Medical students who are female, members of racial/ethnic minorities, and/or nonheterosexual report experiencing more mistreatment than do their white, male, heterosexual counterparts, according to a study published online today in JAMA Internal Medicine
"Based on our study results, we feel that schools have prioritized recruitment over the climate of equity and inclusion," said lead author Katherine A. Hill, BA, BS, of Yale School of Medicine in New Haven, Connecticut.
Mistreatment is often seen as "a rite of passage that hardens and makes you a stronger doctor," said Alexa Mieses, MD, MPH, from the Department of Community and Family Medicine at Duke University, Durham, North Carolina, who was not involved in the study.
She noted that mistreatment comes in a variety of forms. It is "not always overt discrimination or physical, verbal, or sexual abuse. Sometimes it is choosing a student to do something because of a physical characteristic, or making someone who answers a question incorrectly carry a bucket of surgical supplies," she told Medscape Medical News.
Microaggression, which consists of indignities that might appear minor to others, is part of the picture too. For example, Mieses recalls an attending who made eye contact with her two male, Asian classmates but not with her, a woman of color. She didn't tell anyone because she feared they'd say she was imagining the slight.
Jillian Horton, MD, former associate dean at the University of Manitoba, Winnipeg, Canada, has had similar experiences. "Because the culture is so historically hierarchical, people often cite a fear of repercussions for speaking out, and those concerns range all the way from perceived to very, very real," she said.
Sexually suggestive comments, unwanted sexual attention, and persistent advances from higher-ups occur too. "Some of those things happened to me, and all of them happened to people I know, too many times to count," Horton said in an interview with Medscape Medical News.
Derision, such as being called an idiot in front of a patient, can have lasting effects, added Horton, who recently won a national award for humanism in medical education.
Meaningful Data From the AAMC-GQ
In the new study, Hill and colleagues explored a "spectrum of abusive behaviors," a problem that has been well documented for more than 30 years.
"Researchers have found that women, racial/ethnic minorities, and sexual minorities face barriers in the medical field that include representation, compensation, career advancement, and discrimination," Hill told Medscape Medical News.
The researchers used the Association of American Medical Colleges Graduation Questionnaire (AAMC-GQ), which has been given to US medical students since 1991. The survey responses are analyzed annually in aggregate, but they have not previously been stratified by demographic groups. "We thought it was important to use a large, nationally representative sample to determine whether groups that are already marginalized in the medical field also face a higher burden of mistreatment than their peers," Hill explained.
The study assessed "negative behaviors" from faculty, nurses, interns, residents, other staff, and other students. Demographic factors that were considered were sex, race/ethnicity (white; Asian; underrepresented minority [URM] of American Indian, Alaskan, African American, Hispanic, Latino, Spanish, Native Hawaiian, or Pacific Islander; multiracial [for persons of two or more nonwhite designations]); and sexual orientation (heterosexual; lesbian, gay, or bisexual [LGB]).
The retrospective cohort study included 27,504 graduating students who filled out the survey in 2016 and 2017. The group accounted for 72.1% of all medical school graduates and comprised 13,351 (48.5%) women, 16,521 (60.1%) whites, 5641 (20.5%) Asians, 2433 (8.8%) URM, 2376 (8.6%) multiracial, and 1463 (5.3%) LGB.
The study tracked eight types of mistreatment: five general and three based on discrimination by gender, race/ethnicity, or sexual orientation.
The question that addressed general negative behaviors was, How frequently have you been…
threatened with physical harm?
subjected to unwanted sexual advances?
asked to exchange sexual favors for grades or other rewards?
The other measures parsed by gender, race/ethnicity, and sexual orientation were (1) denial of opportunities for training or other rewards, (2) sexist remarks or names, and (3) lower evaluations or grades that were not based on performance.
Overall, more than one third (35.4%) of students reported experiencing at least one type of mistreatment, most commonly public humiliation (21.1%). In addition, 18.5% of students reported discrimination based on gender, 8.8% reported discrimination related to race/ethnicity, and 2.3% reported discrimination based on sexual orientation.
When examined more closely, the findings revealed striking differences among already marginalized groups.
For example, 40.9% of female graduates reported experiencing at least one type of mistreatment, compared with 25.2% of men. These included public humiliation (22.9% vs 19.5%) and unwanted sexual advances (6.8% vs 1.3%).
Women also reported more gender-based discrimination (28.2% vs 9.4%), including denial of opportunities for training (6.7% vs 4.7%), sexist remarks (24.3% vs 3.4%), and lower evaluations (6.8% vs 4.6%). More women experienced two or more types of mistreatment (17.8% vs 7.0%).
A similar pattern was seen when analyzed by race/ethinicity: 24% of white students reported mistreatment; 31.9% of Asian graduates did so; 38.0% of URM graduates; and 32.9% of multiracial individuals. Only 4.9% of whites reported experiencing two or more types of mistreatment, compared with 10.7% of Asians, 16.3% of URM, and 11.3% of multiracial individuals.
For LGB respondents, 43.5% reported experiencing mistreatment, compared with 23.6% of their heterosexual peers; 27.1% of LGB graduates reported experiencing humiliation, vs 20.7% of heterosexual graduates; and 7.7% experienced unwanted sexual advances, vs 3.7%.
Further parsing amplified differences between LGB and heterosexual graduates: denial of opportunities for training (3.2% vs 0.3%), offensive remarks (21.8% vs 0.8%), and lower evaluations (4.0% vs 0.3%). For LGB students, 16.4% experienced two or more types of mistreatment, compared with 3.6% of heterosexual students.
Time for Action
"The findings by Hill et al are a harsh reminder of the need to improve the current learning climate in medical education," writes Anjali B. Thakkar, MD, MBA, from the University of California, San Francisco, and colleagues in an accompanying editorial. "The stakes are high: mistreatment contributes to high rates of depression and suicidality among medical students and has long-term consequences on career choices and career satisfaction. Ultimately, mistreatment perpetuates inequity and lack of diversity in medicine by discouraging certain groups."
To change the pattern, Thakkar and colleagues say attendings and residents should serve as "first responders" to handle microaggression; supervisors should not mistake a student's preoccupation or silence as disinterest or lack of knowledge, and schools should improve systems for confidential reporting of mistreatment.
Horton, who has written extensively on student treatment and care, is optimistic that the increasing diversity of medical school classes will help usher in a brighter future for medical students. "Diversity in groups has been shown to be good for performance," she said. "So I believe a time will come when we will reach a tipping point and those changes will create a lasting impact and improve the system."
Limitations of the study include poor recall, self-reporting, and underestimations because those who experienced the most egregious mistreatment may have left medical school or may not have completed the survey.
The researchers and commentators have disclosed no relevant financial relationships.
JAMA Intern Med. Published online February 24, 2020. Full text, Editorial
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Cite this: Medical Student Mistreatment Higher Among Women, Minorities - Medscape - Feb 24, 2020.