With the fundamental role that a respectful teaching and learning environment plays in medical education, medical schools and teaching hospitals are enhancing efforts to address this issue through innovative programs and policies that address unprofessional conduct. A number of institutions are striving to raise awareness of inappropriate behavior through conversations, while others are creating atmospheres that are more open to communication and complaint reporting. Some are launching unique initiatives to highlight and reward exemplary conduct by mentors and teachers.
“As academic medical centers embrace efforts to improve professional conduct, we cannot separate the learning environment from the clinical care environment in our thinking, as they are often one and the same,” said AAMC Chair Lorris Betz, M.D., Ph.D., senior vice president emeritus of health sciences at University of Utah. “In this space, inappropriate attitudes influence the patient experience and working relationships among health care professionals as well. Our charge is to train students to usher in a new era of health care delivery, and unprofessional conduct stands to undo much of the hard work we have before us.”
Unprofessionalism and mistreatment are on the radar screen of medical schools and teaching hospitals like never before, explained Marsha D. Rappley, M.D., dean of Michigan State University College of Human Medicine. “We realized this is a problem we’ve been facing in isolation from one another,” she said. “Today we’re better able to identify it and are better able to share best practices. From this point on, we should hopefully see some changes.”
Assistance through an intermediary
One way education leaders are addressing negative communication among students, residents, and instructors is through the use of ombudsmen. These mediators act as go-to advisers for concerns and complaints about behavior.
At Michigan State, administrators have instituted an ombudsman who is not directly involved in teaching but provides a safe harbor in which to have sensitive discussions, according to Rappley. Working directly with the student who has reported concerns, the ombudsman helps with next steps and potential resolutions.
The ombudsman concept also is playing a major role at the Brody School of Medicine at East Carolina University. “We’re using an ombudsman who serves as a neutral party to mediate conflict between students and others,” said Randall Renegar, Ph.D., assistant dean for student affairs at Brody. “The ombudsman reports about the prevalence [of issues] and makes recommendations. It’s intended to be as anonymous as possible so [no involved parties] feel threatened.”
Brody also provides students with an algorithm that clearly outlines what direction to take if they experience perceived mistreatment or unprofessionalism. A diagram provided to students illustrates various levels of behavior and what actions to pursue in each case—for example, what to do about mistreatment versus a criminal act.
“We’re trying to change the culture by rewarding the [educators] who model the behavior that we want to see.”
Joyce Fried, University of California, Los Angeles, David Geffen School of Medicine
Medical schools also are using evaluations as a central component in identifying and reducing mistreatment. At the University of California, Los Angeles, David Geffen School of Medicine (UCLA) administrators have incorporated questions about respect in teacher and resident evaluations, said Joyce Fried, UCLA assistant dean and co-director of the Office of Continuing Medical Education. The evaluations ask students whether faculty who taught them during rotations were respectful of them and others.
The medical school is working to streamline both the time it takes to receive and review evaluation feedback and how quickly leaders address the issues brought to light, Fried explained. “The difficulty is discerning whether it’s just one student in one place who had one situation and how egregious it was. We’re trying to apply metrics as to severity of these reports and the frequency.”
At Harvard Medical School, opportunities for anonymity make students feel more comfortable about reporting incidents and concerns, according to Ilana Yurkiewicz, a fourth-year medical student who has written on the subject of mistreatment in medical education. “In the current climate, people might be afraid to call out incidents of disrespect,” she said. “That’s a very reasonable concern. Anonymous reporting can be helpful.”
Along with identifying potential unprofessionalism, schools such as UCLA are celebrating model behavior among educators. In 2013, Fried approached the Medical Student Council and challenged leaders to develop an award for residents who were exemplary teachers. The result was the Excellence in Teaching with Humanism Residents and Fellows Award, an honor bestowed upon nominated residents who meet a number of criteria. Recipients must empower student doctors on the wards, foster a safe learning environment, and show respect for health care teams and patients, among other criteria. Ten awards are given each year.
“We’re trying to change the culture by rewarding the [educators] who model the behavior that we want to see,” Fried said. “To make the culture change, you have to admonish the people who behave poorly, but you have to really reward the people who [demonstrate exemplary conduct].”
Discussions with offenders that address behavioral concerns in a calm, sensitive manner also are key, said Donald W. Brady, M.D., senior associate dean for graduate medical education and continuing professional development at Vanderbilt University Medical Center. During the sit-down interactions, referred to as “cup-of coffee conversations,” the faculty member or resident is made aware of the reported complaint and the incident’s impact on the student.
“It’s often all that’s needed,” Brady said. “About 80 percent of people will improve with just simple reflection or simple intervention.” Vanderbilt has been using the strategy for some time and is now formalizing it at the resident level, he noted.
Restorative justice is another strategy that could make a significant difference in resolving mistreatment complaints and unprofessionalism within the medical education system, noted David Acosta, M.D., associate vice chancellor of diversity and inclusion for the University of California, Davis, Health System. He hopes to see a pilot program for the approach, which brings a facilitator together with the involved parties to discuss the incident and formulate a plan to resolve the issue.
“It’s about bringing all three stakeholders to the table and allowing the victim to share their story not only about what happened, but how they were harmed by the offender,” Acosta said.
AAMC Statement on the Learning Environment
To support and reinforce these efforts, the AAMC Board of Directors recently approved a statement developed by the AAMC Council of Deans (and endorsed by a broad cross-section of AAMC affinity groups) on the shared accountability for creating an optimal learning environment across the continuum of medical education that fosters respect, resilience, integrity, and excellence.
“What started with an intensive review of failures in professional educational conduct developed into a comprehensive statement reaffirming a culture of respect for all,” explained John E. Prescott, M.D., AAMC chief academic officer. “The learning environment plays such a key role in student formation. Medical education is dependent upon an inclusive curriculum and an environment designed to promote student learning and maturation.”
The statement also encourages shared efforts to better understand the complex factors that lead to mistreatment, promotion of educators’ ability to recognize emotional challenges, and cultivation of learners own resilience in the learning environment. It also encourages research into the most effective methods of supporting an ideal learning environment and developing policies that demonstrate zero tolerance for illegal or otherwise reprehensible behaviors.
Insight on student perceptions
Understanding student perceptions of mistreatment helps academic medicine leaders devise an effective approach. In 2012, the AAMC revised the Graduation Questionnaire, an annual survey of graduating medical students, to gain more insight on student perceptions of mistreatment in the learner environment. Respondents now rate their personal experience with multiple examples of unprofessional conduct. In 2013, the association added a section regarding embarrassment, making it separate from humiliation.
“I think we have much more meaningful data,” said Henry Sondheimer, M.D., AAMC senior director of medical education projects. “The [questionnaire’s] focus is to improve the learner environment. We have to be able to show that over the next four or five years, we really are seeing improvements as perceived by the students. We’re very hopeful that we will start to see some progress.”
Noting the positive steps that many medical schools and teaching hospitals are taking to address professionalism and improve the culture at their institutions, Ann Steinecke, Ph.D., AAMC senior director of academic affairs programs and engagement, said the AAMC statement is “not asking people to reinvent the wheel. The statement is more of a catalyst for elevating best practices, renewing attention across the continuum, and building on what has been shown to work at our member institutions.”
The learning environment statement is part of a broader AAMC initiative to recognize and combat unprofessionalism in the educational setting. An information hub on the AAMC website will include best practices, summary reports of the Graduation Questionnaire and other data, and a toolkit of resources for member institutions to use in assessing and improving the learning environment. In addition, the AAMC annual meeting in November will feature related sessions.
This article originally appeared in print in the September 2014 issue of the AAMC Reporter.