In this Invited Commentary, the authors identify the ugly, the bad, and the good in teaching in medical education, based on their experiences as medical students and then educators. They conclude by describing the elements of learner-centered education that they practice, and call on their fellow educators to end the practice of humiliating learners by moving away from a controlled-motivation model toward an autonomy-supportive approach to education.
The Ugly
The movie An Officer and a Gentleman famously depicts officer candidates undergoing the rigors of training. Academy Award winner Louis Gossett Jr plays their drill sergeant, whose behavior would have been considered bullying, harassment, and mistreatment in a medical education setting. Some medical students have endured treatment that is not too dissimilar from that of Gossett’s recruits. Thirty years ago, we did.
Each morning at 8 am, having arrived at 5:30 am to see our patients, we shuffled into the morning report room, students and residents taking chairs in a semicircle around a chalkboard. Then, for the next two hours, our attending would lecture us, question us, and “pimp” us. This attending’s friend and role model for teaching was “Black Jack” Myers, another internist infamous across the country for striking terror into the hearts of residency graduates taking their oral board examination.1
We were humiliated in front of our peers many times in that room. Our attending’s favorite response to a wrong answer was “Son, have you ever considered pumping gas?!” One fellow intern, a woman, was brought to tears as this attending shouted at her for not knowing details about a patient she presented, while the rest of us sat and watched, silent. Our medical school leadership overlooked this mistreatment, as unhealthy as it was. It was accepted as the norm at the time.
According to self-determination theory, such a setting is an extreme example of controlled motivation, incorporating shaming or “down-dressing.”2 Any learning derived from this kind of setting comes at the cost of emotional turmoil and sets a bad standard for how physicians should behave. It was an unhealthy environment, fostering no trust between fellow learners, as no one could defend each other. For us, it created a sense of anger, a corrosion of the soul.
We were both students when the landmark 1990 Silver and Glicken3 study about medical student abuse appeared in the Journal of the American Medical Association. The authors had surveyed 519 students at “one major medical school” and found that 80% of the seniors reported being “abused” at some point during their four years of medical school, and “[20%] of juniors and seniors reported more than five episodes of abuse during [their] junior year and an additional 23% reported being abused two to five times that year.” The study played well in the media.4 But no one in medicine seemed surprised. Instead, we all said, “That wasn’t my medical school.”
To be fair, we had outstanding faculty in other areas who absolutely modeled a learner-centered approach to education. And our experience with bullying likely was not much better or worse than that of students at other schools. At least that is what the data seem to say. According to the Association of American Medical Colleges’ Graduation Questionnaire, 22% of medical students in 2018 reported being publicly humiliated during medical school, and the majority of that abuse was perpetrated by faculty.5 Those data were reported more than 28 years after the Silver and Glicken study. What is more, the longitudinal data show that graduates in some years report more mistreatment than those in other years, so the treatment of students may not be getting much better.5,6
This mistreatment leaves learners with a fear of recrimination. It cements not only the memory of the learning point, which is the intended objective, but also the pain and anxiety that accompany it. After enduring a continuous onslaught of mistreatment during training, learners can (1) feel demoralized and (2) be led to believe that such conduct is the “correct way” to teach.7 These actions imprint on us for years, and the pain from bad behavior possibly never goes away. It has not gone away for us; instead we are left with the conviction that humiliation has no place in education ever.
The Bad
Reflecting further on the mistreatment we endured as learners, another frequent offender comes to mind. Every single day on this faculty member’s consult service, something would “go wrong.” Usually, it was a simple error in documenting, such as a missed blood sugar reading, that caused him to become aggressive and unpleasant. He usually directed this anger toward a nurse. His behavior would not be tolerated today. Unfortunately, some learners observed his behavior and came to think of it as the proper way to deal with errors. After all, perfection was the goal. The motto “The patient comes first!” seemed to justify this faculty member’s actions, and residents were led to believe that that was how they needed to act too. This one person had a profound negative impact on so many others that went unrecognized at the time. Learners simply repeated what they saw—behavior that was modeled as “the right thing to do.”
Freud described introjection or the mechanism by which an individual internalizes and repeats the behaviors of parents, peers, teachers, and mentors.8 Medical students may be in their 20s, but they are still very impressionable, and they are always watching us, even when we do not think they are. They are learning not only the medical facts we teach them but also how to behave in their new world of medicine.
How does this hidden curriculum play out in the way we approach learners now? First, we must strive to not role model unethical behaviors on rounds. A few such behaviors come to mind: using derogatory comments to describe patients who do not “do what we say,” like the patient who smokes and spends his money on cigarettes instead of his medications, or the patient with a substance use disorder who “never stops drinking,” who is deathly afraid of withdrawal but wants help, or the patient with end-stage cancer, emphysema, and heart failure who is on dialysis and “just doesn’t get it.” Or, the coup de grâce, when we murmur under our breath that “de-Nile is not just a river in Egypt.” Knowing and using proper, respectful language when discussing the reality of our patients’ lives can be challenging but is a behavior we must adopt.
Also, we must stop using unprofessional language to describe our coproviders. Statements about the case manager who “just doesn’t understand,” the dietitian who “can’t see the big picture,” or the physical therapist who “thinks all our patients must be Olympic athletes before they are ready for discharge” cannot continue. We must carefully phrase our comments on rounds and role model good behaviors for our learners.
The Good
In transitioning from learners to educators, we debated whether a controlled-motivation model and intimidation held any value or whether they should be altogether abandoned. In the end, we chose to discard the old style of teaching forever. The result is that teaching has become a joy. We are working to employ a learner-centered, autonomy-supportive approach in our teaching. We “take the perspective of students into account, provide relevant information and opportunities for choice, and encourage the students to take more responsibility for their own learning and behavior.”9 For example, we focus on scaffolding, which is a way to support learners as they build their skills.10
As part of our approach to teaching, we also focus on other aspects of learner-centered education that we think may be helpful for others to consider. First, students start medical school motivated to acquire the skills they need to succeed in medicine. Sometimes, in their fatigue and anxiety, we may not readily recognize this motivation in their behavior, but we must remember that it is there. In addition, the curriculum must break the processes of patient care into attainable components that faculty can model in daily practice, learners can observe, and evaluators can recognize when achieved.
Then, when it is the learners’ turn to practice those behaviors, we must provide supervision and coaching to foster their further growth, and we must focus on how we can support them in achieving each defined goal. For example, we offer practical, explicit, and concurrent feedback describing differences between what we have observed and what is expected, minimizing the frustration and risk to students, patients, and even ourselves, by ensuring everyone’s emotional and physical safety.
We recognized these elements during our own learning experience when reflecting on the behavior of an excellent role model. We can still recall his approach to teaching during our fourth-year elective in cardiology. He valued being thorough and displayed obvious concern for his patients and genuine sincerity in the quality of care he provided. We copied that behavior and paid it forward, role modeling it for our own learners now. He was a great mentor not only because of his medical knowledge but also because we could see his passion for medicine and for his patients.
About 10 years ago, Menachery and colleagues11 surveyed learners to determine what characteristics they associated with faculty proficiency in learner-centered teaching. We recognize a number of their findings in our own practice—being adept at giving lectures and creating presentations, identifying resources to meet learners’ needs, and looking to resources to improve our teaching. We also identified a number of items on which we can improve—eliciting feedback from learners and detecting and discussing their emotional reactions. The last item Menachery and colleagues identified—letting learners know how different situations affect us as teachers—is one we are striving to employ more often in our teaching.
Conclusions
It has been 30 years since we started medical school. And since then, we have seen an explosion in basic science knowledge about the human body and its genetics and molecular structures. We have developed new technologies that allow us to diagnose disease rapidly and accurately. But the science of clinical education, the theories of how students learn best, and our understanding of the behaviors and power structures within clinical teams all have advanced more slowly, less deliberately, and often only in response to oversight agencies’ punitive measures. We call on our colleagues—those who round with and educate our students, residents, and fellows—to join us in our pledge to end humiliation as a learning tool, to monitor ourselves and our partners for unprofessionalism, and to learn about and employ the cutting-edge science brought to us by our medical education research colleagues.
References
1. Keister E. First family of medicine. PittMed. 2003;5:29–33.
2. Trépanier SG, Fernet C, Austin S. A longitudinal investigation of workplace bullying, basic need satisfaction, and employee functioning. J Occup Health Psychol. 2015;20:105–116.
3. Silver HK, Glicken AD. Medical student abuse. Incidence, severity, and significance. JAMA. 1990;263:527–532.
4. Altman LK. Wide abuse of medical students found. N Y Times. January 26, 1990:B00007.
5. Association of American Medical Colleges. Medical school graduation questionnaire: 2018 all schools summary report.
https://www.aamc.org/download/490454/data/2018gqallschoolssummaryreport.pdf. Published July 2018. Accessed December 21, 2018.
6. Fnais N, Soobiah C, Chen MH, et al. Harassment and discrimination in medical training: A systematic review and meta-analysis. Acad Med. 2014;89:817–827.
7. Leisy HB, Ahmad M. Altering workplace attitudes for resident education (A.W.A.R.E.): Discovering solutions for medical resident bullying through literature review. BMC Med Educ. 2016;16:127.
8. Argyle M. Introjection: A form of social learning. Br J Psychol. 1964;55:391–402.
9. Williams GC, Saizow RB, Ryan RM. The importance of self-determination theory for medical education. Acad Med. 1999;74:992–995.
10. Biondi EA, Varade WS, Garfunkel LC, et al. Discordance between resident and faculty perceptions of resident autonomy: Can self-determination theory help interpret differences and guide strategies for bridging the divide? Acad Med. 2015;90:462–471.
11. Menachery EP, Wright SM, Howell EE, Knight AM. Physician–teacher characteristics associated with learner-centered teaching skills. Med Teach. 2008;30:e137–e144.
