This article is intended for members of the surgical learning environment who serve a role in educating medical student trainees. The following are learning objectives for this article:
Despite being extensively documented in the literature for over 30 years, medical student mistreatment remains widespread. In the most recent Association of American Medical Colleges (AAMC) Graduate Questionnaire, 39 percent of graduating medical students reported mistreatment; however, this is a significant underestimation, as nearly 80 percent of mistreatment behaviors were not reported.1 The most common reason for non-reporting was student perception that the incident was not important enough to report (56.6 percent); additionally, they did not think anything would be done about it (37.4 percent).1 Despite these concerning numbers, a recent study by Ross et al, using an A3 framework, documented the potential to increase student reports of mistreatment, moving towards being able to fully capture the breadth of this problem.2
The issue of medical student mistreatment is of particular concern on the surgery clerkship where reported rates are particularly high.3–7 By immersing themselves in patient care, clerkships are an opportunity for medical students to hone their basic science and clinical knowledge and their professionalism, communication, and teamwork skills. A novel (for the student) clinical environment that may contain urgent patient situations, coupled with educational dynamics, can set the stage for stress, anxiety, and sometimes mistreatment. These pressures and potentialities are ubiquitous; every hospital and surgery program that educates medical students faces this challenge. If not addressed, mistreatment may have deleterious effects on medical students such as increased rates of burnout, symptoms of post-traumatic stress, depressive symptoms, drinking for escape, and decreased confidence in clinical skills.8–11
There has been a concerted effort at a number of institutions to implement mistreatment programs aimed to increase reporting and thus move towards eradicating medical student mistreatment. While displaying a diverse approach to combating mistreatment, many programs limit their understanding of mistreatment to explicit actions (i.e.: verbal and physical abuse, sexual harassment, etc.) such as those put forth by the AAMC and the Liaison Committee on Medical Education (LCME); such positions do not account for behaviors that fall outside these official definitions (i.e.: neglect, failure to teach, etc.).12–19 Furthermore, reported mistreatment seems to vary by student role and student career choice, suggesting that the perception of mistreatment is individualized and unlikely to be fully captured by institutional or organizational definitions.20,21
As students embark on their clerkship journey, the protective effect of belonging to a medical student cohort diminishes.22–25 Additionally, clerkships may be vulnerable settings as medical students navigate the transition from a traditional classroom setting to a clinical learner, medical provider, and member of the medical team.22,26 Often, students come face-to-face with a culture of medicine in which mistreatment is a common occurrence and even culturally acceptable facet of clinical training. As a first step in combating mistreatment we sought to understand how medical students define and perceive mistreatment. Over a two-year period, we collected individual student definitions, and developed a definitional framework based on this work. Student responses reflected their multiple roles on the medical team: student-learner, individual, and team member. As such, their definitions of mistreatment centered around these roles: (1) Obstruction of Learning (student-learner role), (2) Exploitation of Vulnerability (individual role), and (3) Exclusion from Medical Team (team member role) (see Figure 1).21 In addition, a fourth overarching theme, (4) Contextual Amplifiers of Mistreatment, emerged from student responses, suggesting that there are factors that amplify or dampen the mistreatment behavior (see Figure 2).21 Institutions may reduce and mitigate the effects of medical student mistreatment by ensuring students’ self-identified roles are supported and validated.
In order to empower students to achieve these goals, we designed and implemented a rotation-specific, longitudinal mistreatment program as a part of our institution’s third-year surgery clerkship (see Figure 1).27 One of the most important aspects of this student-centric program is the facilitated discussion with the program’s Clerkship Director and the Surgical Education Fellows.28 These discussions were to help students establish expectations for the surgical learning environment, create a shared and personal definition of mistreatment as it applies to the surgical learning environment, and promote advocacy and empowerment for students to address mistreatment. We were able to show a decrease in formal mistreatment reports from fourteen per year prior to the program, nine the year after, and four the subsequent year.29
A mistreatment program for medical students has the potential to create long-term cultural change from the ground up, by educating students explicitly about what has unfortunately too often been part of the hidden curriculum. In any teaching intervention, a discussion centered on the educational environment should emphasize setting expectations bidirectionally, creating an environment of student centricity and safety, as well as addressing real-time conflict resolution. While we have shown a decrease in the number of mistreatment reports, we have not focused on repairing the harm caused by mistreatment. Recently, restorative justice has been proposed as a possible solution. Restorative justice is a collaborative discussion and decision-making process that brings together offenders and medical students in order for the offender to accept responsibility, work to repair the harm their actions or inactions caused, work to reduce the risk of repeat offenses, and build positive relationships within the learning environment.30 Promoting awareness, recognizing patterns of mistreatment and vulnerability, facilitating dialog, and exploring strategies to address and repair harm with a view to restoration and prevention are all strategies which may be meaningfully incorporated into addressing this important issue and understanding its implications for physician development.