Medical students typically look forward to their required clerkships, anticipating the in-depth exploration of clinical medicine, determining or revisiting their own personal calling, and choosing a specialty based on that calling.1,2 Yet, as medical students move toward their preferred specialty, they may encounter various obstacles. These obstacles may include mistreatment from attending and resident physicians, specifically regarding the specialties with which the students identify.3–10
The mistreatment of medical students is a serious and pervasive problem in medical education. The Association of American Medical Colleges includes questions regarding public humiliation, physical harm, verbal abuse, and various forms of coercion on its annual Medical School Graduation Questionnaire. Recent data from the Graduation Questionnaire demonstrate that 17% to 20% of medical students experience various forms of mistreatment at some point during medical school.11 Previous work has shown that such mistreatment can have long-term, undesirable effects, including negatively affecting students’ career choices and contributing to long term stress.3–5,12,13 In response, a number of groups and individuals have issued a widespread call to adopt a zero tolerance policy toward student mistreatment.14 Over the past decade, many institutions, including ours, have introduced initiatives, such as retreats and regular seminars, aimed at increasing professionalism among faculty and resident physicians.15 Although medical schools have been focusing on improving professionalism curricula, they have not identified specific solutions for preventing medical student mistreatment.14,16
Mistreatment based on specialty choice represents a distinct category of abuse that may have its own long-term consequences. Given shortages in various specialties, such as family medicine, general internal medicine, general pediatrics, and general surgery, mistreatment based on specialty choice may exacerbate such shortages if it has an undue influence on students’ interest in pursuing one of these disciplines.17,18 Woolley and colleagues8 demonstrated that such mistreatment was common and that certain patterns of mistreatment correlated with particular career interests, clerkship rotations, and teaching personnel. What is not known, however, is whether such mistreatment fluctuates over time, what the content and nature of such mistreatment is, whether differences exist in mistreatment based on specialty interest, and whether students’ changes in specialty choice are related to mistreatment. In this longitudinal study, we explored these issues using eight years of mistreatment data. We defined mistreatment as verbal abuse, negative consequences, or coercion based on a student’s stated specialty choice.8
We conducted this study at a medium-sized medical school within an academic health center in a suburban setting, and it was approved by the medical school’s institutional review board (protocol 2003-151EM).
We distributed our survey to 1,059 students at the completion of their third-year clerkships each year from 2003 to 2010. Student participation was voluntary, and responses were anonymous. Our survey included seven items that were based on those used by Woolley and colleagues.8 It asked students to rate the frequency and negative impact (i.e., how much it bothered the student) of any mistreatment based on specialty choice that they had experienced, using the following item stems:
- I was told directly or overheard negative comments about my specialty/career interest.
- I was discouraged from continuing in my specialty/career interest.
- I was called offensive names (i.e., stupid, idiot, etc.) because of my specialty/career interest.
- I witnessed other students receiving negative comments or treatment based on their specialty/career interest.
- I believed I had to be less than completely honest about my specialty/career interest to receive fair treatment.
- It seemed I was denied teaching, training, or clinical opportunities because of my specialty/career interest.
- It seemed I received lower evaluations or grades because of my specialty/career interest.
To indicate frequency, students chose between “never,” “rarely,” “occasionally,” and “frequently.” To indicate negative impact, they chose between “no,” “little,” “moderate,” and “high.”
In addition to these items, we asked students to rate the frequency of mistreatment from various sources, including attending physicians, residents, nurses, and other students, as well as the frequency of mistreatment during each of their third-year core clerkships (internal medicine, surgery, pediatrics, obstetrics–gynecology, primary care/underserved medicine, family and community medicine, psychiatry, and neurology). We asked students to identify their single strongest specialty interest at the start of the clerkship year then at the time of survey completion. Finally, we asked a single open-ended question: “Please describe the circumstances and outcomes of any mistreatment experiences based on your career interest.”
We divided the respondents into two groups based on their interest in either primary care or a subspecialty at the end of their third year. The primary care group consisted of students identifying family medicine, internal medicine, or pediatrics as their strongest specialty interest, and the subspecialty group of students interested in any other specialty.
To evaluate possible associations between the frequency and impact of mistreatment, we first dichotomized the responses into either “low” (never/rarely or no/little) or “high” (occasionally/frequently or moderate/high). For each survey question, we examined a 2 × 2 table of frequency versus impact and used a chi-square analysis to examine for significance. We then calculated summary scores for all seven frequency items and all seven impact items and calculated the Pearson correlation coefficient for the association between overall frequency and impact.
Next, we explored differences in patterns of mistreatment among subspecialty students compared with primary care students. For each survey question, we compared mean frequency scores for subspecialty students with those for primary care students, using t tests to examine for statistical significance. We also compared mean impact scores between both groups for each survey question, again using t tests to examine for significance. As our dataset contained complete data for 745 students who articulated a clear preference at both the beginning and end of the third year, we divided these students into four categories: students who originally had an interest in a subspecialty and switched to primary care, students who originally had an interest in primary care and switched to a subspecialty, and students who were originally interested in either primary care or a subspecialty and did not change their preference. We used chi-square analyses to examine for differences among these four groups on each survey question and on summary scores for both frequency and impact items.
Then we calculated the frequency of mistreatment for each clerkship and source (full-time clerkship faculty, other attendings/faculty, residents, preceptors, other students, nurses, and administrators).
Subsequently, we compared the number of students who reported a high frequency/high impact of mistreatment with those who reported a low frequency/low impact of mistreatment for each question and each year of the study to identify trends over time. For each survey question, we used a chi-square analysis to examine the significance of frequency/impact for each year of the study. We conducted all quantitative analyses using SAS version 9.2 (SAS Inc., Cary, North Carolina).
Finally, we performed a qualitative content analysis of the responses to the open-ended question. Two authors (T.K.O. and P.H.) read all of the responses individually and noted initial impressions of themes. Together, they developed a codebook and reached agreement on the themes. One author (T.K.O.) coded all of the data, and then the second author (P.H.) read all of the coded statements and found no discrepancies. As a final check, we presented the codes and themes to all authors with a sampling of the coded statements and, again, found no disagreements. We used ATLAS.ti qualitative analysis software (ATLAS.ti Scientific Software Development, GmbH, Berlin, Germany), to organize the data, code themes, and record our analytical impressions.
We distributed our survey to 1,059 students over an eight-year period. Response rates for each class varied from 63% to 88%, with 801 students total returning surveys for an overall response rate of 76%. The mean age of respondents was 26 years. Of all 801 respondents, 53% (427) were female, and 568 (71%) identified themselves as Caucasian, 98 (12%) as Asian/Pacific Islander, 40 (5%) as African American, 10 (1%) as Hispanic, and the rest as “other.”
At the start of the third year, 430 respondents (58%) reported that they were interested in a subspecialty and 315 (42%) in primary care. At the end of the third year, 467 respondents (63%) reported an interest in a subspecialty and 278 (37%) in primary care.
Patterns of mistreatment
The most commonly reported type of mistreatment was students being “told directly or overhearing negative comments” about their specialty choice (488/747 [65%] reporting high frequency and 245/747 [33%] reporting an associated negative impact) (see Table 1). Of respondents, 45% (334/739) “believed [they] had to be less than completely honest [about their specialty choice] to receive fair treatment,” and 38% (284/739) reported an associated negative impact. The least commonly reported type of mistreatment was being called offensive names, with 4% (26/713) of respondents indicating a high frequency and 5% (34/713) a high negative impact.
Mistreatment occurred most frequently on the surgery clerkship, followed by the obstetrics–gynecology and internal medicine clerkships. Of respondents, 36% (253/696) reported occasional or frequent mistreatment during the surgery clerkship, 25% (168/668) during the obstetrics–gynecology clerkship, and 16% (112/688) during the internal medicine clerkship. Respondents identified resident physicians almost twice as often as the source of the mistreatment (285/726; 39%) (see Figure 1).
Connection between frequency and impact of mistreatment
In examining the combined data across all study years, we found a positive association between the frequency of mistreatment and the degree of negative impact for each question (P < .001 in all cases). In addition, the sum frequency and impact scores were highly correlated (Pearson r = 0.8, P < .001).
Mistreatment based on specialty choice
Although the absolute differences were small, respondents who expressed an interest in a subspecialty tended to report mistreatment more frequently than those who expressed an interest in primary care (see Table 2). In particular, they reported more frequently being called offensive names because of their specialty interest (P = .01), believing they had to be less than completely honest about their specialty interest to receive fair treatment (P = .004), and believing that they received lower evaluations or grades because of their specialty interest (P < .001). We also found a trend toward the primary care respondents reporting a higher degree of negative impact from being told directly or overhearing negative comments about their specialty choice (P = .06). The respondents interested in a subspecialty, on the other hand, reported a higher degree of negative impact from being called offensive names (P = .004) and in believing that they received lower evaluations or grades because of their specialty interest (P < .001).
Of the 745 respondents who indicated a specialty choice both at the beginning and end of the third year, 377 indicated an interest in a subspecialty and did not change their response. Similarly, 225 respondents indicated an interest in primary care and did not change their response. In contrast, 53 respondents indicated an interest in a subspecialty and switched to primary care, and 90 indicated an interest in primary care and switched to a subspecialty. We found no significant differences between these four groups in frequency and impact summary scores. However, both groups of respondents who indicated an interest in a subspecialty at the end of the third year perceived that they received lower evaluations because of their particular interest and perceived that this mistreatment had a higher degree of negative impact.
Patterns of mistreatment over time
We examined the percentage of respondents reporting a combination of a high frequency and high degree of negative impact across the eight years of the study for each survey question. The combined frequency and impact of mistreatment (according to the first survey question, “told directly or overheard negative comments about my specialty interest”) remained stable over the years of the study (P = .3 for the association of frequency/impact versus study year) (see Figure 2). Although two of the survey questions (“called offensive names” and “witnessed other students receiving negative comments/treatment”) demonstrated P < .05 for this analysis, neither graph demonstrated a consistent pattern across the study years. Instead, each contained one to two low outlier years, accounting for the observed difference.
Themes of mistreatment
Of respondents, 258 provided open-ended comments about mistreatment. Compared with those respondents who did not provide comments, these respondents did not differ with respect to gender or race but were more likely to have experienced mistreatment on two of the seven questions (negative comments and had to be less than completely honest), and they reported a higher degree of negative impact on four of the seven questions (negative comments, discouraged from continuing, had to be less than completely honest, and denied teaching).
In our qualitative analysis, we observed that mistreatment fell into the following themes: respect, casual context of mistreatment (comments made in passing), financial consequences of career choice, perceived less teaching, and perception that grading is linked to specialty choice (see Table 3 for representative quotations). A significant number of comments contained multiple themes. Of the 258 respondents who provided open-ended comments, 69 included information related to whether or not mistreatment might have led them to consider changing their specialty choice. These comments fell along a spectrum ranging from doubting their career choice to directly stating that they planned to switch careers. Of the five themes, respect was most frequently associated with respondents stating that they were considering changing their career choice (14/18; 78%), compared with comments about finances (1/18; 6%) or those occurring in a casual context (1/18; 6%).
This longitudinal study examined the mistreatment that medical students face based on specialty choice. We found that the frequency of mistreatment correlated with the degree of negative impact, underscoring the need for interventions to reduce mistreatment based on specialty choice. Although our institution did not implement interventions specifically targeting mistreatment based on specialty choice during the study period, several departments did institute initiatives aimed at increasing professionalism in faculty and residents.15 For example, two well-attended faculty retreats in 2003 and 2004 focused on teaching, promoting, and assessing professionalism and aimed to increase positive behaviors among general faculty and resident physicians. In addition to formal graduate medical education sessions and a process to aid and protect students who call attention to lapses among faculty and residents, these retreats resulted in improved student satisfaction ratings for several of the clinical clerkships. However, despite these interventions, we found no substantive changes in third-year medical students’ reporting of mistreatment over the study’s eight-year period. This finding is consistent with other research that demonstrates that despite multipronged interventions, mistreatment persists,16 suggesting that mistreatment based on specialty choice is not affected by general professionalism and student–teacher relationship-oriented interventions, and thus may require significant, sustained, and targeted efforts to address.
Mistreatment based on specialty choice does not occur within a vacuum; rather, it occurs in a specific life and role context, which may in turn determine what a student perceives. This context includes a number of dimensions, including the student’s own resilience (although other research has demonstrated that medical students who perceive mistreatment may not simply be more sensitive),19 the issues that surround various specialties and success in obtaining a residency in that specialty, and traditional stereotyping of particular specialties. For example, such factors may explain why hearing negative comments about their specialty/career interest affected students interested in primary care in a more negative way. Perhaps those students are more concerned with the level of respect of their chosen profession, and are therefore more bothered by hearing negative comments about it. Likewise, students interested in a subspecialty may have been more concerned with lower evaluations and grades because of the importance of high academic achievement in securing a highly competitive residency spot. Interestingly, students interested in a subspecialty more frequently felt constrained to be less than completely honest about their specialty/career interest, yet they perceived no increase in the degree of negative impact from this situation compared with students interested in primary care. Feeling the need to be less than completely honest was alarmingly frequent across both groups, and a fear of mistreatment is likely causing students to compromise an aspect of professionalism (i.e., honesty) that is a cornerstone of relationships with patients and other professionals.
In our study, students experienced more mistreatment during the surgery, obstetrics–gynecology, and internal medicine clerkships, which is consistent with other findings.8 In addition, our study corroborates previous findings that resident physicians are the most frequent sources of abuse.7,8,16 Resident physicians have very recently been medical students and may have suffered from mistreatment themselves, perhaps representing a self-perpetuating effect. Alternately, the challenging demands of residency may contribute to their less-than-ideal behavior.20,21 Given the potentially high degree of negative impact that mistreatment can have on learners, one would question if being a victim of mistreatment or observing unprofessional conduct from superiors and peers may contribute to the decline in empathy and ethical erosion over time that has been documented in medical students and resident physicians.22–27
Most medical students make their career choice during the clinical years,1,2 so the clerkship rotations are an ideal opportunity for career counseling and nurturing by attending and resident physicians. Effective advising should be student-centered, matching the student’s unique set of talents, aptitudes, and personal aspirations with a career that would most likely lead to success and fulfillment.28–30 Unfortunately, advice on career choice is often informally and inappropriately dispensed on the basis of biased and stereotyped views of the various medical specialties.31 As we found in our study, students can perceive such comments as derogatory, only serving to enhance a hidden curriculum that tolerates disrespectful behavior32,33 and forces students into the ethical dilemma of believing they need to be less than completely honest about their career aspirations to receive fair treatment. In addition, students are more likely to change career paths when they are exposed to negative comments about their specialty, resulting in missed opportunities to support students in their career pursuits and potentially contributing to physician shortages in certain specialties.34–36
Another important implication of our findings is related to the intentional or unintentional nature of the mistreatment that our students encountered. Some of our data suggest that faculty meant to say what they said (e.g., “Family medicine is a waste of $200,000 in training”), whereas other cases were less clear (e.g., “I wouldn’t describe it as mistreatment as much as joking or sarcastic remarks about the specialty”). This finding raises the question as to whether the mistreatment is intentional or not. We suggest that this is an important question for further study and that educators and academic leaders should try to ascertain the relative amounts of each kind of mistreatment at their own institutions, because the two types suggest different targets and methods for intervention. Mistreatment that is unintentional may be addressed with mindfulness interventions that aim to enhance the awareness of faculty and residents about the content, meaning, and effects of their own communications. On the other hand, intentional mistreatment may require interventions that challenge assumptions and biases or even disciplinary action.
Our study has several limitations. First, although the longitudinal nature of our data is a strength, our findings may not be generalizable to other medical schools. Our institution is a private medical school with a medium class size (145–150 students); student demographics are similar to those of other schools of a similar size. Second, although our response rates were high, nonrespondent bias and recall bias may be issues—it may be that students who experienced mistreatment more frequently, or were more bothered by it, were more or less likely to respond to our survey. Finally, by measuring specialty interest at the beginning and end of the third year using a single survey administered at the end of the year, our measurement of this variable may be subject to recall bias and may not accurately reflect our students’ actual specialty interests at the beginning of their third year.
In conclusion, our eight-year longitudinal study of medical student mistreatment based on specialty choice found that such mistreatment is pervasive, variable by student contexts, and remarkably stable over time. We found that the fear of such mistreatment may be leading medical students to compromise aspects of professionalism, including honesty. In addition, we found that students view this mistreatment as affecting their assessment and learning opportunities, as well as causing them to consider changing their intended career paths. More research is needed to explore the potential hidden curriculum drivers of these findings. With a broader understanding of the context of these perceived forms of mistreatment, we can devise interventions to allow medical students the freedom to explore different career paths during their third year without fear of mistreatment. To develop a generation of physicians who can work in teams and who value empathy, altruism, and respect, medical schools must focus on developing processes that align internal organizational policies with national regulations to promote a healthy learning environment.
Acknowledgments: The authors wish to acknowledge Wendy Willenbecher for her assistance with data collection and manuscript preparation.
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