Optimizing Tx of med students

Medical student mistreatment appears to be more common than one might think.

One medical student was slapped for answering a question wrong. Another was groped. A third was subjected to racist jokes about her last name.

These were only a few of the incidents reported in a recent analysis of medical student mistreatment. On surveys collected between 1996 and 2008, more than half of the students at the David Geffen School of Medicine at the University of California, Los Angeles (UCLA), described experiencing some form of mistreatment.

Photo courtesy of Joyce M Fried
Photo courtesy of Joyce M. Fried.

The surveys were conducted as part of UCLA's comprehensive effort to reduce medical student mistreatment, a problem that has been found to be troublingly common at medical schools across the country. Administrators at UCLA implemented a number of programs to address mistreatment and have annually surveyed third-year students to measure the effects of their efforts.

They have not been overwhelmingly successful, according to results published in the September Academic Medicine. The percentage of the third-year class that reported being mistreated did drop from a high of 75% in 1996-1998 to an average of 57% in 1999-2008. But that's still far from ideal, and little change has been seen since 2000 despite a number of new initiatives.

Joyce M. Fried, the medical school's assistant dean, is not one to give up easily, though. She spoke to ACP Hospitalist about the survey results and UCLA's ongoing efforts to treat medical students better.

Q: What led you to measure medical student mistreatment?

A: [In 1995] we had read the literature that had been published to date about student mistreatment and we thought it would be a good idea to see what our students were experiencing. We went into it with an open mind. We had not had any complaints and we had no idea what to expect. We administered the survey to the entire student body. We found that in the first and second years, a handful of students said they had had an issue. Then, in the third year, there was this huge spike. The fourth year, it was still significant, but less so. We realized the problem is predominantly in the third year. So we got into the routine of annually surveying only students at the end of the third year.

Q: What steps did you take to try to remedy this problem?

A: [In 1998] our gender and power abuse committee began by writing a statement on an abuse-free academic community. We created bookmarks and we put the statement on one side and listed all the members of the gender and power abuse committee on the other side including their contact information. These people can all serve as resources to our students, faculty, and staff.

We agreed that it would be important to have an Ombuds office in the Center for the Health Sciences. There was an Ombuds office on upper campus but it was not highly utilized by the medical school community. We were able to accomplish this and from day 1, that office has been busy, busy, busy dealing with lots of issues and helping our school and hospital faculty, staff and students with their concerns.

[Then in 2001] we wrote a formal mistreatment policy and procedures. We also started teaching a workshop at the beginning of the third year to alert students that there are these behaviors out there. We wanted to prepare them for [potential mistreatment] and teach them how to deal with it themselves and how to report it. I give them scenarios to discuss, some of them egregious but some of them gray-area situations and try to teach them how to turn the situation into a mentoring opportunity or how to draw the line and set some limits about what is acceptable behavior.

Q: As you monitored the annual survey responses, what did you find?

A: We were not able to effect much change. We had a couple of dips, but other than that….That's when I suggested we analyze the comments [in which students described specific incidents]. The frequency hadn't lessened, but I was hoping the severity of the behaviors might have decreased. We were disappointed to see that that was not the case.

Q: Are you still optimistic that this situation can be improved?

A: Definitely. That's what prompted us to go public. We knew there was a little risk in putting [our results] out there, but we knew it was the right thing to do and we felt very passionately that we wanted to revive the national conversation [about medical student mistreatment].

Q: Your paper mentions that you plan to focus future efforts on the perpetrators of mistreatment, rather than the medical students themselves. How and why are you doing that?

A: The challenge is that in an anonymous survey, [mistreated students] don't have a problem checking off the box and even giving a little description of what occurred. But students have been unwilling to come forward with specific actionable complaints. We ask, “Why haven't you reported this?” The answers are always “This is just part of the culture,” “In medical school you just have to learn how to suck it up,” “I don't want to be seen as a complainer,” “I fear for my grade.”

We've also been reticent about pursuing anonymous allegations. We want some kind of due process. But since we haven't made such a difference with all our other efforts, we decided to change the wording in our evaluations of residents and faculty. Instead of asking “Did they model professional behavior?” we've substituted two very specific questions: “Did this person treat you with respect?” and “Did this person treat others with respect?” University of California San Francisco did this and it helped discourage mistreatment behavior there. A small group of deans is going to meet monthly to discuss any blip that comes up in the evaluations and we will decide how to deal with each situation.

Q: Do you expect to find a few perpetrators, rather than widespread incidence?

A: I don't have data to back this up, but I would guess that [for] 98% of people it's just a one-time aberration caused by burnout or stress. A lot of times when the behavior is pointed out to people—maybe they don't even realize that they are doing it—they are able to moderate their behavior. We're going to get the word out that we have changed the evaluation wording. I think just doing that is going to be a deterrent. On the other hand, there are a few people who have a real issue, perhaps anger management or some other kind of personality issue. Those are the people that we will hopefully be able to identify and then try to find some resolution.

Q: Do you think you can eventually eliminate this problem at UCLA?

A: If this were a closed system…if our students all became our residents and our residents became our faculty, then we would be able, as a single institution, to deal with it and get better results. But the problem is it's just a big revolving door. This is a national problem. Everybody's got to be involved. Everybody has to raise their standards and tackle this issue.

We still feel that all of our interventions are best practices that every medical school should think about doing. I think every school should have a statement describing what the environment should be, everybody should have policies and procedures for dealing with mistreatment, everybody should have resources for informal discussion and resolution of issues. We wouldn't change any of that. We now just need to build on that.

Q: What's the biggest challenge going forward?

A: The group that's really tough to reach is the residents. Residents are in a really unique place because they are the object of mistreatment and they are the perpetrators as well. It's hard to address all of this. I do trainings—a half-hour at their orientation. In that time, I have to talk to them about the resources that are available if it happens to them and then I have to turn around and tell them, “You can't mistreat students either.” It's a large message to give them in a very short amount of time. We've been thinking about creating a module that we would require residents to take. It would show some scenarios and make residents think about the problem. It would be nice to collaboratively create something that could be used by all programs nationally.

Q: Do you have any advice for the average individual attending physician on this issue?

A: Attending physicians are the role models. Junior physicians, residents, nurses and students all look up to them. I think sometimes they may forget just how much they are watched and emulated. They also need to intervene when they see bad behavior in others and make it clear that they do not condone it. Sending this clear message will go a long way in changing the culture.

Q: Are you getting a lot of response to your findings?

A: Very much so. When a blog on our paper came out in The New York Times, there were hundreds of comments. What really surprised me was the number of patients commenting. They commented about how their physicians mistreated them or were rude to them. Maybe I was a little Pollyannaish about it, but I thought that physicians who got impatient or abusive to our medical students or our trainees, might show better behavior when they walked into the patient room. I guess maybe that's not so realistic.

Q: Do some physicians still respond that mistreatment is a rite of passage?

A: Yes, but in this day and age it's much more difficult to make the argument that it's a rite of passage. With increased awareness and attention on hazing, bullying and student mistreatment, it's really hard to look someone in the eye and say, “It's just a rite of passage. It's OK.” It may have been accepted years ago, but I think it's much harder to be able to say that with a straight face today.