How to address the mistreatment of medical students is a hot topic in medical education right now. The LCME, the body that accredits medical schools, is interested in this and their attention seems to be lending credibility to the issue and leading to some soul searching. It’s a difficult topic to approach for many reasons, especially since defining it is incredibly difficult. Medical training is notorious for its hierarchical culture and public humiliation has traditionally been a teaching tool in medicine. With this in mind, how do we know when something has crossed the line into abuse?
The American Association of Medical Colleges defines medical student mistreatment as public belittlement; threats of or actual physical punishment; requirements to perform personal services, such as shopping; sexual harassment; and discrimination or offensive remarks based on gender, race, ethnicity or sexual orientation. An early JAMA study of medical student abuse used this definition: “To abuse is to treat in a harmful, injurious, or offensive way; to attack in words; to speak insultingly, harshly, and unjustly to or about a person.” The authors also specified that abuse “refer[s] particularly to unnecessary or avoidable acts or words.”
Depending on the definition of abuse, the prevalence varies. By the AAMC definition, 30% of graduating students report abuse during medical school. In the JAMA study, 80% of students reported abuse. Either way, the number is way too high.
We know that abuse has detrimental effects on students. One study found that mistreated students frequently have symptoms of PTSD. And it’s not hard to imagine that humiliation, mistreatment and discrimination play a role in the loss of empathy seen during medical school.
So what to do? It is not enough to draw attention to bad behavior, telling medical students to treat the next generation of trainees differently. We have a deep cultural problem and we need a more comprehensive approach. Here are some ideas:
1. Cultivate awareness. This is the place to start. Every school should initiate an open process, engaging students, residents and faculty, in creating a consensus definition of abuse. The process is meant to engage the community in a debate about what behavior is and isn’t appropriate. I’d suggest that the definition should include the AAMC’s definition of mistreatment, but that it may also reflect the values of the institution. After it is created, the definition should be well publicized, especially to students starting the third year.
2. Create safe spaces for students. Students benefit from supportive spaces and faculty with whom to discuss their experiences. Sharing with other students reduces the sense of isolation that many students feel and may help to blunt the effects of abuse. Students, especially in the clinical years, need time and space set aside for this process.
3. Make reporting mistreatment safe and easy. According to AAMC graduation surveys, only about 15% of mistreated students report abuse through official channels at their school. Some have taken this to mean that students don’t actually want change. I suspect that it reflects a resignation to the culture of training, a fear of impact on grades, a hesitancy to rock a very hierarchical boat and doubt that reporting will have any effect. All of these concerns need to be addressed, ideally starting with the process and policy created in #1.
4. Require accountability. Collecting reports is the easy part; to truly change the culture, leadership at the highest levels needs to make this a priority. The department chairs who control salaries, promotions and hiring decisions need to use these strings to encourage faculty to treat students (and staff) well. Program directors should hold residents accountable. Medical students contribute to the culture as well and our clerkship directors and schools should hold us accountable when we contribute to abuse.
5. Reform the curriculum. Get students out of places where they are being mistreated and empower them to do so themselves. If a particular service is mistreating students, don’t send them there. Reform the clerkships to maximize student contact with faculty who care about teaching and have a strong track record with students. Give students a voice in these decisions.
Awareness of this issue is growing, and momentum for change is building. The schools that succeed in improving the student experience will be places where leadership has a vision for change. Do you know of a school that’s been particularly successful in combating mistreatment and changing the culture? How are things at your school?
Nathan Favini is a medical student who blogs at A Stranger in this World, and can be reached on Twitter @natefavini.
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