Larkin, Gregory Luke MD, MA, MSPH; Mello, Michael J. MD, MPH
Even the best pedagogical and interpersonal relationships can be challenging. In graduate medical education (GME), as elsewhere in academe, teachers and their charges have numerous close interpersonal interactions over the course of training, creating the possibility for both good and bad results. Although the professional roles of learners and faculty are interdependent, there are obvious asymmetries in power and position within the academic medical ecosystem that create the potential for mistreatment, abuse, and even sexual trespass between mentor and mentee. In this commentary, we use examples from history, literature, and scholarship to underline some of these interpersonal pitfalls and describe the professional norms under which teacher–learner mistreatment may be minimized and positive pedagogical relationships can prosper.
Toward Mutual Respect
Historical foundations of learner abuse: Master and servant revisited
Forerunners of modern interns, cleric–physician oblates in the European Dark Ages, took vows of obedience, chastity, and poverty. Ranking among the most educated people in medieval Europe, cloistered priests and monks were often forced into the physician role. Feudalism and monasticism eventually gave way to the Enlightenment and, ultimately, the Industrial Revolution in which workers of all types suffered for a different motive: profit. Early labor laws were designed to crush insubordination, enforce obedience, and weaken, inhibit, or otherwise suppress unions.
Similar master and servant themes have influenced the American medical–industrial complex as well. Despite paying for the privilege of participating in frequently mundane clinical chores, medical student charges and acting interns seldom receive sufficient credit when they quietly save the day. A long-held lack of reciprocity, mutuality, and respect for the doctor-in-training has resulted in unflattering portrayals of residents and other trainees in literature and in the media. For example, Dr. Stephen Bergman's (a.k.a. Dr. Samuel Shem's) The House of God1 showcases sycophantic intern “scut puppies” running for food, disimpacting the obstipated, running bloods to lab, fetching records, cleaning up sharps after procedures they were “allowed” to watch, and being “pimped” daily on rounds as emblematic of time-tested rites of passage for initiates into Aesculapius' secret society. Unfortunately, negative early work experiences and interactions impact not only the immediate teacher–learner dyad but can also carry adverse emotional and unprofessional ripple effects into the hospital, residency, medical school, and the greater community of learners and teachers as a whole. In addition, studies show that a hostile educational milieu can be self-perpetuating, handed down from generation to generation by those who were themselves maltreated as students.2,3
Recent reports link medical student problems of burnout, debt, and suicidal ideation. In addition, workplace harassment can have serious ethical as well as legal consequences when residents or students are scored poorly on rotations or forced to work extra when disliked on merely personal grounds.4,5 Even now, work hours restrictions do not protect against hospital workplace biases.6 While fiction and film have provided exemplary role models for successful mentor and mentee relationships (Obi Wan Kenobe and Luke Skywalker, Merlin and King Arthur, and Professor Dumbledore and Harry Potter, just to name three),7 better models for protecting medical mentee relationships are needed.
In the absence of strong mentorship and academic advocacy, trainees have sought assistance elsewhere. For more than a decade, U.S. residents have been joining trade unions hoping to secure work hours limits, salary increases, and improved work conditions.8–10 However, organized labor may also threaten the Oslerian teaching enterprise by clouding the learning atmosphere with the specter of binding arbitration, picketing, boycotts, and even strikes. Although only a minority of medical residents currently pay union dues, the ongoing socialization of American medicine may result in unions increasingly affecting the sanctity of the teacher–learner relationship.11
Appreciation and servant leadership
To engender more fair and consistent treatment without collective action or unionization, teachers, evaluators, administrators, and mentors should strive to emulate the ideals of servant leadership12 and thereby emphasize supervisor magnanimity, acknowledgement, and gratitude as integral to the academic work environment. Robert Greenleaf12 adopted the idea of the servant leader in education and elsewhere after reading Hermann Hesse's Journey to the East: “… the great leader is seen as the servant first.”
Academic leaders with vision show appreciation to those they serve, and vice versa. A faculty member's explicitly stated appreciation for a trainee's effort and accomplishments can go a long way. This is exemplified by medical scientists who encourage resident researchers' authorship on projects (in which it is deserved), rather than opportunistically riding piggyback on student labor in the lab or elsewhere. Attending teaching staff should demonstrate respect for the young men and women of medicine, who make the toils of the trenches considerably easier.
When Professional Relationships Get Personal
Teachers have fraternized with their students since antiquity. Moreover, there are levels of attraction within academe that promote the learning process itself; students learn better from teachers they genuinely like. At Plato's Academy and later at Aristotle's Lyceum, young Greek men studied and recreated in close proximity to their masters. In the Symposium,13 Plato asserts a strong love between Socrates and his admiring male acolyte, Alcibiades. This love was deep, masculine, and sometimes seductive. The idea of a higher spiritual love in interpersonal human relations gave birth to the very notion of platonic love, a strong counterpoint to any rumors of Eros in the ancient Athenian Academy. This elevated idea of spiritual kinship between students and teachers has lasted through the millennia and, in modern times, has found archetypal incarnations in such inspiring teacher–student pairs as Anne Sullivan (1866–1936) and Helen Keller (1880–1968). Now legendary, their work together in the American South illuminated the plight of vision-impaired learners everywhere. Indeed, their sharing underscores, for teachers and students alike, that the very best learning partnerships are often those limning the line between interprofessional and interpersonal norms of conduct.
However, although explicit affairs among teacher–student dyads are rare, subtle forms of emotional, social, and sexual abuse of medical learners are not uncommon. Being intimate with students remains a serious, public, and punishable offense, but the opportunities for inappropriate contact with students have never been greater than in this age of social media.14 At the micro level, threats of academic intimacy can injure hearts, damage careers, ruin reputations, and blind faculty to the objective evaluation or remediation of their favorite students. Between claims of nepotism on one hand or sexual harassment on the other, the mere perception of sexual intimacy between students and faculty creates an uncomfortable learning milieu for other pupils and faculty as well. With the great amount of interaction between faculty and trainees in the GME setting, close interpersonal relationships may engender fears of discrimination, favoritism, coercion, “grades for sex,” or sexual predation at the meso or departmental level. Hence, most universities have strict policies forbidding consensual sexual relationships with students. Finally, at the macro level, unwritten codes of conduct within both the house of medicine and within civil society are offended when intimate relationships bring shame into the virtual classroom, lecture hall, or hospital.15
To combat a loss of trust in the educational environment or in public opinion, countervailing professional forces, icons of chastity and charity, and professional oaths and codes can provide a moral vaccination that protects medicine's status trust and immunizes the workplace from forms of sexual contamination. Below, we offer examples of codes of ethics generally responsive to boundary issues. We present codes specific to our specialty, emergency medicine, but their general principles may apply to all of clinical and academic medicine.
Codes of Ethics and Learner–Teacher Relations
The considerable perils of doctor–patient sex have been proscribed from the time of the Hippocratic Oath until the publication of the Current Opinions of the American Medical Association's Council on Ethical and Judicial Affairs.16 However, faculty–trainee intimacy has not been similarly proscribed. Indeed, there is frequently little to prevent physicians of different academic castes from cavorting within academe. Although university policies may prohibit classroom professors from dating medical students, such hierarchically mismatched relationships in hospitals or other training settings are frequently not held to the same level of scrutiny. Similarly, sexual misconduct and learner mistreatment in GME have often been heretofore tolerated.17–19 More recent codes of ethics within organized emergency medicine can provide a more explicit basis for promoting fairness and sexual restraint in GME.
Interprofessional impropriety is not well defined by most modern codes of medical ethics, though perhaps like Supreme Court Justice Potter Stewart's infamous definition of pornography, we “know it when we see it.” More explicit guidance is needed. In response, the American College of Emergency Physicians (ACEP) Code of Ethics20 states the following with respect to physicians' relationships with trainees:
Emergency physicians must take seriously their responsibilities to medical students, residents, prehospital care personnel, and trainees of all types to teach them both the moral and technical aspects of emergency medical practice.
Recognizing that example is the best teacher, the authors of the ACEP code further state that “the ethical aspects of academic emergency medicine, teaching, and research should also be taught and modeled for students by emergency physicians in practice.”20 In addition, the code states clearly that “[t]rainees, like patients, are a vulnerable population, and they must not be mistreated, abused, or coerced for faculty self interest.”20
Like the ACEP, the Society of Academic Emergency Medicine (SAEM) adopted a parallel Code of Conduct for Academic Emergency Medicine. Therein, SAEM enjoins teachers abiding by its code to follow a similar spirit of moral protection toward students and residents. The preamble of general obligations within the SAEM Code of Conduct makes the following promises: “I will be considerate, forthright, and just in all of my dealings with patients and colleagues, regardless of their power, position or station in life” (emphasis added).15
As with the recognition of learner “vulnerability” within the ACEP Code of Ethics, the SAEM Code of Conduct also underscores the power differential within the academic hierarchy; this sentiment is implicitly acknowledged by the following statement in the SAEM code: “I will advance the ideals of the profession, and I will not abuse the privilege of my knowledge or position.”15
Those who even appear to be abusing their position for student exploitation, coercive sex, or other self-aggrandizement must be prepared for remediation or dismissal.
After the preamble, the SAEM Code of Conduct takes the form of an oath for researchers and teachers alike. The following three statements enjoin teachers of emergency medicine to espouse important virtues that will serve their students' interests:
As a teacher of emergency medicine, I vow:
1. Respect, giving all who seek to learn emergency medicine the dignity due a colleague.
2. Fairness, treating all students and fellow teachers equitably, in a manner free of prejudice, abuse, or coercion.
3. Mentorship, nurturing and encouraging the requisite technical, intellectual, and moral virtues of the profession in students of every kind through my words and deeds.15
The net goods that might result by following the SAEM Code of Conduct are suggested by the final statement: “By keeping these promises, may I bring honor to myself and my profession, enriching the lives of patients, students, and colleagues” (emphasis added).15
The SAEM code represents a written version of an otherwise unwritten social contract and, along with the ACEP Code of Ethics, reflects the commitment of organized emergency medicine to support more explicit notions of professionalism. Professionalism, in turn, is a core competency required by the Accreditation Council for Graduate Medical Education, and it connotes a general obligation for self-policing and self-reflection that distinguishes professionals from other members of the workforce. These core competencies must be formally included into residency training, and then trainees should be evaluated on their understanding and practice. Furthermore, junior faculty should again have these values reviewed on entering their new role in academia, and their evaluation should be part of all ongoing faculty reviews.
Relationships in Context
Of course, faculty celibacy and trainee chastity are not always mandatory.21 It may not be uncommon in small university towns for postgraduate students and faculty to encounter one another in off-campus settings. Similarly, globalized cyber campuses, like Facebook, blogs, and other Web-based cyber venues may also increase the likelihood of student–faculty interaction outside the academic institution. Professionals, however, carry inherent obligations to limit and carefully monitor such exposure in order to uphold the dignity and reputation of the profession they represent.
Professors and physicians do not lose all professional standing as soon as they leave campus or the hospital; pedagogic power differentials and their proper stewardship do not necessarily dissipate on the basis of setting. However, as free-thinking, consenting adults, faculty may date or socialize with age-appropriate students who are not now nor ever likely to be under their supervision. This largely excludes undergraduate students, trainees, and faculty working within the same department. Intimate intradepartmental relationships at all levels are problematic. The institution has a duty to formally address inappropriate relationships and to provide confidential mechanisms for colleagues who wish to report such a relationship. Friendships, however, can enhance the experience of learning and promote mentorship, collaboration, learning, and inquiry. However, friendship, though appropriate, must also have boundaries, as excessive unequal friendship contact between select dyads of faculty and trainees gives rises to jealousy among colleagues and creates a divisive department.
Like Aristotle, teacher to Alexander the Great, honorable academics want their students to be successful. Some students simply attract more faculty attention—positive or negative— than do others. Attraction and revulsion are normal aspects of the human psyche, but they must, as with all passions, be kept in check, lest one threaten the integrity of the academic environment in which medicine is taught and practiced. Indeed, teachers must strive for balance between nepotism on one hand and total student neglect on the other, neither playing favorites nor bullying the least favorite pupils. Fairness and trust are at the heart of the model teacher–learner relationship.
Educators can adopt the role of servant leadership and, within that role, model exemplary behavior by following employment guidelines, adhering to university policies, and practicing the virtues of magnanimity, restraint, and platonic friendship. At the institutional level, an infrastructure within academic medicine is required for confronting and resolving transgressions of learner abuse; this may include ethics committees and continuing education for both junior and senior faculty, having new faculty tested on institutional policy, and incorporating teacher–student relationship training into faculty orientation curricula.