Medical Teacher
ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage: http://www.tandfonline.com/loi/imte20
Mistreatment of medical students in the third year may not be the problem Stuart J. Slavin & John T. Chibnall To cite this article: Stuart J. Slavin & John T. Chibnall (2017): Mistreatment of medical students in the third year may not be the problem, Medical Teacher, DOI: 10.1080/0142159X.2016.1270438 To link to this article: http://dx.doi.org/10.1080/0142159X.2016.1270438
Published online: 18 Jan 2017.
Submit your article to this journal
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=imte20 Download by: [188.60.178.66]
Date: 18 January 2017, At: 06:36
MEDICAL TEACHER, 2017 http://dx.doi.org/10.1080/0142159X.2016.1270438
PERSONAL VIEW
Mistreatment of medical students in the third year may not be the problem Stuart J. Slavina and John T. Chibnallb a Department of Pediatrics, Office of Curricular Affairs, Saint Louis University School of Medicine, St. Louis, MO, USA; bDepartment of Neurology and Psychiatry, Saint Louis University School of Medicine, St. Louis, MO, USA
ABSTRACT
Mistreatment and abuse of medical students has been recognized as a significant problem in medical schools. We believe, however, that the problem of mistreatment has been viewed incorrectly. This misperception of mistreatment exists in two primary ways. First, mistreatment has tended to be viewed as a “diagnosis” of unprofessionalism of the perpetrator when it may be more appropriately viewed as a symptom with a range of possible underlying causes. The second misconception that appears to be prevalent is the belief that the link between mistreatment and student well-being, distress, and falling empathy is clear. It is not. We present (1) evidence that other factors in the clinical learning environment may be having a greater negative impact on student mental health and well-being and (2) recommendations for changes that may produce enhancement to medical student mental health in the clerkship year.
Introduction Mistreatment and abuse of medical students has been recognized for some time as a significant problem in medical schools across the US (Fnais et al. 2014). The Association of Medical Colleges Graduation Questionnaire distributed to every graduating medical student in the country (AAMC 2016) has an entire section in which it asks students a series of questions about 17 specific forms of mistreatment including public humiliation, physical harm, unwanted sexual advances, and lower evaluations or grades because of race, gender, or sexual orientation. The problem has been the focus of a number of studies, most notably at UCLA which found that despite a multi-pronged 13-year campaign to reduce mistreatment of medical students that the problem persisted and “the majority of our students continued to report some form of mistreatment at least once during their third-year clerkships” (Fried et al. 2012). The Licensing Commission on Medical Education has a standard that requires that a medical school “defines and publicizes its code of professional conduct for faculty–student relationships in its medical education program, develops effective written policies that address violations of the code, has effective mechanisms in place for a prompt response to any complaints, and supports educational activities aimed at preventing inappropriate behavior” (LCME 2015). To remain accredited, schools must have programs in place to address these requirements. We believe, however, that the problem of mistreatment has been viewed incorrectly. This misperception of mistreatment exists in two primary ways. First, mistreatment has tended to be viewed as a “diagnosis” of unprofessionalism of the perpetrator when it may be more appropriately viewed as a symptom with a range of possible underlying causes. These potential causes include burnout, depression, CONTACT Stuart Slavin St. Louis, MO 63104, USA
[email protected]
alcoholism, other substance abuse, personality disorder, poor emotional self-regulation, relationship issues, lack of cultural competency (within the US medical culture), arrogance, or a belief that their behavior is completely appropriate and that they are simply holding up standards and everyone else is too soft and sensitive. The second misconception that appears to be prevalent is the belief that the link between mistreatment and student well-being, distress, and falling empathy is clear. It’s not. Mistreatment of medical students certainly exists. And student mental health certainly declines, distress rises, and empathy falls during medical school (Dyrbye et al. 2005; Neumann et al. 2011). Unfortunately, it is not at all clear that the former is the primary cause of the latter. Other toxic elements exist in the third year and we have evidence at Saint Louis University (SLU) that these other elements are viewed by students as having significantly greater impact on their feelings of distress than mistreatment.
Third-year student perceptions at SLU Medical students from three consecutive classes (graduating classes of 2013–2015) were given surveys at the end of their third year that asked them to rate the extent of impact of 25 potential sources of demoralization (defined as undermining of confidence, determination, spirit, or morale) on a 5-point Likert scale, where 0 ¼ Not at all, 1 ¼ Somewhat, 2 ¼ Moderately, 3 ¼ Quite a bit, and 4 ¼ Extremely (Table 1). Out of 495, 385 students completed the survey. Working with unhappy residents and attendings, feeling ignored by residents, not feeling a part of the team, feeling incompetent, and unfair evaluations from attendings and residents were rated highest as demoralizing factors. The lowest ratings were related to
Department of Pediatrics, Saint Louis University School of Medicine, Office of Curricular Affairs, LRC 101,
ß 2017 Informa UK Limited, trading as Taylor & Francis Group
2
S. J. SLAVIN AND J. T. CHIBNALL
Table 1. Rating of impact of sources of demoralization. Sources of demoralization Working with unhappy residents Working with unhappy attendings Being ignored by residents Feeling incompetent Getting an unfair evaluation by an attending Getting an unfair evaluation by a resident Being ignored by attendings Culture of negativity in medicine Working with unhappy nurses Non-verbal mistreatment by residents Non-verbal mistreatment by attendings Verbal mistreatment by attendings Verbal mistreatment by residents Feeling ignored by nurses Non-verbal mistreatment by nurses Caring for very sick/dying patients Verbal mistreatment by nurses Discrimination by attendings Discrimination by residents Discrimination by nurses Sexual harassment by patients Sexual harassment by residents Sexual harassment by attendings Sexual harassment by nurses
Mean rating (SD) 2.7 2.3 2.2 2.2 2.1 2.0 1.9 1.8 1.8 1.6 1.5 1.4 1.4 1.2 1.1 0.9 0.8 0.5 0.4 0.3 0.3 0.2 0.2 0.1
(1.1) (1.2) (1.2) (1.2) (1.4) (1.4) (1.2) (1.3) (1.2) (1.4) (1.4) (1.5) (1.3) (1.2) (1.2) (0.9) (1.2) (1.0) (1.0) (0.8) (0.8) (0.8) (0.8) (0.6)
Scale: 0 ¼ Not at all, 1 ¼ Somewhat, 2 ¼ Moderately, 3 ¼ Quite a bit, 4 ¼ Extremely. Within each group of ratings, mean differences of j.3j are significantly different at p < .001.
direct forms of mistreatment, including verbal and non-verbal mistreatment, sexual harassment, and discrimination.
Discussion If we are going to improve the mental health of third-year medical students, making reduction or elimination of mistreatment a primary focus may not be the most effective strategy. If we take a resident or faculty member who is unhappy and get them to stop mistreating students but they remain unhappy, then the toxicity that they are contributing to the educational environment for students may remain. Unfortunately, the primary approach to prevent mistreatment of medical students used at many institutions appears to be to tell faculty (and residents) not do it and when mistreatment occurs, the first step that tends to be taken is to say don’t do that. Most medical schools do not appear to be routinely exploring the potential underlying causes that may be contributing to the misbehavior. Perhaps it should be no surprise that the problem has been so resistant to change. New strategies are needed if we are going to be able to improve the clinical learning environment. Focusing on the factors that students report as being most demoralizing would seem to be the most appropriate strategy. Given the high prevalence of burnout and depression in residents and faculty, it should be no surprise that working with unhappy residents and faculty were the highest rated demoralizing factors for SLU third-year students. Preventive approaches are clearly needed to reduce the systemic drivers of burnout for faculty and residents in the clinical environment as well as to provide them with tools and strategies to manage stress and better regulate their emotions. Management of faculty and residents who engage in mistreatment needs to be refined to better explore the potential causes of unprofessional behavior. Confidential structured interviews using validated screening tools could be conducted by trained staff to explore possible diagnoses
such as burnout, depression, and substance abuse and then interventions targeted at those particular diagnoses could be initiated. A one-size-fits-all approach to management seems completely misguided given the wide range of potential causes of the behavior. While assessment and management of underlying causes moves forward, the faculty member needs to still receive the clear message that continuing unprofessional behavior is not acceptable. Causes should be seen as an explanation of, not an excuse for, the behavior. Efforts to improve the evaluation of students also appear warranted given the high ranking students give to subjectivity and unfairness of grading as a cause of demoralization. Approaches could include greater use of objective measures such as Objective Structured Clinical Exams (OSCE’s) as well as initiatives to improve the validity of subjective evaluations of students by residents and faculty Further studies, ideally multi-institutional, need to be performed to explore whether the demoralizing factors found in our study have as great a negative impact on students in other medical schools. In addition though, medical schools could also begin to track, as is done at SLU, depression and anxiety rates in their students and assess whether interventions to enhance faculty and resident well-being and job satisfaction have a positive impact on students’ educational experiences and mental health in the clerkship year. Seeing mistreatment for what it is, a symptom rather than a diagnosis may make those efforts more impactful.
Acknowledgements This study was approved by the institutional review board of Saint Louis University.
Disclosure statement The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.
Notes on contributors Stuart J. Slavin, MD, MEd is Associate Dean for Curriculum and Professor of Pediatrics at Saint Louis University School of Medicine. His recent work has focused on understanding and improving the mental health and well-being of medical students and residents. John T. Chibnall, PhD, is Adjunct Professor of Psychiatry and Behavioral Neuroscience at Saint Louis University School of Medicine. He is a research psychologist with special interest in psychosocial and mental health factors in education and chronic illness.
References Association of American Medical Colleges Graduation Questionnaire [Internet]. Washington (DC): AAMC; [cited 2016 Sep 15]. Available from: https://www.aamc.org/data/gq/ Dyrbye LN, Thomas MR, Shanafelt TD. 2005. Medical student distress: causes, consequences, and proposed solutions. Mayo Clin Proc. 80:1613–1622. Fnais N, Soobiah C, Chen MH, Lillie E, Perrier L, Tashkhandi M, Straus SE, Mamdani M, Al-Omran M, Tricco AC. 2014. Harassment and discrimination in medical training: a systematic review and meta-analysis. Acad Med. 89:817–827. Fried JM, Vermillion M, Parker NH, Uijtdehaage S. 2012. Eradicating medical student mistreatment: a longitudinal study of one institution’s efforts. Acad Med. 87:1191–1198.
MEDICAL TEACHER
LCME Functions and Structure of a Medical School- Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree 2015, Standard 3.6 [Internet]. Chicago, Licensing Council on Medical Education; [cited 2016 Sep 15]. Available from: https:// www.lcme.org/publications
3
Neumann M, Edelhauser F, Tauschel D, Fischer MR, Wirtz M, Woopen C, Haramati A, Scheffer C. 2011. Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med. 86:996– 1009.
