Mistreated Medical Students: A Cultural Shift Is Underway

Ingrid Hein

May 08, 2019

Shelly Holmström, MD, is all too aware of what it is like to be mistreated as a medical student. "The only thing I see that you lack is a Y chromosome," she was told after a 4-week residency with a small-town male attending physician.

And when she went to report the comment, the female attending physician on her next rotation said, "Do you really want to be the woman who draws attention to yourself, who gives yourself a label, calling out an old attending?"

Holmström also remembers crying behind her surgical mask in the operating room — after not having slept for 24 hours — when she was yelled at for not tying a knot exactly as directed.

"This is the culture of medicine; we're taught to suck it up," Holmström, from the University of South Florida in Tampa, told Medscape Medical News. "Even overt sexual harassment, you're taught to ignore it. It's part of the training. You just have to accept it and get through it."

Even overt sexual harassment, you're taught to ignore it. It's part of the training. You just have to accept it and get through it.

Holmström said she wants to help change that culture for current and future generations of medical students in obstetrics and gynecology. When she was offered the opportunity to be an attending physician, she jumped at the chance and vowed to treat students well. "There needs to be a culture change. There is a better way," she said.

Holmström outlined research on understanding and identifying mistreatment during a lunch presentation at the American College of Obstetricians and Gynecologists 2019 Annual Meeting in Nashville, Tennessee.

Medical students are under extreme pressure, often dealing with depression and anxiety. And they increasingly misuse substances, alcohol, and illegal drugs.

Med Students Maxed Out

Abuse is passed down from physicians because that's the culture, Holmström explained. The rates of mistreatment of medical students peak in "high stakes" specialties like internal medicine, surgery, and obstetrics and gynecology.

"There seems to be a certain personality and mentality attracted to these fields, where there is crisis after crisis, where things are acute all the time," said Holmström. And if these attitudes are left to fester, they can create a "toxic learning environment."

Holmström and her colleagues assessed this issue by asking study participants — eight attending physicians, 10 resident physicians, and 10 medical students — to watch three videos of medical students being mistreated and then to rate the severity of mistreatment.

"In general, everyone agreed what represented mistreatment and what did not," she told Medscape Medical News. Participants also agreed on the severity of abuse.

Perceptions did not change if the participants had, themselves, been mistreated. Fourteen reported experiencing mistreatment, all when they were in their third year of medical school.

After watching the videos, participants shared their experiences from med school, some of which were "horrifying," said Holmström.

Her team is currently developing five videos depicting mistreatment in an obstetrics and gynecology setting. They hope to conduct a study at 15 to 20 universities across the country to validate whether everyone sees mistreatment the same way.

The project is part of an initiative led by Kevin O'Brien, MD, from the University of South Florida Morsani College of Medicine. O'Brien has people from several specialties creating scenarios and videos to show to students, resident physicians, and attending physicians across the country.

After Holmström's presentation, a retired professor from Johns Hopkins explained that his group used to have a "safe" word, used when they heard a colleague take a negative tone with a medical student. This helped physicians to be aware of their behavior, he said.

Although awareness of mistreatment has been increasing, the jury is still out on whether students feel that they can safely report abuse and remain anonymous.

Better Reporting Needed

In a review of publications related to mistreatment in medical schools, only 10 of the 3300 articles on the topic described outcomes from a mistreatment prevention program (JAMA Netw Open. 2018;1:e180870).

"There's still a lot to lose if you speak out," said Holmström. "The perceived consequences are severe. "There are very few published descriptions of programs attempting to decrease mistreatment of medical trainees, and there is a need for improved quantity and quality of such reports.

But the pendulum might be swinging in the other direction.

In the wake of the #MeToo movement, medical students have been using the #MeTooMedicine hashtag to share stories. "Just knowing this is a more acceptable topic of discussion is a start," said Holmström. "Old school behaviors are becoming less acceptable."

Abuse in medicine has made headlines in several publications in the past few months. A recent Bloomberg article — America's Medical Profession Has a Sexual Harassment Problem — highlighted the "power discrepancy" that "manifests in rates of sexual harassment, assault, and retaliation that far outpace other professions."

And InStyle, a fashion magazine, offered women in medicine a forum to discuss their experiences of sexual harassment after highly publicized lawsuits against USA Gymnastics team doctor Larry Nassar, who was sentenced to 175 years, and against Columbia University and the NewYork–Presbyterian hospital system for enabling Robert Hadden, a gynecologist who has been accused of penetrating, fondling, and licking women on his exam table, for more than 20 years.

That culture still remains in many forms so the discussion has to continue, said Holmström.

"When you start out as a student, you get indoctrinated" to expect this type of treatment, she pointed out. "Students can end up paying it forward and possibly mistreat their students. The cycle has to end."

Holmström has disclosed no relevant financial relationships.

American College of Obstetricians and Gynecologists (ACOG) 2019 Annual Meeting. Presented May 4, 2019.

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