Medical student mistreatment was initially described in 1982 by Henry Silver,1 who highlighted its similarities to child abuse. Subsequent studies have shown that the majority of medical students in the United States experience some form of mistreatment during training.2–9 Reported mistreatment ranges from gender and racial discrimination to physical intimidation to public belittlement and humiliation. Clinical faculty and residents are the most commonly identified sources, but other perpetrators include nurses, ancillary staff, and even other students. The experience of mistreatment during training is not unique to the United States; studies in other countries describe similar problems.10–12
Despite increased awareness and denunciation of the practice, as well as numerous institutional initiatives,13–15 medical student mistreatment persists. The prevalence of mistreatment is tracked predominantly by the annual Association of American Medical Colleges (AAMC) Medical School Graduation Questionnaire (GQ), which has documented a relatively stable rate of reported mistreatment from 20.3% in 2000 to 16.8% in 2011 (with a low of 12.2% in 2006).16,17 In 2012, the AAMC revised the GQ to eliminate the so-called gateway question (“Have you personally been mistreated during medical school?”) to, instead, inquire only about the specific behaviors (public embarrassment, threats to physical well-being) students may have experienced (i.e., “For each of the following behaviors, please indicate the frequency you personally experienced that behavior during medical school”).18 The GQ, however, surveys students retrospectively at the end of medical school, asking them to recall events over their entire medical school experience. This gap from early experiences to survey may easily lead to underreporting. Several recent studies, including one large multi-institutional study, suggest that mistreatment may be more common than indicated by the GQ.15,19
Medical student mistreatment is problematic both in its effects on the learning environment and its potentially harmful effects on student well-being and professional choices. Mistreatment correlates with poor emotional and mental health outcomes such as problem drinking, decreased self-confidence and self-esteem, and depression.20,21 Additionally, mistreatment is associated with increased thoughts of dropping out of medical school, lower career satisfaction, and regret for having chosen the profession of medicine.22 For example, according to one study, mistreated students are less likely to plan careers in academic medicine.23 Some medical students may demonstrate symptoms of posttraumatic stress disorder following mistreatment.24 In sum, mistreatment may have potentially serious and long-lasting consequences.
Student mistreatment may lead to burnout.25 The most widely used measure of burnout is the Maslach Burnout Inventory which defines burnout as consisting of a combination of emotional exhaustion, depersonalization of others, and a feeling of reduced personal accomplishment.26 Burnout is common among medical professionals including physicians, nurses, and dentists.27–29 A recent national survey reported a mean burnout rate among U.S. physicians of 45.8%, with variations depending on specialty.30 One study showed that burnout is prevalent among residents who are just starting training.31 Among medical students, burnout has a negative impact on professional behaviors and attitudes, empathy, and personal well-being.32–35 Although burnout has many contributing causes, we theorized that mistreatment may be one of the more common ones. We aimed to determine the prevalence of medical student mistreatment in a nationally representative sample of third-year students and to assess whether mistreatment is associated with burnout.
Our study was conducted as part of a larger longitudinal project examining the professional development of physicians from medical school into residency training. Relevant to the present analysis, we surveyed third-year medical students from 24 U.S. Liaison Committee on Medical Education–accredited medical schools between January and April 2011. To construct our target sample, we selected 960 students from these 24 schools, using a two-stage sample design. In stage one, we selected schools with probabilities proportional to total enrollment so that the larger schools would have a greater chance of being included in the study. (We obtained the data for medical school sampling from published reports).36 In stage two, we used simple random sampling to select a fixed number of students (n = 40) from each selected school. This two-stage procedure is an efficient way of including large schools (which the “typical” medical student attends) while evening out student weights to reduce the effect of disproportional school selection on test statistics.37
We obtained the student sample from the American Medical Association Physician Professional Data (Masterfile), which has a near-complete listing of students pursuing MD degrees at schools within the United States and its territories. We excluded students who were not in their third year of medical school.
Prior to administration, the survey underwent expert review by colleagues as well as cognitive pretesting with a group of third-year medical students from our institution.
Using the following two questions, we asked students whether they had experienced mistreatment: (1) “Since the beginning of your clinical rotations, how many times have you been mistreated by an attending faculty?” and (2) “Since the beginning of your clinical rotations, how many times have you been mistreated by an intern or resident?” We provided neither definitions nor examples of mistreatment. Response categories were “never, “once or twice,” “a few times,” “several times,” and “numerous times.” For the analysis, we classified mistreatment as never, infrequent, or recurrent. We categorized mistreatment as infrequent if it occurred “once or twice” or “a few times” and recurrent if it occurred “several times” or “numerous times.”
We assessed burnout using a validated two-item version of the Maslach Burnout Inventory.38 Respondents were asked about the frequency of statement accuracy in two domains: emotional exhaustion (“I feel burned out from my work”) and depersonalization (“I have become more callous toward people since I took this job”). We classified high burnout as a response of at least weekly for one or both of the items. We categorized the rest of the responses as indicative of low or average burnout.
We collected contextual information about the respondents which we felt might be relevant to their risk of burnout including basic demographics, background characteristics, and factors related to their medical training. We limited demographic information to gender and race. Background information about each respondent included whether they were born in or immigrated to the United States, whether they grew up in a medically underserved setting, and whether they had a physician parent or grandparent. We also asked respondents about their expected total student debt load (premedical and medical), about their intended specialty (primary care versus nonprimary care), and for information about their medical school (private or public school and region of the country). We defined intention to enter primary care as students’ self-report that they would likely enter family medicine, internal medicine, or pediatrics and their self-report that they are likely to pursue primary care. We classified all other career plans as nonprimary care, including the intention to enter family medicine, internal medicine, or pediatrics without pursuing primary care.
The University of Chicago social and behavioral sciences institutional review board approved the study and waived written consent. Each potential respondent received a letter in advance of the study explaining the survey and its voluntary nature and asking for confirmation of mailing address. We sent a total of three requests via e-mail (two requests) and the United States Postal Service (one request). We enclosed, with the initial survey mailing, a $5 bill as an incentive to complete the survey, and with the last request, we offered a $10 gift card as an additional incentive. Each respondent was given a unique identifier in order to track responses; however, all data were deidentified prior to analysis.
We analyzed all quantitative data using STATA (version 12.1; Stata Corporation, College Station, Texas). For statistical analysis, we excluded responses that were left blank because of respondent omission. We used case weights to reflect sources of variance associated with the sample design and to adjust for potential nonresponse bias. We compared groups, using chi-square analysis with significance determined by alpha = .05.
Of 960 potential respondents, 605 (63%) returned partial or complete surveys. We excluded respondents from the analysis if they were not currently in their third year of medical school because of time away from school or for other reasons (n = 41).
Table 1 shows the demographic and other characteristics of the respondents. The 564 respondents were almost evenly divided between male (n = 306 [54%]) and female (n = 258 [46%]), and the majority of them were Caucasian (n = 329 [58%]). Our sample was similar in its percentages of women and minorities in medicine when compared with known demographics of U.S. medical students nationally.39 Of 563 respondents, 25% (n = 138) reported that they grew up in a medically underserved setting, and 22% (n = 123) reported that they had a physician parent or grandparent. The majority of respondents (394 of 561 [70%]) had expected total student debt of more than $100,000, and about a third (193 of 564 [34%]) stated that they intended to pursue a career in primary care.
The vast majority of respondents in our survey had experienced at least one incident of mistreatment by either a faculty member or a resident (466 of 562 [83%]). Of 562 respondents, 64% (n = 361) reported they had experienced mistreatment by faculty, whereas 76% (n = 426) had experienced mistreatment by a resident. Most respondents who had experienced mistreatment reported mistreatment by both faculty and residents (321 of 466 [69%]).
As seen in Figure 1, the majority of respondents who experienced mistreatment reported infrequent mistreatment (mistreatment reported to occur “once or twice” or “a few times”); however, recurrent mistreatment (mistreatment reported to occur “several” or “numerous” times) was not uncommon. Recurrent mistreatment by faculty was reported by 10% (59 of 562) of respondents, whereas 13% (71 of 562) had experienced recurrent mistreatment by residents. Recurrent mistreatment was not associated with any of the collected student or medical school characteristics.
Overall, high burnout identified by the abbreviated Maslach Burnout Inventory was observed for 34% (192 of 561) of the respondents. However, as seen in Figure 2, there were differences in burnout rates by degree of mistreatment. Compared with those students who reported no or infrequent mistreatment, those students who experienced recurrent mistreatment by faculty were significantly more likely to score high on the burnout measure (57% versus 33%; P < .01). The same was true for those who had experienced recurrent mistreatment by residents (49% versus 32%; P < .01). None of the other examined factors, including gender, race, immigration history, student debt load, specialty intention, or medical school characteristics, were significantly associated with high burnout.
Discussion and Conclusions
The prevalence of mistreatment in our sample of third-year medical students was much higher than we expected based on the recent AAMC GQ data. The prevalence of mistreatment in our study (83%) was in the same range as those reported in older studies,7,8 whereas it was much higher compared with the recent rates reported in the AAMC GQ (16.8% in 201117). Further, our rates were higher despite the fact that the students in our study had completed fewer clinical rotations. It is possible, however, that the discrepancy is the result of students taking the GQ failing to recall episodes of mistreatment occurring early in their clinical years. Alternatively, students may become habituated over time and perceive less mistreatment by the end of medical school. The rates of recurrent mistreatment (10%–13% overall) in our sample correspond more closely to the reported mistreatment rates in the GQ, suggesting that at the end of medical school, students may not recall or report less frequent episodes of mistreatment. Periodic assessments of medical students in their clinical years may provide a more accurate picture of mistreatment than a single retrospective survey at graduation.
The cohort of students in our study would have graduated in 2012, the first year of the revised GQ. The 2012 GQ All Schools Summary Report states that 47.1% of students reported they had personally experienced one or more of the listed behaviors.18 This percentage is higher than those found in previous versions of the GQ, which used the earlier gateway question.16,17 This 47.1% prevalence is similar to what we found in the present study, although direct comparisons are difficult to make because we used different questions than the GQ. The revised GQ may provide not only more accurate information about rates of mistreatment but also more actionable information about the specific behaviors and sources of mistreatment. Such information is likely to help institutions as they work to reduce student mistreatment.
From the very first descriptions of medical student mistreatment, there have been doubts about whether student reports can be trusted as accurate.2 Many believe students are overly sensitive to the actions and behaviors of others as they adjust to the unfamiliar demands and pressures of the clinical environment. Hence, the predominant concern about student-reported mistreatment is that students misperceive events as mistreatment directed towards them when others, including educators and administrators, may not judge these events in the same manner. In 2005, Ogden and colleagues40 provided evidence that in fact, medical students perceive events similar to the way attending physicians, residents, and nurses view the same events. Furthermore, in 2013, Bursch and colleagues41 demonstrated that there was no association between student identification of abuse in hypothetical scenarios on an abuse sensitivity questionnaire and their report of personal mistreatment. Although there are undoubtedly some misunderstandings, student report remains the standard measure of mistreatment.
Unlike burnout, there is no accepted measurement tool for mistreatment. Despite the large literature on medical student mistreatment, the validity of various questionnaires has not been established. Almost all studies of mistreatment have relied on student self-report. How the questions are asked and whether or not examples are given may affect the results. In 2011, the AAMC GQ17 provided instruction to students that mistreatment 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.
Prior versions of the GQ did not provide examples.42,43 Nevertheless, the rates of student mistreatment reported in the GQ has remained relatively stable over time, and the GQ remains the accepted reference standard.
Another common argument about mistreatment is that it is simply part of the culture of medical training.44,45 There is a temptation to view these aspects of training as a reality that students must accept as part of their chosen profession. In 2009, Haglund and colleagues46 examined the experiences and responses of medical students to events occurring on their clinical rotations. Although there was evidence that students are resilient to traumatic events involving patient suffering and death, students exposed to personal mistreatment and poor role modeling by their superiors did not demonstrate resilience but instead showed higher depression and stress. That study suggests there is a distinction between events that provide opportunities for personal reflection and growth and those that merely diminish the student’s sense of well-being. Just because mistreatment has persisted for so long does not mean it is an inevitable or necessary experience of medical training.
Residents play a key role in the education of medical students, and many residency programs provide formal training to prepare residents for their role as teachers.47,48 Regrettably, residents can also be the perpetrators of medical student mistreatment. In our study, residents were more commonly sources of mistreatment than were faculty. Given that residents are still in training themselves, there are added opportunities for programmatic intervention and education about student mistreatment.13,49 Promotion of a positive learning environment will necessarily involve institutional change, but beginning with resident education may be one promising strategy to mitigate mistreatment. Faculty development is another target, but less attention has been paid to this idea except in the context of overall institutional change.49–51
In our study, recurrent mistreatment both by clinical faculty and by residents was associated with medical student burnout. Although we cannot discern cause and effect in this cross-sectional analysis, it seems plausible that recurrent mistreatment of students contributes to their burnout. Multiple incidents of mistreatment may make students more vulnerable to the symptoms of burnout, even in their first year of clinical rotations. Conversely, it is also possible that burnout stemming from causes other than mistreatment may prime students to be more likely to recall or interpret faculty and resident actions as mistreatment, thereby leading to our observed association.
Burnout has multifactorial origins that are both social and personal.52 Prevention of burnout will need to address both of those domains. More study is necessary to determine what makes certain students vulnerable to burnout. One may wonder what are the characteristics of students who reported high mistreatment but low burnout and, furthermore, whether those characteristics were innate or learned. Resilience may play a role in preventing some students from experiencing burnout despite situational challenges such as mistreatment.
There are several limitations to this study. First, we do not have mistreatment information about the nonrespondents, and it is conceivable that nonrespondents may differ in their experiences in ways that bias our findings. For example, if students with high rates of mistreatment or burnout were more likely to respond, our estimate of the prevalence of mistreatment may be too high. The converse may also be true. Underestimation, due to students experiencing burnout or mistreatment not responding, may be less likely because the survey was not primarily presented as a study about mistreatment or burnout. Second, mistreatment was evaluated by student report only, which is subject to recall biases that may lead to inaccurate estimates. In addition, we do not have detailed information about the type or severity of episodes of mistreatment. We do not know if incidents were clustered around particular faculty, residents, or clinical rotations. Additionally, there are other psychological and mental health factors, such as stress, depression, and coping skills which we did not measure but which may influence student burnout levels. Finally, as a cross-sectional survey, this study can demonstrate associations but not causation.
We conclude that medical student mistreatment remains frequent despite many efforts to address this issue. The association between medical student mistreatment and burnout is an important area for future research given that both may independently cause adverse personal and professional outcomes for the student.
Acknowledgments: The authors wish to thank Annikea Miller for her assistance in data collection, and Michael Leffel, PhD, for his expert consultation throughout the project.
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