Efforts Increase to Eradicate Student Mistreatment, Improve Culture at Medical Schools
AAMC Reporter: September 2012
—By Sarah Mann
A clinical professor asks a third-year medical student how she would handle a specific case. Unsure of the best course of action, the student stumbles. Frustrated, the professor scolds the student in front of her classmates, explaining that this could be a life-or-death situation.
Although hypothetical, most physicians likely hear similar stories. Some students or faculty might interpret such cases as public humiliation. While what constitutes public humiliation is a gray area, humiliation, and other more serious forms of mistreatment, can affect medical school culture. The AAMC and leaders at medical schools and teaching hospitals have placed a high priority in recent years on eliminating all types of mistreatment toward students during medical education, emphasizing that students need to learn in a supportive environment.
Part of that effort includes defining mistreatment.
“What is humiliation, and what is really trying to push people to be their very best?” asked Marsha Rappley, M.D., dean of Michigan State University College of Human Medicine and chair-elect of the AAMC’s Council of Deans.
“I think we are trying to come to terms with that area. There will always be experiences, as a teacher, where I’m asking an important question, and the student doesn’t know the answer. I need to let them know it’s a problem that they don’t know the answer.”
An article in the September issue of Academic Medicine examined the efforts to eradicate student mistreatment at the University of California, Los Angeles, David Geffen School of Medicine.
“The concept of eradicating student mistreatment needs to be embraced at the highest levels of leadership,” said Joyce M. Fried, assistant dean at UCLA, who led the Academic Medicine study. “If you’re really going to change the culture, it has to come from the top.”
Aside from cultural factors, it has been challenging to measure how often mistreatment occurs and the types of mistreatment students experience.
This year, the AAMC revised the Graduate Questionnaire (GQ), its annual survey of graduating medical students, to get a more comprehensive picture of the culture and climate at medical schools and teaching hospitals. In past years, GQ respondents were asked whether they had experienced mistreatment, and only those students who indicated they had been mistreated during medical school then answered additional questions about specific behaviors. Because student perceptions of what constitutes mistreatment, particularly events involving humiliation or disrespect, can differ, AAMC staff and the advisory committee on the student questionnaires were concerned the earlier GQ left too much to interpretation.
“Somebody could be subjected to a behavior and not view it as mistreatment, whereas someone [who experiences the same behavior] might,” said Thomas W. Koenig, M.D., associate dean for student affairs Johns Hopkins University School of Medicine. “But if we talk about specific behaviors, it takes away the label and allows people to answer more honestly.”
The 2012 GQ asked all respondents to rate on a scale of “never” to “frequently” their personal experience with 15 specific examples of mistreatment. According to Henry Sondheimer, M.D., AAMC senior director of medical education projects, who manages the GQ, the new methodology makes it impossible to compare 2012 data with results from previous years.
“We have much better data now, so we can focus on the issue and how to fix it,” Sondheimer said. “We’re concerned about the climate and culture at our medical schools.”
In the 2012 GQ, 33 percent of respondents reported that they had experienced public humiliation one or more times during medical school. In addition, 15 percent of respondents said they had been subjected to offensive sexist remarks, and 9 percent reported that they had been required to perform personal services. Accounts of more serious behaviors, such as physical harm or requests for sexual favors in exchange for grades, were extremely rare.
While the new GQ is a step forward, the goal for medical school leaders is to determine how to eliminate mistreatment completely. Increased awareness will certainly help, experts said, but, as at least one institution has learned, awareness alone may not solve the problem.
In 1995, UCLA began a concerted effort to address mistreatment of its medical students. Over time, the school phased in a series of policies to support students who had experienced mistreatment, including formal steps to report events, and education about mistreatment for all students, residents, and faculty. At the same time, the school’s leadership wanted to measure the impact of those efforts.
Between 1996 and 2008, students completed an anonymous survey after their third-year clerkships that assessed whether they had experienced physical, verbal, sexual, ethnic, or power mistreatment. According to the results, reported in Academic Medicine, there was not a significant decline in most types of serious mistreatment, and more than half of the 1,946 students who completed the survey reported they had experienced some degree of mistreatment.
Fried said the results were “disappointing.” Still, she said UCLA has moved in the right direction, adding that a greater focus on mistreatment from the AAMC and leaders across academic medicine will go a long way toward addressing the cultural factors that have made it difficult to tackle the issue.
“I think the problem is that, for a long time, this behavior has been condoned in academia, not because anyone has said it’s OK, but because everyone shrugs their shoulders, and they look the other way,” she said. “When you talk to older physicians, they say, ‘It’s part of the culture. I went through it, and you get over it.’ But that’s not OK anymore.”
Rappley added that collaboration among medical school deans and other leaders to discuss practices that have been effective at the institutional level would be helpful in creating a more positive learning culture across academic medicine. To advance that conversation, the AAMC’s Council of Deans will hold a session on learner mistreatment at the 2012 AAMC Annual Meeting in San Francisco, on November 2.
The patient safety movement might inform that discussion, according to Koenig.
“The literature shows us that if communication suffers, which can happen when there are lapses in professionalism and civility, patient safety suffers as well,” Koenig said. “Hopefully we can link [mistreatment efforts] to things we’re already doing that have changed cultures on our medical campuses.”
In Michigan, Rappley agreed. “Our fundamental task in medical education and health care is to improve the health of the people of our nation and to improve their quality of life,” she said. “We can’t do that in an environment in which we’re disrespectful of one another.”
“Our fundamental task in medical education and health care is to improve the health of the people of our nation and to improve their quality of life. We can’t do that in an environment in which we’re disrespectful of one another.”
Marsha Rappley, M.D., dean of Michigan State University College of Human Medicine and chair-elect of the AAMC’s Council of Deans