Longtime culture of mistreating students persists at med schools

A physician slaps the hand of a medical student after the student answers a question incorrectly, then suggests that maybe pain will help him learn.

A chief resident yells at two medical students, falsely accusing them of skipping clinical rotation the previous day.

An attending physician makes unwanted advances on a female medical student and tries to kiss her.

While these incidents at one medical school were referenced in a July 25 Academic Medicine study, mistreatment of medical students has long been a problem nationwide, said Nida Degesys, vice president for internal affairs with the American Medical Student Assn.

“This is not unique to any school,” said Degesys, a fourth-year medical student at Northeast Ohio Medical University in Rootstown. “This is very prevalent.”

A survey of 12,195 students at 126 U.S. medical schools found that 47% experienced some form of mistreatment, according to the Assn. of American Medical College’s 2012 Medical Student Graduation Questionnaire. Of those, only 17% reported the incidents to a faculty member or administrator.

Some of the most common complaints include students being publicly humiliated, subjected to sexist remarks or required to perform personal services, said the report, released in July.

Such behavior can have broad ripple effects, said Marsha Rappley, MD, dean of Michigan State University’s College of Human Medicine. In addition to affecting students’ educational experience and self-esteem, it contributes to communication breakdowns and creates hostile work settings that impact patient care.

“The reason we’re here is to improve the quality of life for our patients,” Dr. Rappley said. “We can’t do that as well if we are in an environment where we are not respectful of one another and not considerate of one another. The whole phenomenon directly affects our quality of health care across the country.”

Despite policies and programs aimed at curtailing mistreatment of medical students, many institutions are having difficulty stopping it.

For example, a 13-year study at the David Geffen School of Medicine at the University of California, Los Angeles, found that student mistreatment persisted despite long-running, multipronged efforts to address the issue.

Sixty percent of 1,946 third-year students surveyed between 1996 and 2008 experienced mistreatment, said the study, published online July 25 in Academic Medicine. Incidence peaked at 75% between 1996 and 1998 and dropped to 57% between 1999 and 2008, the study said.

During that time, the school implemented numerous programs, including a mechanism for reporting and investigating complaints as well as regular, mandatory educational sessions for students, residents and faculty.

“When we analyzed the numbers, we found that it hadn’t been eliminated and it hadn’t gone down in the way that we wanted,” said lead study author Joyce Fried, assistant dean and director of the Geffen school’s strategic planning initiative. “We were pretty disappointed.”

The impact of abuse

For students, mistreatment can have lasting repercussions, said Jerald Kay, MD, professor and chair of the Dept. of Psychiatry at Boonshoft School of Medicine at Wright State University in Dayton, Ohio.

“Medical student cynicism has been a perpetual problem in medical education,” Dr. Kay said. “That is one of the fallouts from medical student abuse. Many students come to school with great enthusiasm. By the time they come out, they are well-trained and certainly their knowledge base has grown, but there is no question that their attitudes have changed.”

Schools that have higher rates of medical student mistreatment also face difficulties, said Henry Sondheimer, MD, AAMC senior director for student affairs and student programs. Medical student abuse is one factor considered by the Liaison Committee on Medical Education, which accredits allopathic medical schools in the United States and Canada.

“We know that, for at least a couple of the schools that are on probation, high levels of mistreatment were a factor,” Dr. Sondheimer said. “It’s just not acceptable.”

Academic medical centers where mistreatment is prevalent have trouble recruiting students back as residents, and they often experience high burnout and turnover among faculty and staff, Dr. Rappley said.

Unfortunately, the general environment of teaching hospitals is ripe for abuse of students, Fried said.

“People are stressed. People are burned out,” she said. “Academic medicine is hard. It’s demanding. There’s less money, and people are working harder. People are tired, and they [mistreat students], unfortunately, because they can. It’s been in the culture for decades.”

Dr. Rappley said some educators teach through intimidation. While it’s important to challenge students and push them to their maximum potential, instruction has to be framed in a respectful way, she said.

“We are going to have to work on that difference between what is humiliating and what is inspiring people to do their best,” Dr. Rappley said. “It’s a fine line.”

Mistreatment also plays a role in students’ choice of specialty, and therefore has an impact on the diversity of students going into different specialties, Degesys said. It affects patient safety, with harassed students being more likely to make mistakes in patient care, she said.

“Being a physician is a very stressful job, and all of these things contribute to a culture of medicine that is contributing to this type of behavior — to the hidden curriculum of medicine,” Degesys said. “Part of it also is this idea that ‘It happened to me, so I should do it to someone else. It’s a rite of passage for medical students to be yelled at or mistreated.’ ”

Changing the culture

The University of Chicago Pritzker School of Medicine began to target medical student mistreatment about a decade ago. Because rates nationwide are highest when students transition to clinical training, the school surveys third-year students at the completion of each clinical block rotation.

Most interventions have focused on educating students, residents, faculty and staff about appropriate behaviors, said James Woodruff, MD, associate dean of students at Pritzker. For example, the school created an ombudsman system that provides students and residents confidential assistance and advice. It also has held mandatory workshops on the topic for faculty from departments with the highest reports of mistreatment.

Since the school launched its interventions in 2006, incidents have dropped by more than 50%, he said.

“It is a topic of discussion multiple times during the four-year curriculum,” Dr. Woodruff said. “Parties on both sides of the issue need constant reminding of what mistreatment is and how to address it. Overall, we have felt our focus on education and positive role modeling has been the major contributor to our progress in mistreatment.”

Schools face multiple obstacles

One of the biggest challenges is that most students don’t report when they are mistreated. Not knowing how prevalent a problem is makes it difficult to address, Dr. Sondheimer said.

When asked in the AAMC questionnaire why they didn’t report incidents, students said they felt it wouldn’t help or they would face repercussions, he said.

“They’re not reporting it because they are afraid to,” Fried said. “They are vulnerable, and they are afraid of retaliation. They feel that they need to suck it up, that it’s part of the culture and they don’t want to be seen as troublemakers.”

Compounding the problem is that students do clinical rotations in small groups, which makes it more difficult to report because they have less anonymity, Dr. Rappley said. Schools have to create safe reporting environments for students and protect them from any repercussions, she said.

“It’s still a system in which how people regard you is all important to your future,” Dr. Rappley said. “The impression you make on your team and your attending physician goes on your record and can affect the kind of recommendations you get for residency. The stakes are incredibly high, and the circumstances are intensely personal.”

Academic medicine in general is placing more emphasis on civility and interpersonal skills­ — traits that traditionally have not been a big focus, said Andrew Klein, MD, professor and vice chair of the Dept. of Surgery at Cedars-Sinai Medical Center in Los Angeles.

“Historically, the traits that we have looked for when we train doctors are not focused on civility,” he said. “We are looking at their test scores, their contributions to literature. We’re not necessarily looking at how well they interact with others.”

The problem perpetuates itself as students move on to become physicians and faculty, he said.

“The way we train the medical students is the way they are going to learn to train the next generation,” Dr. Klein said. “That is the culture they are going to adopt.”