In 1982, in a commentary in the Journal of the American Medical Association, Dr. Henry Silver1 drew comparisons between medical students and foster children, reflecting that changes in students during medical school were reminiscent of “battered child syndrome.” In surveys of senior medical students in the 1990s, more than 80% reported abuse or mistreatment, ranging from public humiliation, to gender or ethnic discrimination, to threats of physical harm, at some point during medical school.2,3 Moreover, similarly high rates of abuse have been reported internationally4–7 and for half a century.8
Medical student mistreatment is associated with a range of deleterious effects, including burnout,9 posttraumatic stress,10 and decreased confidence in clinical abilities.11 In the 2016 Association of American Medical Colleges Graduation Questionnaire, excluding reports of public embarrassment, 38.1% of graduating medical students reported experiencing some form of mistreatment during medical school.12 On the same questionnaire, 95.7% of students indicated that they were aware of mistreatment policies at their institution; this percentage has been increasing yearly since 2005.12
Over the same time period (2005–2016), a number of policies and programs have been published that are directed at decreasing incidences of mistreatment at medical schools and affiliated hospitals.13–15 Yet despite the increasing awareness of policies and frequency of mistreatment programs, the problem of medical student mistreatment persists. This problem is particularly severe in surgical departments16 and can negatively impact a student’s specialty choice.17 One published study reported that 37.0% of student mistreatment occurs on surgery clerkships.18 Despite this high prevalence, only one medical student mistreatment intervention at the departmental level in surgery has been published that we know of.19
To address this problem and the gap in the literature, we initiated a program for third-year medical students to decrease mistreatment during the required surgery core clerkship. This novel program was directed toward medical students, with the aims of setting expectations prior to the clerkship, developing a shared and personal understanding of mistreatment, establishing a relationship of student trust with the clerkship director and surgical education fellows, and elucidating more effective avenues for reporting mistreatment. The purpose of this study was to review medical student mistreatment reports from before and after program implementation, and student ratings of and qualitative responses to this program to evaluate the short-term impact of this program on students.
All third-year medical students at the Stanford University School of Medicine complete an eight-week core clerkship in surgery. Starting in January 2014, all third-year medical students on the surgery core clerkship participated in the mistreatment program.
Mistreatment program description
The surgery core clerkship’s formal curriculum is divided into eight 1-week modules. One afternoon per week, students from all clerkship sites attend scheduled educational activities that employ a blended learning format at the Stanford University School of Medicine.20 The mistreatment program (see Figure 1) is embedded into this curriculum. The overall purpose of the mistreatment program is to introduce third-year medical students to the culture of a surgical clinical learning environment and to empower them to succeed in this environment. Specifically, the program includes facilitated discussions to help students establish expectations for the surgical learning environment; help students create a shared and personal definition of mistreatment as it applies to the clinical learning environment; and promote advocacy and empowerment for students to address mistreatment if, and as, it occurs. Additionally, students in the surgery clerkship are specifically encouraged to communicate with the clerkship director (J.N.L.) and with trained surgical education fellows about any concerns; to that end, they are given direct contact information for these individuals.
During the second day of the clerkship, after one day on clinical service, students attend the first education session dedicated to the mistreatment program led by the clerkship director and surgical education fellows. No faculty or residents are present during this or subsequent education sessions, and all group discussions are confidential to allow for open discussion among students. They first complete a written exercise, generating personal definitions of mistreatment, then they participate in a group discussion regarding their perceptions of mistreatment and are encouraged to share personal or related experiences of mistreatment on their clinical clerkships.
To facilitate this discussion, students view short learning environment videos created for the mistreatment program that portray common scenarios in and out of the operating room with various degrees of suboptimal clinical learning situations.21 These videos include examples of “pimping,” where a medical student or resident faces a barrage of questions. In some instances, the attending is polite and encouraging; in others, the attending is abrasive or personally insulting. Other videos feature morning rounds where medical students are abandoned by busy resident teams or chastised in front of patients. Another video shows an attending physically manipulating the medical student’s hand on a suction device, and then pushing the student away to address sudden bleeding. After viewing these videos, students reflect on the different scenarios and anticipate how they would respond to each situation in a group discussion. Through guided discussion, the clerkship director and surgical education fellows help set expectations by illuminating that teaching in the clinical setting is almost always public and full of communication miscues, and that attendings’ educational intentions are mixed with clinical responsibilities and worries. Through this process, the students begin to share their own personal expectations and to develop common expectations about mistreatment, a conversation that continues throughout the clerkship.
Throughout weeks 2 through 7 of the clerkship, each education session begins with a group “check-in” by the clerkship director and surgical education fellows. During these check-ins, students discuss their experiences from an educational environment standpoint in a quiet, protected environment, without residents or attendings. These weekly check-ins are designed to support a culture of safe reporting and open communication; students can discuss issues in the group setting or in private one-on-one debriefs with the clerkship director and surgical education fellows.
The mistreatment session during the final week of the clerkship is dedicated to a group debriefing. They reflect about their presurgery expectations, may watch a pertinent learning environment video,21 and discuss the written exercise on their definition of mistreatment after their surgery clerkship experiences. They are encouraged to advocate for themselves and other students, and to take the tools learned in this program to their remaining clerkships. After this session, students are invited to complete the end-of-clerkship evaluations, which include Likert scale ratings of the program and qualitative open-ended questions.
The Department of Surgery chair fully supports this initiative as well as forthcoming mistreatment programs and studies aimed at residents and faculty.
Data collection and analysis
In January 2013, the Stanford University School of Medicine began to collect mistreatment reports through the Respectful Educator and Mistreatment Committee (REMC). Additionally, each student must complete an end-of-clerkship evaluation regarding the clerkship, and starting in January 2013, this evaluation included a single question on whether the student experienced or witnessed mistreatment or both (see Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A420). If any of these are chosen, the rest of the evaluation questions on mistreatment are displayed for the student to answer. Quarterly reports to the surgery clerkship director on the data from this instrument and the REMC mistreatment reports were reviewed by J.N.L. and L.M.M. in the context of the postimplementation evaluation of the mistreatment program and include the number of mistreatment incidents reported, perpetrator’s role, and types of mistreatment reported. The reported types of mistreatment were categorized by the REMC as follows: offensive remarks/verbal, physical, public embarrassment/humiliation, and performing personal services. Identified repeat offenders were referred to previously identified department coaches who were trained to provide feedback and coach to student-centered behaviors. We compared counts of mistreatment and mistreatment types from a year prior to (January–December 2013) and the first two years after (January 2014–December 2015) the program’s implementation.
End-of-clerkship ratings survey.
From March 2014 to December 2015, we collected anonymous, online end-of-clerkship surveys to evaluate each curricular element of the clerkship, including the mistreatment program. Students in the surgery core clerkship voluntarily completed these surveys. The survey ratings were on a five-point Likert scale (where 1 = poor, 2 = fair, 3 = average, 4 = excellent, 5 = outstanding). We calculated means and standard deviations (SDs) for Likert scale responses for all respondents and grouped them by clerkship period. Student t tests and chi-square tests were performed, with P < .05 considered statistically significant. We also collected student demographic data (SPSS Statistics Version 22.0, IBM, Armonk, New York).
End-of-clerkship open-ended questions survey.
Additionally, we qualitatively evaluated the program’s effectiveness and immediate impact on students enrolled only in the first four clerkship periods after implementation of the mistreatment program (January–August 2014) who provided anonymous responses to the open-ended questions on the end-of-clerkship survey (see Supplemental Digital Appendix 2 at http://links.lww.com/ACADMED/A421). We used a consolidated thematic approach to analyze these responses.22 Two investigators (L.M.M., J.N.L) inductively generated a codebook including code weights (positive, negative, or neutral) and independently coded all of the responses.23 Discrepancies were resolved via adjudication until 100% interrater agreement was reached. We consolidated thematic analysis24 findings by question domain and themes (Table 1). We managed text with Excel 2015 (Microsoft Corp., Redmond, Washington).
The Stanford University Institutional Review Board determined that the study did not meet federal regulations’ definition of human subject research and deemed the study exempt from full institutional review board review.
A total of 179 third-year students completed the mistreatment program between January 2014 and December 2015 (the overall sample). From March 2014 to December 2015, 164 students participated in the surgery core clerkship and mistreatment program and were invited to complete the anonymous, online end-of-clerkship ratings survey. One hundred forty-one (86%) of these students completed the survey. In addition, all 47 (100%) students who were enrolled during the first four clerkship periods after implementation of the mistreatment program (January–August 2014) also completed a survey of open-ended questions specific to the effectiveness and impact of the mistreatment program implementation (see Supplemental Digital Appendix 2 at http://links.lww.com/ACADMED/A421). In the overall sample, the mean age was 27.8 (SD = 3.2, range: 21–40), 93 of 179 (52%) students were female, and 39 of 179 (22%) students had prior advanced degrees. There were no statistically significant differences in mean age or gender between all students in the overall sample and those that completed the end-of-clerkship open-ended questions and/or ratings surveys.
In the year prior to the mistreatment program (January–December 2013), there were 14 total mistreatment reports from the surgery clerkship (an average of 1.17 reports per month). After introducing the mistreatment program, there were 9 reports (0.75 reports per month) and 4 reports (0.33 reports per month) during the first (January–December 2014) and second (January–December 2015) intervention years (Figure 2). The most common forms of mistreatment reported were offensive remarks/verbal (8 of 27 [30%]) and public embarrassment/humiliation (15 of 27 [56%]). All types of reports decreased over the study period (Figure 3). Of the students who reported mistreatment that they had experienced themselves, witnessed, or both, they reported the mistreatment at the time of the episode in 1 of 4 (25%) cases during the preintervention year, 3 of 4 (75%) cases during the first postintervention year, and 2 of 4 (50%) cases during the second postintervention year.
End-of-clerkship ratings survey
As noted above, a total of 141 (86%) students completed the anonymous, online end-of-clerkship ratings survey. The mistreatment program sessions during the first and last weeks of the clerkship were rated at a mean of 4.02 (SD = 0.85) and 4.30 (SD = 0.74), respectively (see above for rating definitions). Most students rated the initial mistreatment program session as excellent or outstanding (108 [77%]), with 2 students rating it poor (< 1%). Students rated the mistreatment program session during the final week of the clerkship similarly, with a majority rating the session as excellent or outstanding (120 [85%]) and 1 student rating it poor (< 1%). There was no statistically significant difference in survey ratings between the students who provided responses to open-ended questions and those who only completed the survey ratings.
End-of-clerkship open-ended questions survey
Of the 47 students who were enrolled during the first four clerkship periods after implementation of the mistreatment program (January–August 2014), all (100%) responded to the open-ended questions. All of these responses were coded as positive. We organized the responses into three question domains: mistreatment program provided intrinsic value to students, mistreatment program broadened students’ views of the surgical environment, and concrete suggestions for improvement. The question domains, the resulting 10 themes, and representative quotations are presented in Table 1.
Mistreatment program provided intrinsic value to students.
The majority of student responses focused on the program’s intrinsic value to students. We identified four themes in this domain. First, the program guided how students established expectations about mistreatment. Nearly all students indicated that by establishing expectations the program helped them to understand behaviors on the wards, and referred specifically to how the learning environment videos helped to create this shared understanding of expectations. Second, over half of the students commented that they appreciated opportunities for sharing their experiences. They indicated that the program helped them to feel less alone, in recognizing that others were having similar experiences in the surgical learning environment. Third, over half of the students valued that the program provided an environment for emotional support; for example, one student stated that they “feel supported [because of the program].” Finally, students commented that they appreciated that the program provided formal resources. For example, the mistreatment program relies heavily on personal interaction with the clerkship director, and several of the student comments reflected specific awareness of, and trust in, the clerkship director as a resource.
Mistreatment program broadened students’ views of the surgical environment.
We identified three themes related to how the program, although focused on mistreatment, ultimately broadened students’ views about experiences in the surgical environment, as discussed by a majority of students. First, some students indicated that through the program, a learning environment of openness to questions was created because students became more comfortable, both in the weekly sessions and also on their rotations. Second, along with the more open learning environment, a few students perceived a noticeable culture change in the clerkship. They reflected that while the mistreatment program may be directed at students, it may also impact those whom they work with, such as residents and faculty. Last, perhaps because of the supportive learning environment and noticeable culture change, nearly half of the students also described an increased interest in surgery, suggesting that there were positive shifts in the learning environment influencing students who would otherwise not consider a surgical career.
Concrete suggestions for improvements.
Some students proposed improvements to the mistreatment program, resulting in three themes. First, one student suggested increasing the student discussions, either by increasing the amount of time for group reflection, altering the type of group discussions, or by inviting former students to participate in the discussion. Second, a few other students thought there was a need to also educate faculty and attendings via immediate or real-time feedback regarding mistreatment topics. Third, although students did not discuss it often, another theme we noted was that there is a need to formalize or streamline the reporting process. Overall, though, a majority of students did not provide any suggestions or instead wrote generally positive comments, such as “I think [the program] is great as is.”
Medical student mistreatment is not new. Abuse and mistreatment of medical trainees has been described for more than half a century.1,8 The majority of mistreatment reports fall into the realm of public humiliation, classified by some authors as “misguided efforts to reinforce learning” or “a … problem of student–faculty communication.”25 Residents or attendings may believe that medical students who experience mistreatment are simply overly sensitive.26 Whether attributed to poor communication, overly sensitive students, or simply the cultural norms within medicine, it is well established that the perception of mistreatment carries significant consequences for the recipients.9–11
In our experience, an intervention to address student, and faculty and resident miscommunication should first start with empowering the students to advocate for their own education or reporting mistreatment and changing the environment to be more conducive to learning. We, for example, are applying what we learned from our mistreatment program for students to inform the design of an educational intervention for faculty and residents.
Although we acknowledge that the definition of mistreatment is subjective and heavily context based, especially in the surgical environment, we present here an initial evaluation of a novel mistreatment program for third-year students that is grounded in a surgery core clerkship. We use learning environment videos with common scenarios to trigger discussions of specific experiences, as students begin and sometimes as they end the clerkship. In our mixed-methods evaluation, we demonstrate a decrease in mistreatment reports after this program was introduced into the surgery clerkship, with reports decreasing during each of the two successive years of the study, complemented by positive student responses to the program. Although the number of students was small throughout the observed time period, there was an increase in the percentage of students reporting mistreatment in real time after implementation of the program and a decrease in the number of formal mistreatment reports, though these could be due to more students reporting mistreatment directly to the clerkship director rather than waiting for end-of-clerkship evaluations. Students identified multiple immediate benefits from the program, including establishing learning environment expectations for the rotation, providing emotional support, providing opportunities to share experiences with other students, and providing formal resources. Students also saw broader impacts from this program—for example, creating long-term noticeable culture changes and increasing career interest in surgery.
When discussing the program’s potential long-term impact, it is worth emphasizing that reports of abuse and mistreatment are so prevalent in the literature that they are considered an integral part of medical culture.25,27 Medical students initially approach the clinical learning environment from the perspective of semioutsiders. During early clerkships, students exist in a process of “legitimate peripheral participation,” unconsciously adopting both the knowledge and values of the culture around them.28 To create long-term durable change in the surgical education culture, there are two necessary and equally important targets: improving the professionalism of the residents or attendings who mistreat students, and ensuring that medical students approach such incidents prepared to effectively understand and address them. By ensuring that students who encounter these behaviors do not assume they are normal, the cycle of mistreatment can be broken. A mistreatment program directed at medical students has the potential to create long-term cultural change from the ground up by educating students explicitly about what has too often only been part of the hidden curriculum. Taking the themes of guiding how students establish expectations about mistreatment and providing an environment for emotional support and safety from this study, we are implementing a teaching intervention for residents embedded in “resident as educator” skills sessions. In this teaching intervention, the discussion session on the educational environment emphasizes setting expectations bidirectionally, creating an environment of student centricity and safety, as well as addressing real-time conflict resolution. A future faculty education program will parallel this content and will be placed within an annual department grand rounds discussion.
This is a single-clerkship, single-institution study at one academic center, with the associated limitations. The overall quantitative reports of mistreatment decreased, but were small from the beginning. An increased effort by the Stanford University School of Medicine to address student mistreatment, in creating a mistreatment committee, appointing an ombudsperson, obtaining all clinical department chairs’ support, and implementing a reporting schema, had begun in July 2012. It is likely a combination of this program and these efforts focused on mistreatment that has contributed to the decreasing number of reports. This study analyzes student reports of mistreatment, along with ratings and qualitative data regarding the perceptions and immediate impact of this mistreatment program. We only collected qualitative responses from clerkship students from January to August 2014 during the intervention period; the perceptions of these students may not be representative of all third-year students. To fully understand the impact of this type of program, multi-institutional and long-term studies are necessary. Also, although the surveys were anonymous, students did develop a rapport with the clerkship director, and their responses may be more positive because of that personal relationship. It is unclear how a similar video- and discussion-based mistreatment program would be perceived if implemented in a different institution and setting.
Mistreatment is an extremely personal experience, and it can have detrimental effects on students’ emotional well-being and clinical learning.9–11 Medical student mistreatment is pervasive in clinical clerkships,12 especially in surgery.16 A video- and discussion-based, rotation-specific mistreatment program, focused on creating a shared understanding about mistreatment, was well received among surgery core clerkship students at our institution, and the number of mistreatment reports has decreased each year following the program’s implementation. This mistreatment program may help to establish expectations, improve the clinical learning experience for students, and promote cultural change. Further research is warranted to better understand the long-term impact of this program, its feasibility at other institutions, and how complementary programs addressing residents and faculty would affect the overall surgery core clerkship educational environment and culture.
Acknowledgments: The authors wish to thank Thomas Krummel, MD, former chair of the Department of Surgery, and Mary Hawn, MD, MPH, chair of the Department of Surgery, for their continued support of the mistreatment program for the surgery clerkship. We also wish to thank Kiranjit Sidhu, Irina Russell, PhD, and Jen Deitz, MEd, from the Office of Medical Education Research and Evaluation, Stanford University School of Medicine, and Rebecca Smith-Coggins, MD, and the Stanford University Respectful Educator and Mistreatment Committee for mistreatment report data collection.
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