Addressing Resident Mistreatment Through the Use of a Forum Theatre Intervention

Purpose:

The problem of ongoing mistreatment in academic medical education remains a challenge. Within the clinical learning environment (CLE), residents are recipients of mistreatment from faculty, peers, nurses, and patients. Residents can choose to propagate or mitigate mistreatment, but the fast pace of clinical service and long hours may pose a challenge for intentionality. Residents can be both victims and perpetrators. We sought to assess interventions targeted toward residents as they are responsible for mistreatment of other residents and students 15% of the time. ¹ Few studies address interventions to help residents navigate mistreatment. We propose that drama, specifically Forum Theatre, ² is a modality well suited for resident engagement, discussion, and reflection of complex professionalism challenges such as mistreatment in the CLE. Forum Theatre “plays” are based on realistic conflict scenarios geared toward problem solving at a moment of crisis. Learners become participating spect-actors who watch, respond, and step into the play exploring potential solutions. Throughout, the facilitator debriefs with participants and solidifies key messages. The purpose of this pilot is to explore the use of Forum Theatre to address mistreatment concerns among residents.

Approach/Methods:

This project was undertaken in obstetrics–gynecology (n = 10) and urology (n = 18). It consists of 2 phases: first, a focus group with residents to identify mistreatment that they experience and that could subsequently be used in the Forum Theatre, and second, the enactment during regularly scheduled 1-hour didactic sessions. Residents develop and enact the scenarios and through guided facilitation generate their own solutions. Residents completed an anonymous retrospective pre–post survey and a 6-month follow-up assessing knowledge, attitudes, and self-reported and observed behaviors. The instrument was modeled after Didwania et al. ³ Data were analyzed using 2-sample paired t tests and 2-proportion z-tests for dichotomous variables. Institutional review board exemption was obtained.

Results/Outcomes:

Each department created their own mistreatment scenario, one related to bullying and the other to gossiping. The survey response rate was 93%. Most respondents (92%) would recommend Forum Theatre to colleagues for teaching professionalism issues. Sixty-two percent of participants stated that their behavior changed as a result of participating in the program. After 6 months, self-reported mistreatment behaviors decreased including “making fun of others” (63% to 38%, P = .04), sending “disparaging texts” (54% to 27%, P = .02).

Observed mistreatment behaviors also decreased by 39% to 56%. Confidence in ability to recognize and intervene when mistreatment was directed at them or others increased immediately after the intervention from 3.6 ± 1 and 2.6 ± 0.9, respectively, to 4.21 ± 0.8 (P = .005) and 3.7 ± 0.86 (P < .001). The change was sustained at 6 months: 4.25 ± 0.15 (P = .006) and 3.54 ± 0.16 (P = .004).

In the comments, residents remarked on the benefits of communication in this forum, dealing with program hierarchy and it being an engaging way to strategize solutions to complex situations.

For example, “…the acting made it feel like something we could actually talk about without it being us.”

Discussion:

The use of Forum Theatre during regularly scheduled didactic times is not only feasible but also well received among residents. This evaluation demonstrates sustained self-reported behavior changes (Level 3a). In contrast to the study by Didwania et al, ³ residents reported behavioral changes that were sustained over 6 months. Plans are underway to upscale this approach to other medical specialties in our institution.

Significance:

The humanities engender self-reflection and discussion surrounding difficult topics. The unique power of the Forum Theatre is that it is tailored to the groups’ needs and provides opportunities for experimentation and peer influence. Such modalities offer opportunities for reflection and behavior change regarding other sensitive, professionalism, and communication topics such as social justice, power differentials, and conflict management.