Rites of initiation

“I’m not sure why they even gave you a spot in the medical school class.  That was a waste.”

Since it’s the third Tuesday of the month, that also makes it time for Schwartz Rounds at the University of Utah. Today was a topic that ties back to my research and informs the culture that I strive for us to create in healthcare- hazing in the healthcare hierarchy.

Mistreatment is something that is real within the educational process, particularly for young physicians, because of the hierarchies that exist in healthcare.  While the language that is most often used is that of mistreatment, use of the word “hazing” paints a more dramatic but no less accurate picture of what happens when these power inequities are abused.

Overheard at the nursing station: “You must be the stupidest intern ever!” 

Hazing Is: “Any activity expected of someone joining or participating in a group that humiliates, degrades, abuses, or endangers them regardless of a person’s willingness to participate.” I’ll grant that in the healthcare context we’re not talking about making someone drink themselves into oblivion or get their pledge signature book filled, but if we embrace the idea that hazing involves disrespect, that it infringes upon personal safety (physical or emotional), and that it fails to serve the purpose of the greater organization, we can all probably think of some examples from our workplace.  And when we put those into the context of how harshly we judge fraternities, sororities, or athletic organizations that haze, we get uncomfortable quite quickly.

Most hazing behaviors in healthcare- or mistreatment if that makes you less squeamish- are a historical holdover. “Well, it happened to me and I’m a better doctor for it, so it’s okay” is a statement I’ve heard more than once from a resident or student who experienced verbal abuse from a faculty member.  While it may be true that they did learn something from a public berating, the reality is that it’s unlikely to be durable learning because it preyed on their sense of shame (unhealthy motivator) rather than a sense of guilt (healthy motivator). Until we both name it and stop excusing it- and recognizing that it is NOT harmless to our trainees’ mental health- hazing is not going to slink off into the dark where it belongs. Let me clarify my point: It is NOT okay.  End of discussion.

I’m too busy to teach you today in clinic.  Can you just go get us all some coffee?

One of the reasons that hazing happens is based upon an idea of weeding out the weak. If you work in medicine, regardless of your team role, you already know two things for sure:

  1. Medicine is hard. We all do lots of hard things every day. We don’t need to make it harder.
  2. Entering a career in medicine already has a high bar, and if someone is truly “weak” they’ve already been culled.  Yes, there are people who are a poor fit for certain specialties; the likelihood that they are weak and need to be taken out of the herd entirely is inordinately low.  It’s also not one individual person’s decision to make.

I trained in a time (pre-workhour restrictions) and in a specialty (surgery) that weren’t known for kindness. In spite of that, I can’t look back at my training and call it malignant.  I’ll confess that as a 2nd year resident I was found crying in the corner of the SICU one day, and when the pharmacist who found me in that condition asked me what was wrong my answer was simply, “I’m tired of people being mean.” I’m also certain that in the sleep-deprived state of some of my training years there were days when I was one of those mean people (and if you were on the receiving end, I am still truly sorry for that). Overall, though? I was generally treated well by people even if the system wasn’t designed around kindness.

I’m fortunate to be at a point in my life where it’s a priority to me to lead within a culture that doesn’t tolerate meanness/ mistreatment/ hazing for its own sake. The negative things that happened to me weren’t necessarily right, and it’s my responsibility to not pay them forward. We all owe kindness and respect to one another as humans who are being.

“You seem like you’re struggling right now.  Let’s find some time to talk about it so I can figure out how to best help you.”

Yes.  That’s better, isn’t it?

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?”