No Cure for Mistreated Trainees

Tinker Ready

July 27, 2018

Awareness programs reflect the increasing focus on harassment in the workplace, but a new study finds that little high-quality research is available on how to solve the problem for medical trainees.

A review of more than 3300 articles uncovered just 10 peer-reviewed studies that both described programs aimed at reducing mistreatment among medical trainees and reported outcomes, Laura M. Mazer, MD, from the Goodman Surgical Education Center in the Department of Surgery at Stanford University School of Medicine in Palo Alto, California, and colleagues report in an article published online today in JAMA Network Open.

"The incidence of mistreatment has been extensively and repeatedly documented since the 1980s, reflecting the increasing cultural focus worldwide on the topic of harassment in the workplace," they write. "Yet there are comparably few articles and no systematic reviews describing attempts to prevent or address mistreatment when it occurs in hospitals or medical schools."

The authors note that among the studies they did find, the methodology was lacking. Background literature review was mostly minimal to moderate, they write. Two articles had no statement of intent, either for the mistreatment program or for the research study. Only one had an explicitly stated conceptual framework, and almost half the studies did not cite institutional review board approval.

Given the paucity of high-quality information, "[w]e emphasize the need to continue addressing this problem, not just with acknowledgment of its existence but with proactive programs to change the academic medical culture," the authors write. They say a theoretical framework for programs needs to be in place to ensure participants and researchers have a shared understanding, and so any proposed solutions can be assessed.

"This review identifies a clear need for additional and more extensive studies on this topic," they conclude.

The new data highlight "critical gaps in our knowledge about the effectiveness of educational interventions and underscores the lack of rigor in the analysis of many of the interventions published," write Amy E. Fleming, MD, from Vanderbilt University School of Medicine, Nashville, Tennessee, and Sherilyn Smith, MD, from the University of Washington School of Medicine in Seattle, in an accompanying editorial.

Diverse Programs

For the current review, Mazer and colleagues searched the medical literature using terms designed to identify studies on mistreatment and medical students, interns, residents, or clinical fellows. They excluded reports with no outcomes data and those with no description of the prevention program.

They found 38 potentially relevant studies, but only 10 included both a description and outcomes data, all of which were conducted at academic medical centers.

The interventions ranged from half-day workshops to a multiyear effort. Many included lectures or workshops, as well as improved reporting programs. Of the 10 programs, four were voluntary, two were mandatory, two included both voluntary and mandatory components, and two did not specify whether they were voluntary or mandatory.

Some of the methods tested included:

  • 1- or 2-day retreats,

  • participation of staff as actors in videos depicting mistreatment,

  • anonymous web-based reporting,

  • statements of faculty behavioral expectations,

  • small group discussions,

  • an 8-week seminar series with video triggers and group discussion,

  • tool kits with strategies to prevent mistreatment, and

  • small group discussions.

The number of study subjects ranged from 14 to 2000. The programs in the studies were evaluated via surveys and reports of mistreatment. All evaluated participant satisfaction, and seven looked at the frequency of mistreatment reports.

One study noted that the "definition of mistreatment is subjective and heavily context based."

One study reviewed a 13-year "multipronged effort" that looked at physical, sexual, ethnic, and verbal mistreatment of medical students, including incidents of slapping, shouting, ethnic jokes, and intimidation The results showed "[n]o change in frequency, severity, or type of mistreatment reports."

"The programs are very diverse in concept, content, and outcome measures, preventing any real conclusions regarding best practices for future educators wishing to address this problem," Mazer and colleagues write.

The editorialists suggest that creation of a national collaborative research network would "help overcome the methodological limitations of single-institution interventions and questionable generalizability." However, they note, financial support is needed to create and test effective interventions.

The authors and editorialists have disclosed no relevant financial relationships.

JAMA Network Open. Published online July 27, 2018.

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