Mavis, Brian PhD; Sousa, Aron MD; Lipscomb, Wanda PhD; Rappley, Marsha D. MD
The contemporary discussion in the medical literature of the mistreatment of medical students started over 20 years ago by Henry Silver and his colleagues at the University of Colorado.1,2 Since then, many studies, reflections, editorials, and reports of mistreatment have appeared in journals and the popular press. At a late 2010 meeting of the Liaison Committee on Medical Education (LCME), in which one of us was a participant (M.D.R.), it was noted that since 1991, when the Association of American Medical Colleges (AAMC) first included questions about mistreatment on the Medical School Graduation Questionnaire (GQ), approximately 17% to 20% of medical students across the country each year reported mistreatment. The LCME sent a letter to their sponsoring organizations, the AAMC and the American Medical Association (AMA), requesting that these organizations look further into these consistent reports of the mistreatment of medical students. The LCME felt strongly that this was not a matter to assess and benchmark according to percentile or other types of ranking but instead was sufficiently urgent as to require further study.
The AMA and the AAMC responded quickly. In less than six months, the AMA Section on Medical Schools organized a special session at their 2011 national meeting, at which some of the data presented in this article were discussed. The AAMC immediately examined if the GQ might be adapted to better assess mistreatment, and the AAMC Council of Deans, the Organization of Student Representatives, and the Organization of Resident Representatives began discussions in earnest about the many dimensions of the problem. Meetings continued through 2011 and 2012, including a well-attended town hall session at the 2012 AAMC Annual Meeting. In short, the medical education community acknowledged the problem and was activated to find a way to understand and intercede to prevent further mistreatment. At the 2011 meeting of the AAMC Council of Deans, one dean stated: “I never talked about this with the other deans before. I thought this was happening only in our institution.”
These many meetings and discussions revealed that medical schools across the country were struggling to manage the complexity of this problem, which pertained to residents as well as medical students and could be generalized to include all learners and teachers within the milieu of our health systems. Through these meetings and discussions, participants identified at least five important aspects of the issue that required further study and discussion—strong evidence was lacking regarding (1) a definition of mistreatment, (2) the reporting of mistreatment, (3) the assessment of alleged mistreatment, (4) any interventions after mistreatment was identified, and (5) the prevention of mistreatment. The purpose of this article is to review the national data on mistreatment, using medical students’ responses to the AAMC GQ, to document the findings from the national meetings and discussions regarding what is known about medical students’ experiences of mistreatment and how these experiences have changed over time, and to highlight the many implications of this information for the broader medical education system.
About the GQ: The Evidence of Mistreatment
The AAMC surveys all graduating medical students annually, using the GQ. Each year, medical schools receive the aggregated responses of their graduates as well as comparative national data. They use this information to guide their efforts to enhance the medical school experience for students, and it has been an important data source for institutional program evaluation. The GQ is endorsed by the AMA Medical Student Section, the American Medical Student Association, and the American College of Physicians Council of Student Members.3
The GQ was first administered in 1978 and included questions related to students’ preclinical and clinical curricular experiences, financial aid and indebtedness, use of support services, career planning and goals, as well as a variety of special topics. The inclusion of questions about medical student mistreatment in 1991 was important for a variety of reasons. First, the questions made explicit the behaviors and experiences considered to be abusive or oppressive and brought to light an issue that had historically received little public acknowledgment and blithely been considered a normal part of the medical school experience. In addition, the resulting data have become the primary source of information for institutions and researchers exploring issues related to the mistreatment of medical students.
What Is Mistreatment?
Defining mistreatment remains a challenging task. The first GQ questions about mistreatment focused on denied opportunities, lower evaluations or grades, and offensive names and remarks predicated on gender, race/ethnicity, and/or sexual orientation. Other questions addressed public humiliation, requests to perform personal services, threatened or actual physical harm, sexual harassment and unwanted sexual advances, and others taking credit for a student’s work.
In 1992, new questions were added which asked students about feeling ostracized by their peers because of age, race/ethnicity, gender, sexual orientation, or physical handicap. Over the years, changes in the question wording and content have reflected the growing awareness and concerns about mistreatment as more information about the prevalence and types of mistreatment have become available. Questions on the 2012 GQ were organized into five themes: general mistreatment, as well as sexual, racial/ethnic, gender, and sexual orientation mistreatment.
In 2001, the GQ included a definition of mistreatment to guide respondents:
Mistreatment arises when behavior shows disrespect for the dignity of others and unreasonably interferes with the learning process. It can take the form of physical punishment, sexual harassment, psychological cruelty, and discrimination based on race, religion, ethnicity, sex, age, or sexual orientation.
This definition was updated in 2011:
Mistreatment either intentional or unintentional occurs when behavior shows disrespect for the dignity of others and unreasonably interferes with the learning process. Examples of mistreatment include sexual harassment; discrimination or harassment based on race, religion, ethnicity, gender, or sexual orientation; humiliation; psychological or physical punishment; and the use of grading and other forms of assessment in a punitive manner.
None of the original questions asked respondents directly if they felt they had been mistreated, only if they had experienced specific situations defined as mistreatment. In 2000, the following question was added: “Have you been personally mistreated during medical school?” It served as a screening question, and those who responded yes were presented with 14 follow-up questions representing specific types of mistreatment. This format remained unchanged until the 2012 survey, when the screening question was removed. Now, any respondent who acknowledges having experienced one or more of the situations presented is considered to have been mistreated, removing the student’s subjective evaluation of a situation from decisions about what constitutes mistreatment.
Are Medical Students Mistreated?
Between 2000 and 2011, 12% to 20% of GQ respondents nationally reported mistreatment (see Table 1), which represents 1,200 to 2,800 students per year. When considered from an institutional perspective, the percentage of students at a single medical school reporting mistreatment is highly variable. For example, based on 2010 GQ data, an average of 17% (median of 15%) of respondents per medical school reported mistreatment, but this average varied from 4% to 41% across medical schools (see Figure 1). Although part of this variability was attributable to data quality differences, including variable response rates and missing data across institutions, it also was a reflection of the differences in institutional culture and climate.
The addition of the screening question in 2000 brought attention to the meaning of mistreatment. Specifically, it highlighted the percentage of students reporting public belittlement or humiliation. From 1991 to 1999, between 40% and 50% of respondents reported being publicly belittled or humiliated (Figure 2). After the addition of the screening question, only respondents who indicated that they had been mistreated had the opportunity to respond to the questions about specific types of mistreatment. After this change, only 11% to 17% of respondents indicated being publicly belittled or humiliated. These findings suggest that many students experienced public humiliation but that not all considered it mistreatment, highlighting the importance both of subjective experience in students’ responses and the need to better define behaviors representing mistreatment.
When the screening question was removed in 2012, mistreatment was operationally defined as the percentage of students reporting experience with any of the specific mistreatment situations. For example, 47% of respondents—approximately 5,700 graduating students—endorsed one or more situations, indicating that the prevalence of mistreatment in 2012 was greater than in prior years.4 Public humiliation was reported by 34% of respondents and likely accounted for a large proportion of the graduates considered to have been mistreated.4
What Types of Abuse Are Medical Students Experiencing?
Table 2 shows the specific types of mistreatment reported by those respondents to the GQ who indicated that they were mistreated. From 2000 through 2011, when the screening question was in place, 82% to 91% of mistreated students reported being publicly belittled or humiliated. In 2012, when the screening question was removed, 34% of all respondents reported being publicly humiliated. Regardless of whether or not the screening question was used, public humiliation was the most commonly reported form of mistreatment. From 2000 to 2011, other frequently reported forms of mistreatment included sexist names or remarks (25%), requests to perform personal services (24%), and lower evaluations or grades because of gender (21%) (see Table 2). In 2012, offensive sexist remarks (16%), requests to perform personal services (9%), lower evaluations or grades because of gender (7%), and racially or ethnically offensive remarks (7%) were most frequently reported.4
What Are the Sources of Mistreatment?
According to the 2012 GQ responses, clinical faculty in the hospital (31%) and residents or interns (28%) were the most frequent sources of mistreatment, followed by nurses (11%). These groups also were the most frequent sources of mistreatment from 2000 through 2011, although the magnitude of the numbers was different because the screening question was used. Other sources of mistreatment, such as classroom faculty, administrators, and other hospital staff, each accounted for 4% or less of responses. Six percent of 2012 respondents identified medical students as the source of the mistreatment.
Are Medical Students Reporting Incidents of Abuse?
Approximately one-third of the respondents who were mistreated reported these incidences to faculty or administrators (see Table 1). Among those who did not, most indicated that the incident was not important enough to report (median of 49%) or that they feared reprisal (median of 48%). A smaller percentage (21%) were unsure of what to do. Of all respondents to the 2012 GQ, 37% felt that reporting the incident would not be effective, and 22% indicated that they resolved the issue themselves. On a positive note, the number of respondents reporting an awareness of their school’s mistreatment policy has increased over time (see Table 1).
Next Steps to Address Mistreatment
Defining the problem
Arriving at a commonly held definition of mistreatment may be the greatest challenge. The academic medicine community has reached a broad consensus that we should not tolerate illegal and unethical behavior, such as physical harm and denigration or denial of opportunity based on ethnicity, gender, or sexual orientation. Discussions of humiliation, however, elicit suggestions from simply “stop whining” to an abandonment of the Socratic method of teaching. Although most physicians identify episodes in their training that resulted in feelings of humiliation, many see these experiences as motivation to do better or as a rite of passage in the education of physicians.1,5
Although humiliation is the most commonly reported type of mistreat ment, it is also the murkiest because in some ways humiliation is in the eye of the beholder.6,7 Most would agree that name calling is unacceptable. But we also have a responsibility to give each other honest feedback. For example, faculty must provide feedback to a student who is not prepared for a presentation or rounds, doing so with directions for improvement and without public humiliation. That faculty member, however, cannot control how the student will respond to such feedback. Well-executed feedback that leads a student to realize that he presented poorly in front of his fellow students and residents may make him feel humiliated, but his sense of humiliation does not mean that the faculty member mistreated him.
The biggest challenge in defining humiliation and belittling is identifying the borderline between asking students questions and “pimping.”8,9 Disagreement exists around whether or not pushing students to the point where they can no longer provide a reasonable answer constitutes a valuable teaching method or is unnecessarily humiliating. When a reasonable person can tell that a student does not know the answers to questions, yet the faculty member continues to pepper the student with questions, the goal of the questions likely has shifted from assessment and teaching to humiliation and disgrace. Gray areas will always exist, and as educators, we are challenged to develop a standard for “having gone too far” based on what a reasonable observer would conclude.
Understanding the influence of culture
The apparent variability in mistreatment across institutions draws attention to the importance of local culture and climate. Culture is the complex and enduring values, expectations, traditions, customs, and role modeling that have a direct impact on the learning climate. Institutional culture is predicated on the people within the institution and can be affected by the composition of the study body, administration, and faculty.
The differences in mistreatment across institutions suggest that we could learn something from a closer examination of the institutions with the highest and lowest rates of reported mistreatment. A 2012 report by Fried and collegues,10 for example, documented multiple strategies implemented over 13 years at one institution to eradicate medical student mistreatment and the relative lack of impact those strategies had on the prevalence of mistreatment reported by students. At other institutions, approaches have varied considerably, from institutional policies and definitions11 and educational programs for students and residents10 to online student forums12 and role-playing.13 When examined together, these efforts have the potential to bring us closer to a shared understanding and adoption of a standard of teaching, much like the now widely adopted standards of patient care.
Reporting and responding to reports of mistreatment
For institutions to understand, intervene, and prevent mistreatment, students first must report it. A large majority of the data about mistreatment is derived from medical students’ reports of such experiences. Thus, an essential quality for any effective reporting mechanism is safety. The complexity of the matter is inherent in our need to provide safety for all participants in our medical education system, all of whom are entitled to learn and work in an atmosphere of respect, free from mistreatment. For example, patients must be protected from interactions between team members characterized by disrespect and mistreatment. Students must be protected from retribution or retaliation for reporting mistreatment. Faculty must be protected from false accusations as the sources of mistreatment. Yet, the safety of students and faculty is difficult to ensure. The small-group learning process and the intimate nature of the relationship between student, resident, and attending physician juxtaposed with the trainee’s future opportunities in a given discipline make the safe reporting of mistreatment seem highly improbable to students and residents.5 As reports of mistreatment have become part of faculty evaluations and determinants of promotions, raises, and future opportunities, faculty feel unsafe in an environment in which reports of mistreatment can be made without compunction. To address this issue, methods are in place to ensure that faculty are not falsely accused, such as the use of an external agent to receive and act on reports and of internal networks of peer review. Future studies should evaluate the success of such methods in creating an environment in which the rights of all are respected. Doing so will help to create a national bank of best practices, which other institutions then can adopt.
At the institutional level, how to act on a report of mistreatment is seemingly unchartered territory. Although maintaining anonymity at all levels is highly desired, doing so seems to result in limited feedback to those involved. Approaching witnesses to document a description of the incident or to establish a pattern is also highly desired but has the risk of compromising the safety of others, including the student reporting the abuse, those who witnessed it, and those who have been accused. The investigation of the reported mistreatment may be associated with the labeling of a person or group of people in a way that may turn out to be unwarranted. Finally, adjudication is typically handled administratively, and traditional models exist for this process in the context of other kinds of disruptive behavior and breaches of professionalism. Although peer adjudication is one such model, it is not well described. Yet, it has the potential to move the concept of an honor code into the realm of how we interact with one another at all levels of our institutions and to emphasize our responsibilities to maintain an environment of respect for the dignity of others.
We also must develop interventions to address mistreatment once an incident or pattern of behavior has been identified. Models for such interventions exist on an anecdotal level. For example, individual counseling and remediation, such as anger management classes, are two such interventions. Further research should analyze the effectiveness of such methods, as well as appropriate intervals of implementation and tools for assessment, to identify best practices.
The challenge of giving feedback to the person reporting the mistreatment in a manner that does not compromise the due process for the person accused further complicates any intervention. Although evidence of mistreatment can be strong, due process can take months to unfold. Furthermore, interventions to address mistreatment should follow the same “no fault” principles as do those in patient safety and medical error reporting. However, such necessary delays for due process and no fault system evaluations can contribute to a belief among students that nothing is being done to address the mistreatment. Alternately, removing an accused faculty member from teaching duties or faculty appointments may lead to less of a disruption of due process, under the auspices of “no one has a right to teach” or “no one has a right to a faculty appointment.” Although such interventions are used, they have not been studied and deemed feasible on a large scale.
Finding Our Way
Many advocate that we should include mistreatment as part of our efforts to measure professionalism in our evaluation of performance. This shift is reassuring, in that the premise of teaching using methods respectful of human dignity has foundations that are widely established and embraced in other disciplines. However, this shift in how we frame discussions of mistreatment may result in a conceptualization of the issue that is too heavily focused on ourselves—on what is good for medical students and physicians—thereby further distancing us from the people we serve, our patients. Including mistreatment in discussions of patient safety, patient satisfaction, and how to ensure the best patient outcomes is equally plausible. These domains—academics and service—are not mutually exclusive, and in fact may represent two of the missions of academic medicine, which could both benefit from a better integration of values.
Mistreatment is not unique to Western medical education and has been widely documented elsewhere.14–17 In addition, it remains a transgenerational legacy5 handed down from teacher to learner. Although mistreatment has been documented and discussed consistently for the last 30 years, little progress has been made in determining what can effectively change the complicated interactions that produce it. Today, more than ever before, we are cognizant of the needs of those we serve, as is evident in national quality and safety initiatives and the work to establish medical homes. In addition, we are moving toward a consensus on the need for patient-centered organizations for health care delivery and for student-centered learning. These shifts are complementary and will help to effectively address the issue of mistreatment.
Important next steps for eradicating mistreatment include the clear declaration of intent across medical education, and the institutions that serve this mission, to provide, maintain, and support learning environments that are rooted in respect for all patients, learners, teachers, and team members. This can be accomplished with support from the AAMC, the AMA and other organizations that have taken leadership in addressing these concerns. Next, active discussion that includes students and residents must continue to document progress toward the goals of establishing a respectful learning environment, zero tolerance for abuse, and a greater understanding of what constitutes mistreatment. Important areas of research for the future include the prevalence of mistreatment among residents, approaches to creating a shared understanding of the definition of mistreatment and humiliation, the impact of reporting mechanisms, and interventions for change, prevention, and assessment.
Core to this effort will be the actions of medical schools, faculty, staff, and students. Medical schools will need to experiment with identifiable and anonymous reporting systems, investigators who are seen as impartial by all, and zero-tolerance policies that protect students but do not stifle faculty and staff feedback. Perhaps the most important effort will be the creation of a vigilant and self-sustaining culture across education, research, and clinical networks that does not tolerate the abuse of anyone. Institutions also must take responsibility to educate their faculty, staff, residents, and students regarding the definition of mistreatment and to engage them in identifying ways to improve the institution’s overall educational culture. To achieve these goals, schools, institutes, and clinical partners must report best practices, and individuals like Fried and colleagues10 must undertake longer-term research and publish their findings. The LCME highlighted the need to go beyond recording mistreatment, and the AMA and the AAMC responded quickly to this call. Together their efforts have gained momentum, a momentum that we must sustain to establish learning environments in which our patients, our learners, and our teachers can thrive.