Strategies to End the Abuse of Medical Students

Marcia Frellick

Disclosures

May 28, 2019

Prevalence of medical trainee mistreatment has changed little over recent years, according to some surveys. Experts say that transforming the culture at individual institutions will probably require new approaches, including some from outside the medical profession. Results of the 2018 Association of American Medical Colleges (AAMC) annual graduation questionnaire show that 42.1% of students nationwide reported being mistreated at least once during medical school, up from 39.3% the previous year. "Those are only the students who decided to respond to the question, because it's optional," said David Acosta, MD, AAMC's chief inclusion and diversity officer. "I think, What about the students who decided not to respond?"

Little Improvement Over 5 Years

The AAMC numbers suggest that little has improved in 5 years. Although the reports don't use the term "bullying" explicitly, behaviors tracked fall under that umbrella and include public humiliation, derogatory remarks, and discrimination based on race, gender, sexual orientation, or other traits or beliefs. For example, the percentage of students who said that they were occasionally publicly humiliated decreased only slightly over 5 years, from 9.6% to 8.2%.

The number of students who reported unwanted sexual advances was 1.8% in both 2014 and 2018, while the number who said they were subjected to sexist remarks and inappropriate names rose from 7.4% in 2014 to 8.3% in 2018.

Awareness appears to be improving, however. The number of respondents who were aware of medical school policies against medical student mistreatment rose slightly, from 93.3% in 2014 to 97.5% in 2018. When asked about procedures at their school for reporting mistreatment, 88.1% of 2018 graduates said they knew about these procedures, compared with 78.6% in 2014.

'Trigger' Videos

James Lau, MD, assistant dean for clerkship education at Stanford University School of Medicine in Stanford, California, told Medscape that the AAMC survey doesn't tell the whole story. Lau said that when "mistreatment" is broadly defined, students are asked to reflect on 4 years rather than evaluate actions in real time; thus, students may interpret the same actions differently, and solutions are unclear. Meaningful measurements and marks of improvement are hard to quantify, he said.

Progress in individual programs is more positive than the national numbers may indicate, according to Lau. Stanford launched an initiative to address mistreatment in surgery clerkships in 2014. At the beginning of students' rotations, students and faculty now discuss what mistreatment might look like and how students can cope. Instructors let them know how and to whom problems should be reported, Lau said.

Leaders also developed "trigger" videos, which Stanford now shares with other schools, to show students hypothetical scenarios of interactions in the operating room or on rounds. These videos are designed to get them talking about what they are experiencing or what they have seen at their individual sites. The videos also help students and faculty come to a shared understanding of mistreatment. Each week, all surgery students come together and share experiences from their sites. Lau and fellows check in weekly with each student on how they feel that things are going. That meeting can be an opportunity to discuss problems on the spot or to contact him later to talk privately, Lau said.

Once you show students that you can take care of problems without risking retaliation, and that their grade won't be affected by reporting, the trust builds, he explained. "It takes a while to establish. And you really have to care for the students. If you don't care for the student, it never works."

Lau and coauthors published a paper in Academic Medicine that compared results from 2013, before the program, through 2015. It showed a reduction from 14 formal mistreatment reports the year prior to the program's implementation to nine reports in the program's first year and four in the second year. Students also are able to report treatment anonymously, he noted.

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