Editor’s Note: Below is the second 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: Brenessa M. Lindeman, MD, resident physician in general surgery, Johns Hopkins Hospital
“Everything is always the intern’s fault, right?” I can recall keeping this line at the top of my mind, ready to break it out whenever any slight mishap occurred in the workflow of the day, whether I, as the intern, had done anything incorrectly or not. This simple phrase served as lubricant for team dynamics, subtly letting the seniors on the care team know that I understood the situation at hand and would do whatever I could to ameliorate the latest, almost-hourly obstacle to our delivery of the highest quality care, while simultaneously modeling acceptance of responsibility to the team’s medical students. Only now, upon reflection, do I realize that the use of this admonishment served another purpose. It was my way of remaining personally empowered during internship–a situation specifically designed to strip traces of power from even the hardiest of individuals. While internship is an essential, adaptive, and formative period in the training of any newly minted physician, it is one that also provides continual reminders of how pervasive cultural beliefs can be within the learning environment.
The recent study in Academic Medicine by Gan and Snell reported results of focus groups about mistreatment and the learning environment with graduating medical students. While the concept of mistreatment has been thought of as existing on a continuum for some time, these students went beyond descriptions of the typical types of mistreatment that have had increasing awareness over the past several years, extending their interpretation of mistreatment to environment-based factors that were much more insidious thus much more common and difficult to report.
These environmentally based factors can extend even more prominently to resident physicians, given their unique position as the potential source, recipient, and/or witness of mistreatment behaviors. Although this has been less frequently documented in the literature, the recent review and meta-analysis by Fnais and colleagues revealed a higher percentage of experiences classified as “mistreatment” among resident physicians than among medical students.
It seems that this model of mistreatment put forth by Gan and Snell, inclusive of both behaviors directed from one individual to another and culturally-embedded negative components of the learning environment, is a likely contributor to the disconnect between the operational definitions of mistreatment at the institutional, faculty, and learner levels. This model also provides an intuitive explanation for observed differences in interpretation of behaviors as mistreatment (or not) between individuals.
They point out that the interpretation of these events is influenced by the power dynamics of the relationship and the emotional state of the learner. This is where I return to the concept of empowerment. As a resident in general surgery, a discipline commonly cited among the worst offenders in regard to mistreatment, I have had almost universally positive experiences. Why? Is it that my baseline sensitivity is lower than others for such behaviors? Perhaps, but what seems equally likely is that I subconsciously wove a sense of empowerment into my interactions with others. There may be lessons for medical schools and teaching hospitals in creating an environment where individuals feel empowered in their respective roles, and that their contributions are valued. Maybe everything being the fault of the intern isn’t as bad as it might seem on the surface.