Medical students and mistreatment

“Mistreatment either intentional or unintentional 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.”- AAMC definition of student mistreatment

One of the eternal challenges presented to clerkship directors, particularly in specialties with lesser reputations for begin “kind and gentle,” is trying to mitigate medical student mistreatment.  Although administrators  (the Deanery, as I refer to them) and those of us in the trenches have made almost heroic efforts, reports of mistreatment from students persist.  The 2012 AAMC Graduation Questionnaire shows at least one incident of mistreatment during their training by 47% of students; public humiliation was indicated by 34% of students.  Variability in rates occurs between institutions, as does variability in cultural expectations- which may in turn effect rates.

One of the real challenges in reporting and addressing mistreatment lies in the variability of definitions.  Excellent work published earlier this Spring in Academic Medicine used grounded theory methods to develop this concept map of student mistreatment when placed within the context of suboptimal learning environments.  I would argue for most of us who are dedicated to fostering positive learning experiences, the second type (environment-based) is the most prevalent, the most insidious, and the most challenging to address.  While incident-based episodes are generally within the framework of broader professionalism issues and effective interventions have been identified, the cultural issues are more deep-seated and may be indicative of institutionalized unconscious bias.  Lingering mistreatment in an institution dedicated to its eradication implies the importance of culture and bias.

My fundamental worry on this issue isn’t that I am concerned about reporting, or even about mistreatment for its own sake.  My concern is the known relationship shown between mistreatment and suboptimal learning environments; the truth is that when learners feel threatened, they develop the phenomenon of “lizard brain.”  Lizard brain may do great things for our survival, but it certainly doesn’t foster a supportive and creative learning environment.  Most dangerously, it doesn’t train our learners to be problem-solving physicians when we make them question their own value in every single clinical decision- and we’re really not helping them establish the confidence in their skills and knowledge to make the right decisions when the chips are down.

I’m not sure I have any great wisdom or solutions.  Yes, we need zero-tolerance policies for mistreatment- and for disruptive/ unprofessional behaviors in general. Yes, we need anonymous reporting with investigators who are seen as impartial by those on both sides of the power divide.  And yes, while my primary commitment is to the students, we must acknowledge that mistreatment of anyone in a professional environment simply is not okay.

Or as succinctly stated by another author in the title of his piece on this topic, “Why can’t we just be nice?”