Editor’s Note: Below is the first in a four-part series on trainee mistreatment. Check back for additional perspectives on this issue. Be sure to read the collection of articles on the topic in our May issue.
By: Joyce M. Fried, assistant dean, Office of the Dean, David Geffen School of Medicine at UCLA
Since 2012, when we published our longitudinal study on our efforts to eradicate medical student mistreatment at our institution (or more accurately our lack of success in eradicating it), we have redoubled our work to effect culture change. That same year we added mistreatment-related questions to the mandatory but anonymous evaluations of attendings and residents. Our surgery clerkship developed a prospective feedback system using a mobile web platform. And our Professionalism Council created an additional anonymous survey for third- and fourth-year students to report mistreatment directly to that group.
This year, to attempt to change behavior using carrots instead of sticks, our Medical Student Council created an award to be given to residents who display exemplary behavior toward medical students and other members of the health care team. Students can nominate residents by writing a 150-word vignette explaining why the resident deserves this honor. Ten awards will be given each year. Awardees will receive a $75 gift card, a pin, and a certificate and will be honored at the Senior Banquet.
Meanwhile, we have given grand rounds on mistreatment, alerted department chairs about our mistreatment data, and made the rounds of our education and governance committees to convince our leaders that attention needs to be paid to this issue. Yet, the needle has not moved.
Looking around the northern hemisphere, although I am gratified to see publication of numerous new studies on various aspects of mistreatment, there is no published evidence that culture change is being effected at any other medical school. In the April issue of Academic Medicine, Gan and Snell at McGill University conducted focus groups with students to elicit their perspective related to the learning environment. Yet, in an all too familiar refrain, the researchers noted that they were “alarmed and surprised” by the amount and degree of unprofessionalism and outright mistreatment described by the students in the focus groups despite concerted efforts by the institution to improve the learning environment.
Other recently published articles on mistreatment include a literature review and meta-analysis of mistreatment studies, a twelve-year review and analysis of Graduation Questionnaire mistreatment question responses, and evidence from the University of Chicago that students who experience recurrent mistreatment by faculty and residents are significantly more likely to score high on burnout measures.
While these studies are important and provide valuable new information, the time has come to move in a new direction. Medical schools don’t exist in a vacuum. As they are part of a complex adaptive system their cultures influence each other. Residents commonly arrive from other institutions to continue training with “baggage” associated with the culture of their medical schools. Thus, we must take a national perspective in tackling a culture of abuse.
In my informal conversations with leaders from venerable institutions, they sheepishly agree that their schools score above the national average, like UCLA, in terms of mistreatment, according to GQ measures. This leaves me wondering which are the institutions that do better than the national average and why. I would like to propose that we identify these institutions, study what they are doing differently, and discover the characteristics in their culture. Are they simply more homogeneous, therefore the students are more accepting of mistreatment? Or are they really doing something more effective to eradicate mistreatment? Are they selecting different perhaps more resilient students? Or can these differences be explained because of regional differences? The AMA, AAMC, and LCME, which hold detailed information on our institutions’ training environments, could at a national level spearhead this much needed research and debate.