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A Word From the President: Building a Culture of Respect in Medical Education: Are We There Yet?

AAMC Reporter: September 2012

We all have heard the stories. The physician who berates a nurse. The chief resident who humiliates a medical student. And who has not heard “trash talk” between the medical specialties? When I was in medical school, I remember a prominent faculty member telling me “what a waste” it was for me to pursue psychiatry.

When things like this happen, we compromise the learning environments of medical students and residents. Tomorrow’s doctors must be able to learn in a safe and supportive culture that fosters the respectful, compassionate behavior we expect them to show their future patients. Though these unprofessional scenarios tend to be the exception rather than the rule, the results of the 2012 Graduation Questionnaire (GQ) tell us we still have work to do.

Often referred to as the informal or hidden curriculum, medical students learn how a physician should act through observation. Pauline Chen, M.D., explored the hidden curriculum in an insightful 2009 New York Times article, saying, “Medical students and residents copy the lingo, manners, and expressions of more established senior residents and attending physicians. The lessons from these role models, who are often tired and stressed out themselves, can be sobering.”

Unprofessional behavior, whether it occurs in the hospital or the classroom, works against the culture of respect so essential to education. Herbert Swick, M.D., offered a relevant definition of professionalism in Academic Medicine more than a decade ago. He wrote that physicians who adhere to a high standard of professionalism show respect for others, are accountable to themselves and their colleagues, and are able to reflect upon their actions and decisions. Clearly, when faculty or staff members treat a medical student or resident inappropriately, they are breaching the standards of professionalism. As educators, we must exhibit at all times the same high standards we expect from our future physicians.

Health care is a high-stress profession, and tensions understandably will run high when lives are at stake. What we should learn to do, however, is turn difficult situations into teachable moments. If a physician reflected on his or her behavior openly and candidly in the name of professionalism, it would send a powerful message to medical students and residents. Just as we hope to instill in our trainees an appreciation for lifelong learning, so, too, must we foster a culture of mutual accountability and respect in our schools and residency programs, among the medical specialties, and with other health professions.

In an effort to gather a more complete picture of the learning environments at our member institutions, the AAMC made changes to the annual GQ. Contrary to past surveys, the 2012 survey asked each student to rate, on a scale of “never” to “frequently,” his or her personal experience with 15 specific negative behaviors, such as being publicly humiliated or subjected to sexist remarks, without being asked to judge whether these behaviors were, or were not, forms of mistreatment.

While this year’s results show that the incidence of the most egregious behaviors is low, it should be disturbing to all of us that they occur at all. Similarly, while many of us—myself included—can recall being on the receiving end of disparaging comments, the percentage of our students who report being subjected to public humiliation one or more times during medical school is unacceptably high at 33 percent.

As educators and leaders in the medical profession, we have an obligation to eliminate any mistreatment of medical students. The solution starts by addressing the culture and climate at each institution. An article in this month’s Academic Medicine that analyzed efforts to combat medical student mistreatment over a 13-year period at UCLA’s David Geffen School of Medicine shows just how challenging, but important, this task is. While implementing stricter policies and faculty workshops were somewhat effective, the authors of the study found they were not sufficient by themselves. What is needed to eradicate medical student mistreatment is, they concluded, “an aggressive, multipronged approach locally at the institution level as well as nationally across institutions.”

Our hope is that the enhanced GQ data will advance the important conversations about the culture and climate that should occur at each medical school and teaching hospital. These conversations not only support learning about what constitutes disrespect or public humiliation and how to improve an institution’s educational climate, but they also advance students’ understanding of differences in patient preferences for interaction.

For the AAMC’s part, we are committed to keeping this conversation at the forefront of medical education. To this end, we will host a major session on this topic at the 2012 AAMC Annual Meeting in San Francisco this November that will bring together medical students, residents, deans, graduate medical education leaders, and faculty and staff working across medical school admissions, financial aid, diversity, student records, and student affairs. This will be a unique opportunity for a broad cross-section of our community to discuss the culture and climate that should exist at each medical school and teaching hospital.

The unfortunate truth is that we can never measure the full impact unprofessional behaviors have on medical students. While some argue that institutional culture can affect students’ specialty choice, others cite concern for how it might negatively influence a future physician’s interaction with patients. That is why we must spend as much time assessing and building the right kind of culture at our institutions as we do developing strategic plans for our curricula, clinical enterprise, and research programs.

Many of the campuses I have had the privilege to visit are addressing culture explicitly, and are reaping the rewards that come from an environment in which all learn and all teach. While our students certainly will benefit from these changes, our patients have the most to gain from our success. And for the nation’s medical schools and teaching hospitals, there could be no better motivation.

Darrell G. Kirch, M.D.
AAMC President and CEO