COMMENTARY

Docs Furious at Student, Resident Concerns: How to React

Jillian Horton, MD

Disclosures

January 29, 2021

You know the pattern: A student or resident posts something about medical education on an internet site, shares feedback in writing at their institution, or publishes their thoughts about medical training in a letter sent to a journal. Shortly thereafter, a small posse of senior physicians pile on faster than a ventricle can fibrillate.

Just read the comment section of any article by a trainee that is in any way critical of medical education. You will be subjected to a deluge of angry responses by established doctors, ranting about everything from that trainee's presumed work ethic, character, suitability for medicine, lack of gratitude, and entitlement.

These reactions are as hurtful as they are bewildering. I know because I've experienced them too. In fact, I still experience them, even as a decidedly mid-career female leader. Although some of the upsetting responses are well intended but poorly articulated, others have complex and downright ugly origins. Some are linked to the darker aspects of medicine — things like systemic racism and misogyny. They come from intolerable, unacceptable aspects of our educational culture that desperately need renovating.

But what about vicious, hostile responses to student concerns about seemingly innocuous issues? Surely, raising questions or sharing ideas about medical education in general shouldn't provoke the animosity with which it is so often met. If you are a trainee who has been bewildered or disheartened after a seemingly disproportionate response by a senior doc to what you thought was an innocent question, here are some factors to consider.

Trainee Concerns Remind Docs of Personal Pain

Although our job is to care for others, doctors often have a deficit of compassion when it comes to our own selves. Medical school emphasizes high achievement, and residency training subjects us to endless criticism and ruthless self-appraisal. Medical culture is only just now beginning to accept that personal struggles are not a marker of low resilience. Our frequent inability to find compassion for trainees is little more than an extension of our inability to have compassion for ourselves. The latter is a source of suffering for many senior physicians and an area where we often lack insight.

Suffering is complex, and we all handle it differently. Some of us respond in a future-oriented manner; we desperately want to make things better for future generations and are relieved to see them calling out medicine's deep-rooted problems. Others, however, get stuck looking backwards and never really leave the past behind. To resolve this dissonance, they retroactively come to view unnecessary hardships as helpful, framing them as character-building instead of as suffering or mistreatment.

If you've completed clinical rotations in psychiatry or pediatrics, you'll know that when a person experiences abuse, they sometimes cope by creating narratives that allow the abuse to appear rational or "corrective." These stories allow them to minimize their own powerlessness and reframe what happened to them as something that was done out of necessity to "help" or "shape" them. It requires significant self-awareness to consider a different truth than the one that many physicians have created about how the abuse and toxic culture they experienced made them the tough people they are today.

I have a big ask: I want you to try to find compassion for some of these faculty members and older colleagues. This is not to excuse aggressive, angry behaviors or rude, dismissive responses. To be abundantly clear, it is not your problem to look after their emotions. But it can help to remember that their reactions are actually not about you at all: They are about their pain; their emotional flaws; and an old, trusted survival mechanism. Knowing that fact can make it easier to tune them out, if that is what is warranted.

A colleague of mine recently commented that her favorite thing about working with learners is that they can help her see both the good and the bad about medical culture with fresh eyes. This culture is inspiring, but it is also toxic. Two things can be true at once. It is appropriate to be inspired by our community and its wells of deep compassion while simultaneously wondering how some senior guardians can react so harshly. But how did those guardians get that way in the first place? They are products of their environment, and they have suffered in order to survive in medicine, just like me and you. Simply put, we can't ask other people to see our humanity without trying to see theirs as well.

If only we all had more humility and compassion — and if only we all paused to reflect before putting pen to paper or typing our remarks into the comment box. That's the culture I aspire to, the one I believe we're slowly working toward. Maybe those old guards are not capable of it. But you know what? It can start with us.

Not Everything Is a 10

A few years ago, I collaborated with a talented graphic artist on a comic book about medicine. It was a really important project for both of us, and we each had strong ideas and convictions about the best way to tell the story. I could sense that our similar personalities would cause us to dig in, in order to try to get what we wanted whenever we disagreed.

I suggested a system. Each time our opinions differed, we had to assign a number from 1 to 10 that represented how important this particular issue felt to us. This quickly became a way for us to disentangle whether we were locked in a power struggle or whether we truly cared about the point we were arguing. If an issue was an 8 for my collaborator but a 6 for me, his wish prevailed. If we both ranked something as a 9 or 10, we had to take time to figure out our direction. Of note, we almost never chose the same number.

Ever since that collaboration, I have used this technique to settle disputes with my spouse, to run successful meetings with my colleagues, and to discern how important something actually is to my children. Among the most important teaching points is this: Not everything can be a 10.

This principle has influenced my writing about medicine. It should influence yours, too. When you present an issue or concern as a trainee, you should be sure that you actually believe that it merits the passion and conviction with which you're arguing. Sometimes, the pieces that evoke an "In my day..." response from senior doctors are about an issue that is really a 5 but is written in a tone more suitable to a 10.

For the record, some issues are always worthy of a 10: trainee suicide, abuse, and racism, for example. But something like too little elective time might be a 4. Work to find an accurate score. Just remember that if you treat everything as if it's a 10, then no matter what you say, the amount of attention you'll eventually command is a 0. The criticism of your opinion as superficial will be warranted. The better you get at assigning a value to your own concerns, the easier it will be to ignore dismissive comments because you'll be certain that your level of urgency was right for the moment.

Maybe You're Wrong?

Unprofessional attacks or verbal assaults based on personal attributes are never okay. But when it comes to educational issues that may seem painfully obvious to you — someone who has yet to truly start your career — it can be beneficial to remember that you may not yet have all the context you need to come up with a fully formed opinion. Again, that doesn't mean that you have to accept someone rudely dismissing your thoughts or expressing themselves in an overly aggressive fashion. It just means that things you are absolutely certain about may not be as simple as you think.

I did my undergraduate training at McMaster University in Canada, a school renowned for pioneering both problem-based learning and evidence-based medicine. My classmates came from widely varying backgrounds. Some were science majors, while others were journalists, ornithologists, musicians, and English scholars. My peers tended to be a little older than the "usual" medical undergraduate. With that age came a high level of self-confidence.

Along with its focus on problem-based learning, McMaster had a history of not awarding grades or administering tests. In fact, the only "test" was a thrice-yearly tool called the Personal Progress Index (PPI), which had no connection to our transcripts. "Grades" were a red, yellow, or green light. This simply told you whether you were keeping up with your peers or falling behind, a system that allowed the faculty to identify and support students who were at risk. It was also meant to teach learners to divine the quality of their work without having to rely on external assessments.

Early on in my first term, a group of my classmates publicly challenged the faculty for administering the PPI. They argued that because it was technically a "test," it shouldn't be allowed at a test-free school. Their challenge took on the quality of an uprising, leading to tension between faculty and students. In the end, the faculty prevailed. The PPI remains a useful tool to identify who might be struggling.

During my years as an associate dean, I would frequently welcome medical learners in my office. They would give me passionate lectures about why a particular test, activity, or clinical rotation should be abandoned. I often found myself thinking of the PPI. My medical school peers had been so sure that they knew more than the faculty about educational methodology. The truth is, they didn't. In fact, their belief that they did was totally misguided.

So, what's the lesson? Accept that there are some aspects of medical education that you really don't have the expertise to appraise. Remind yourself that 2 weeks or 2 months, or even 2 years, of being part of a profession isn't the same as 10, 20, or 30 years, and recognize that, in a decade, you'll be the one itching to remind your students that your experience counts for something. A dose of humility rarely has any negative side effects.

And if none of the above works, then you may need to simply block some voices out. Last year, I wrote a very personal piece about medical culture for a national newspaper. The piece made me feel vulnerable. I knew that there would be a pile-on. A colleague saw the piece and texted me a supportive message. I texted him back, "Some of the online comments are pretty horrible." He replied with a familiar adage: "Never read the comments!"

Your ego thirsts for words of praise, but a handful of trolls can make you doubt what you wrote straight from the heart. Don't let them get that close. So how will I know whether you enjoyed this article if I don't read the comments? It's the funniest thing, but I have a system. When I'm on the right track, I can practically see a green light.

Jillian Horton, MD, is associate head of the Department of Internal Medicine, director of the Alan Klass Program in Health and Humanities, and a former associate dean of undergraduate student affairs at the University of Manitoba in Winnipeg, Canada. She is the recipient of the 2020 Gold Humanism Award from the Gold Foundation Canada and the Association of Faculties of Medicine Canada. Her memoir about medicine and medical education will be released by Harper Collins Canada in February.

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