Addressing Mistreatment in the Learning Environment

Editor’s Note: Below is the fourth in a four-part series on trainee mistreatment. Read additional perspectives on this issue. Be sure to read the collection of articles on the topic in our May issue.

By: Marsha D. Rappley, MD, dean, Michigan State University College of Human Medicine (Pictured above)

The April and May issues of Academic Medicine include five articles that focus on medical student mistreatment. A finding that emerges across these studies is that, as we seek to examine more closely the phenomenon of medical student “mistreatment,” its prevalence appears to be higher than previously believed.

This is not surprising, given that many physicians recall medical school as an experience marked by despairing self-doubt and humiliation. Some of these same physicians believe that this type of experience was necessary to motivate them and build resiliency. This rationalization may be seen in the following explanation by a student, from the report by Gan and Snell:

I’ve personally came from [a background] where I was used to being physically and verbally assaulted, so I kind of have a very high threshold in the level of back and forth I would take.

This is but one of the many complicated dimensions of the mistreatment of medical students, and indeed, all of our learners in the medical education milieu.

Let’s take the notion of humiliation. If we move past name-calling and overtly insulting behavior and into the realm of giving and receiving negative feedback, we are going to encounter humiliation within the context of good intent. A colleague from law described how she teaches a case-based discussion in which she pushes students to reach their limit before the other members of the class. She tells me that it is common in law for the professor to preface a session with something like: “Now I am going to take you to a point at which you do not know the answer. Keep in mind that we do this because you and I both need to know this limit so that we can move past it. And your peers need the benefit of your thinking.” Perhaps something so intentional could help us address the matter of pushing students to their limit and building resiliency at the same time.

Would that it were so simple. Our cultures across geographic regions, clinical specialties, and families of origin all define for us what is respectful and what is outside of that boundary. When a colleague was advised that she was perhaps a bit harsh in how she presented her feedback to a coworker in Michigan, her reply was: “Oh my God, no one would bat an eye at that in Boston!” Hence, the need for resiliency and flexibility. Our patients do not come to us in a homogeneous or well-defined cultural group with all norms and mores mutually understood. Neither do our students, our residents, our staff, or our colleagues.

Researchers have been exploring this issue of the abusive treatment of medical students for more than fifty years. Mavis and colleagues described a momentum and increasing awareness of the subject that is reflected in the fact that these five articles have been published together now in Academic Medicine. In 1955, Eron raised the question: Does the medical school curriculum itself encourage maladaptive behaviors? In 1982, Silver identified the phenomenon of medical student abuse, and in 1984, Rosenberg and Silver went on to describe it as “unnecessary and preventable.” In 1996, Margittai and colleagues described the “forensic aspects of medical student abuse.” In 2002, Nora and colleagues found that 41% of male and 83% of female medical students had experienced gender discrimination and sexual harassment. In 2009, Haglund and colleagues described the association of mistreatment with depression and not with resiliency among medical students. These are just a few examples from the approximately 50 articles on the subject listed in PubMed from the last 40 years.

This momentum does not make me feel proud of my profession. It makes me realize how content we can be with meetings and policies and publications. What is only beginning to emerge are evidenced-based descriptions of effective interventions that can guide our institutions, such as those described by Fried and colleagues and Heru.

Many highly competent, motivated students are clearly isolated from and afraid of the very people they most admire. Again, no one gives us a more powerful statement than a student, again from the report by Gan and Snell:

The thing that hurts the learning experience here and that results in a sense of mistreatment here is more a sense of disempowerment and disenfranchisement and vulnerability and the inability to respond to unjust evaluation or to a resident who’s just an asshole.

In the elaborate equation of medical education and health care, the most vulnerable groups are our patients and our students. The trust of our patients is undermined when we mistreat one another. They deserve and demand our commitment to an experience that is marked by respect for our individual and collective dignity, that builds resilience for us all, and that improves health and well being for us all. We are smart enough to do this. It is our duty to do so.

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One Comment

  1. Kemi
    April 12, 2014 at 11:03 AM

    The comments from students say a lot. Yes, someone’s background may render the person more prone to accept abuse from the mediical experience. It does not make the process OK, especially in an era when academic medicine struggles to survive and there is a shortage of physicians. And the homogenous nature of the medical trainingg environment is not as tolerant of some of the complexities of interactions of people from other backgrounds, such as the upbringing to be obedient. Most backgrounds don’t raise individuals to be passive aggressive or to give bad advice or to lie or cheat to achieve a certain result. Unfortunately, the quest for great grades, letter of recommendations, and stellar grades encourages one to model and accept such behavior in the medical profession.

    The feeling of lack of empowerment thus occurs when a students are expected to achieve a certain standard and cannot respond to lies and other awful comments about performance. When most people have poor performance on the clerkships or at some point in residency or fellowship, it is not necessarily because of poor performance; it could be an angry resident, team politics or the like that results in bad comments. What is worse is when students try to defend themselves and get no support from the leadership. This causes a great deal of isolation, especially upon discovering that others may have had a crappier performance on the wards, but much better grades in the long run.

    The bullying and torture in the training experience must stop, for the sake of students and patients.