Alleging abuse that ranged from racial slurs to subordinates sleeping with superiors in the hopes of gaining favor, medical residents at the University of Maryland joined some faculty in an anonymous letter sent last year to the School of Medicine's dean and others. The details in that letter, along with an associated lawsuit, describe mistreatment on a staggering scale. In exploring how common this experience may be, several recent surveys have concluded that many medical trainees see or experience some form of abuse. These new reports also consistently show that the vast majority of instances go unreported.
Across the country, schools have implemented policies designed to facilitate the reporting of mistreatment. Investigations into awareness of these policies suggest widespread familiarity. What is more difficult to address is the depth to which trainees fear repercussions after using these reporting pathways. New evidence suggests that students and residents choose not to report abuse because they don't want to be seen as "whiners" in a culture that still fosters retaliation.
What Recent Surveys Show About Abuse
Shelly Holmström, MD, described an incident that occurred during her residency in which a male attending told her, "The only thing I see that you lack is a Y chromosome." When she tried to report the comment, a female attending physician on her next rotation asked, "Do you really want to be the woman who draws attention to yourself, who gives yourself a label, calling out an old attending?" Holmström concluded, "This is the culture of medicine; we're taught to suck it up."
People at the highest levels of medical education are aware of a problem. Each year in a graduation questionnaire, the Association of American Medical Colleges asks students about mistreatment, defined as threats of physical harm, actual physical harm, unwanted sexual advances, and opportunities denied because of race, gender, or ethnicity. In the most recent survey, 42% of respondents indicated that they had personally experienced at least one such incident.
When asked whether they were aware of school policies about mistreatment, 97.5% said yes, and 88% said they knew how to report abuse. Yet, when students who said they were mistreated were asked about filing official reports, 77% said they had not done so. These data suggest that the barrier to increased reporting is not policies or procedural awareness but external concerns.
Last fall, the #MeToo movement reached medicine with the launch of Time's Up Healthcare. Among other things, leaders of that movement suggested that colleagues should come to the aid of those who are mistreated by sharing knowledge of how harassment claims should be processed and where to go for support. This would include actions such as reporting Title IX violations, which are incidents that violate the federal protections against discrimination based on sex in education programs or activities that receive federal funding. However, this year's Medscape Resident Happiness and Lifestyle Report showed that 82% of residents who indicated that they had been sexually harassed or abused did not report the abuse.
Answers given for not reporting included the following:
"Afraid of repercussions."
"Didn't feel it was significant enough."
"I was concerned about the impact on future career advancement."
"Based on past reports and complaints, those in management would do nothing about it."
"The person who did it would know it was me who reported."
Those answers were similar to the ones found in a study published in Medical Education Online last year that explored barriers to reporting abuses by third- and fourth-year medical students. Through a survey and focus groups, researchers found that 63% of respondents felt they had experienced mistreatment. Once again, as in other studies, a minority (30%) reported the mistreatment to any member of the medical school administration. One of the students who responded to that survey substantiated concerns about fears of retaliation: "If I had to go back, I probably would not report it just because I would be afraid of what could happen."
Students "Won't Believe" They Are Safe to Report Abuse
The authors of the Medical Education Online study conducted their research because "medical students who are subject to abusive behaviors are more likely to experience mental health issues such as post-traumatic stress, depression and low career satisfaction, and even suicidality." Despite the serious consequences of ongoing mistreatment, the fear of retaliation remains a huge concern, according to Joyce Fried, a coauthor of that article and assistant dean at the David Geffen School of Medicine.
She explained that even with anonymous reporting, students don't believe that they won't experience retaliation after they report inappropriate behaviors. Students know how to report violations, she said, adding that it is a requirement of the Liaison Committee on Medical Education that students know how to report. Getting them to do it is another thing.
Fried said that in all her years in working with reported violations, she has never seen a student retaliated against, "but students won't believe it." Her group found that some students wouldn't report violations even after finishing their clerkship or graduating from med school altogether. Clerkship trainees may be one of a small group on a rotation, she noted, and they feel as though they would be immediately identified.
Fried and her colleagues also found that in some cases, students were not only concerned about harming their own careers by reporting but also were worried they could harm the career of the perpetrator.
Changes to Policy Don't Outweigh Problems With Culture
If trainees are able to overcome the fear of consequences, varied pathways are often available for reporting a violation. At Loma Linda University in California, for example, students are made aware of such policies and procedures "multiple times a year," said Molly Estes, MD, clerkship director. "Every year we reemphasize to students how important it is to be very aware of their own wellness and all the avenues to reach out if any issue comes up."
An employee assistance program is open to students, residents, fellows, and attendings for confidential advice. Trainees also have access to a "physician vitality group," staffed 24/7 by trained therapists, where everything discussed is confidential, she said. "The information doesn't even make it into your medical record, which is a big concern of students. It doesn't exist," she said.
Additionally, she stated, "Our dean's office is always open to any on-the-record, off-the-record student complaints." Of course, if someone is reporting that they have been physically, verbally, or sexually abused, providing personal details can help the university respond appropriately. "It is important that we be able to reach out and help that individual with their problem, as well as addressing the institutional problem," she said. An extensive, multilayered system has been put into place to make sure people aren't falling through the cracks, Estes said.
Some schools have focused on ways to distance the reporter from the violator to increase reporting. A system at Rush University Medical Center in Chicago, Illinois, for instance, uses a group of trusted medical student leaders called the Special Committee on the Rush Medical College Environment (SCORE) to serve as a proxy for the student reporting the mistreatment. That group then discusses the reported grievances with the perpetrator. Three students from each of the four class years serve on the committee.
Fried said that at her school, they have tried including questions about attending physicians on regular evaluations. The idea is to get away from the student having to make a special "report." The evaluations ask, "Did this individual treat you with respect?" and "Did this individual treat others with respect?"
Fried said the problem with that strategy is that the institution then must follow up on every "no" answer, and given the amount of staff time that takes, it may not be sustainable. She said that making department chairs responsible for the behavior of their faculty and requiring them to let faculty members know that certain behaviors will affect promotions is one approach that has merit.
Fried and others believe that real change will only come when there are fewer people at the top who are modeling abusive behavior. People who are now teaching may have learned abusive behaviors from their role models who taught in an era when standards for treatment of students were different.
Although institutions will continue to educate and modify procedures, substantive reform is only likely to occur when the underlying fear that prevents trainee reporting is addressed. "Culture change has to come from the top and from the bottom and be a very coordinated effort," Fried said. Until such time, no amount of procedural education is seemingly sufficient to overcome those barriers.
Marcia Frellick is a Chicago-based independent healthcare journalist who writes periodically about the challenges medical students and residents face and what medical schools and societies are doing to improve their training and well-being. She also has written about primary care, HIV, gastroenterology, oncology, dermatology, and rheumatology for Medscape over the past decade. Twitter: @mfrellick
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Cite this: Medical Trainees Fear Retaliation for Reporting Abuse - Medscape - Oct 22, 2019.