, expecting a standard prior to entering GPST is not feasible.

Despite the legal and professional requirements to treat individuals with SpLDs without disadvantage, alongside the published evidence supporting earlier diagnosis and development of supportive strategies, the Committee of General Practice Education Directors (COGPED) still do not recommend screening of GP Registrars (GPRs) at the commencement of training. Some deaneries, including Yorkshire and Humber and the Defence Deanery, do offer voluntary screening for their trainees, whilst many do not.

This support based on training location means some GPRs will have potential screening and consequent support, and others will need to seek recognition of and support for SLDs using their own time and resources – in essence a postcode lottery. This is of particular importance given the recent change in RCGP exam resit policy allowing for voiding of previous exam attempts should a diagnosis of a disability, such as a SpLD, be made.¹¹

Examining SpLD screening using an ethical ‘lens’

The four principles of medical ethics are widely understood and form a good basis to examine whether we should support screening for SPLDs. They include autonomy, beneficence, non-maleficence, and justice.¹² Further structures could be applied to the discussion, but for the foundation of this argument, a broad approach has been chosen.

Autonomy 

From an autonomy view, by not offering SpLD screening to trainees, we remove their chance to explore an important aspect of their learning and ongoing professional development. With an increasing proportion of trainees being international medical graduates (IMGs), these individuals are more likely to have never been tested and find out they have SpLDs only after failing a higher professional exam (3,4). SpLDs represent a significant ‘unknown-unknown’ for these trainees.

A counter argument may be that by offering screening, we may diagnose individuals with a SpLD, and the stigma associated, who never wanted a diagnosis. This is a valid argument, but fails to acknowledge that screening would be optional, allowing the autonomous decision of the GPR to be screened, or not. Allowing GPR to make the choice, via informed consent, is the best option and one that they are trained to deliver to patients.

Beneficence

Beneficence is focused on doing good for our patients, or in this case our GPRs. By screening for SpLDs we are identifying an important aspect of the individual’s learning style, facilitating their support and development. This is important, not only for higher professional exams such as the AKT, but also for their lifelong learning and workplace support(2,5).

We also know that doctors who are supported appropriately and are self-aware of their own needs comply with the GMC and RCGPs expectations and would perform better(8,9). A well-supported doctor who is self-aware is better for patients.

Non-maleficence

It is important to consider the harm we may cause by screening. The screening process may result in a diagnosis of a SpLD, with the accompanying stigma. However, if this is a concern of a GPR they could chose to not be screened.

By not offering screening, however, it could be argued that harm is coming to GPRs, who later find out they have a SpLD when their performance suffers – through failure to complete aspects of GPST or higher exam failures. This exposes a significant cost to these GPRs, as well as their professional and personal support networks. Higher professional exams are financially costly, as well as taking months of preparation time in the GPRs evenings and weekends. Additional support after exam failures will impact on all these factors.

Justice

Supporting equitable access to healthcare for all who need it is an important principle. The GMC and RCGP both expect doctors to seek treatment for medical conditions that affect their fitness to practice(8,9). SpLDs could be argued fall under this umbrella.

A GP would not recommend ignoring to support a patient who may have difficulties that could be managed. GPRs should not be treated any differently just because they are clinicians.

Screening Tests

Screening tests are assessed by the Wilson and Jungner criteria (See below) (13). These criteria balance the benefit for the individual against the needs of the population and include clear understanding of the condition, how it progresses and how it can be detected and managed, as well as constructs around the screening process.

The criteria are:

1. The condition sought should be an important health problem.
2. There should be an accepted treatment for patients with recognised disease.
3. Facilities for diagnosis and treatment should be available.
4. There should be a recognisable latent or early symptomatic stage.
5. There should be a suitable test or examination.
6. The test should be acceptable to the population.
7. The natural history of the condition, including development from latent to declared disease, should be adequately understood.
8. There should be an agreed policy on whom to treat as patients.
9. The cost of case-finding should be economically balanced in relation to possible expenditure on medical care, as a whole.
10. Case-finding should be a continuing process and not a ‘once and for all’ project.

Dissecting the argument for screening for SpLDs using these principles further strengthens the argument. SpLDs are an important health problem(1,2) and there is an accepted treatment, support, and adjustments, for patients diagnosed, from Professional Support Units (PSUs) (1–5).

The latent phase could be viewed as medical school and training prior to entering GPST, with adult SpLDs being detected in a different manner to childhood SpLDs(2). The screening tests are easy to perform and are either free or low cost, depending on tools used and local agreements, with some deaneries reporting good uptake of screening on an annual basis, reflecting their acceptability to the population, and the continuous process of screening GPRs.

SpLDs are well understood, and the PSUs are well equipped to assess and manage support for those affected. Only those who would like to be screened would be, and only those who go forward to a full PSU assessment would require treatment, which is tailored to the individuals(2).

There is agreed understanding that the sooner support is sought, the better adapted individuals will be (1,2,5). The cost of SpLD screening and treatment varies, but the previously discussed financial and temporal costs of exams and resits, alongside costs to deaneries for extensions to training that is required for individuals who cannot progress through training is significant. A full costs analysis may be of benefit, but the moral argument to provide screening stands independently of the fiscal one.

Conclusion

SpLDs are a significant burden for GPRs, with the challenges of progressing through GPST in a highly pressured work environment being well known and studied (2–4,7). There are strong ethical arguments to screen for SpLDs in GPRs, with a well understood pathway that meet Wilson & Jungner’s criteria already in place in some deaneries. These criteria balance the benefit for the individual against the benefit for the population. A full economic analysis would be required should the recommendation be adopted.

As a routine part of GPST, GPRs should be screened for SpLDs and the author would like to see COGPED recommend screening to all deaneries in the UK.

References

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3. Asghar ZB, Siriwardena AN, Elfes C, Richardson J, Larcombe J, Neden KA, et al. Performance of candidates disclosing dyslexia with other candidates in a UK medical licensing examination: Cross-sectional study. Postgrad Med J. 2018 Apr 1;94(1110):198–203.
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11. Royal College of General Practitioners. MRCGP exam reasonable adjustments [Internet]. 2024 [cited 2025 Jan 14]. Available from: https://www.rcgp.org.uk/mrcgp-exams/mrcgp-important-info/reasonable-adjustments#voided-attempts-following-disability-diagnosis
12. Varkey B. Principles of Clinical Ethics and Their Application to Practice. Vol. 30, Medical Principles and Practice. S. Karger AG; 2021. p. 17–28.
13. Sturdy S, Miller F, Hogarth S, Armstrong N, Chakraborty P, Cressman C, et al. Half a Century of Wilson & Jungner: Reflections on the Governance of Population Screening. Wellcome Open Res. 2020 Jul 6;5:158.

Featured photo by Gift Habeshaw on Unsplash