Regulatory bodies need clear, policies and pathways for fitness to practise concerns. Many FTP regulations conflate by implication the ideas of mental illness and irresponsible behaviour. Policies and protocols should be regularly reviewed, redeveloped and publicised in collaboration with students and recently graduated trainees as well as faculty policy makers. Most people experience mental illnesses at some point in our lives, so it’s impractical as well as unethical to exclude students from professions on such grounds. It is illogical to regard suffering from a mental illness as a disciplinary matter, although failure to address illness in a responsible way is unacceptable. Close-knit student cultures within professional specialities may encourage unhealthy coping strategies and put up obstacles to accessing treatment. Stigma and mistrust have passed into the culture, with a risk of untreated mental illness leading to avoidable suffering and impairment. The most intractable issue in FTP concerns is where a practitioner lacks insight into the consequences of their own behaviour. However, there is positive experience in managing episodic loss of insight during a known mental illness, using advance planning.