It’s a routine day at the hospital. A patient arrives with a suspicious leg swelling. A medical student on duty says the likely cause is a deep venous thrombosis. The attending — eyebrows raised — asks the student why they think this.
The student stammers, explaining that, in addition to taking birth control pills, the patient recently had a long plane flight. “She denied ever having taken any medication,” the attending fires back. “Did you bother to talk to her? Do they teach you how to take medical histories in school or is that not part of the curriculum?”
Now comes the real question: Is this med student mistreatment?
A new study published in Academic Medicine may have an answer. Lead author Kevin O’Brien, MD, and colleagues presented video-recorded scenarios similar to the one above to residents and attendings from various specialties, including surgery, obstetrics and gynecology (OB-GYN), family medicine, and internal medicine. “What we found is that we [doctors] don’t think the same,” says O’Brien, an internal medicine professor at the University of South Florida (USF) Morsani College of Medicine.
When O’Brien’s team asked specialists to share their reactions, they found that surgeons were less likely to perceive student mistreatment in some scenarios than internists or family medicine doctors. OB-GYNs and a few other specialists, such as neurologists and anesthesiologists, saw less mistreatment than internists in scenarios where doctors gave aggressive feedback.
“There were statistically significant differences across the groups and how they rated the severity of those vignettes,” says O’Brien. He speculates that these divides emerge over time due to distinct expectations within each discipline. “Because of the culture they work in, it changes them. They don’t think the same way anymore.”
The new study suggests that in some specialties, ingrained norms permit behaviors that hurt students, says Kate Tulenko, MD, a practicing pediatrician and the founder of Corvus Health. “Researching student mistreatment is important,” she says. “The better we can understand it, the better we can address it.”
O’Brien’s academic work has focused on mistreatment for more than a decade. In the 2000s, he and other researchers wrote and videotaped five different 4- to 6-minute skits, each showing an incident that could be interpreted as student mistreatment. When they surveyed students, nurses, attending physician, and residents in internal medicine to gauge their thoughts, they identified major differences in how the groups responded to the videos. That prompted O’Brien to consider doing another study of a larger cross-section of the medical community.
“I said, ‘Hey, we should really look at all the other specialties, because I’m not convinced everybody thinks about it the same way,’ ” he recalls.
While he set about planning his larger study, O’Brien incorporated the five videos into his teaching approach at USF, showing them to third-year medical students. One of the videos featured what seemed to O’Brien like a clear-cut case of sexual harassment: A supervising resident calls a student after she’s turned him down for a date. He asks her, yet again, if she’d like to go out with him. “I-I don’t know,” the student falters.
“Aw, come on, you should go…. Could make a difference in how high you’re ranked if several of the residents put in a good word for you. Besides, I haven’t filled out your evaluation for last month’s rotation yet.” When the student balks at this apparent quid pro quo, the resident laughs the whole thing off.
After USF students viewed this video one year, O’Brien was taken aback when a fifth-year surgery resident stood up and said, point-blank, “That’s not harassment. He said he was joking.” The resident’s certainty surprised O’Brien. In his past surveys, 96% of doctors had perceived mistreatment in the video. The incident reminded O’Brien just how different specialists’ perceptions of harassment could be — and how important it was to study these differences.
To better understand variations in how doctors saw student mistreatment, O’Brien’s research team recruited 650 doctors from a wide swath of specialties, including family medicine, internal medicine, surgery, and OB-GYN.
All doctors in the study watched the five videos, each depicting an incident that could be construed as mistreatment. In addition to the aggressive questioning and sexual harassment videos, doctors watched a video in which a resident pressures a Vietnamese-speaking student to tell a Vietnamese patient that she has terminal cancer despite the student having had no prior involvement in the case. The doctors then indicated whether they thought each video depicted mistreatment and rated the severity of the mistreatment, if they saw any.
For the ethnic-insensitivity scenario, as well as the sexual harassment one, specialists were close to being on the same page. Most of them, no matter the field, believed that both videos showed significant student mistreatment. In more subtle scenarios, specialists’ opinions diverged, O’Brien says. In a “negative feedback” scenario in which an attending gives a student a dressing-down, OB-GYNs and surgeons were less likely to perceive mistreatment than family medicine doctors or internists.
Even when specialists agreed that mistreatment was taking place, their perceptions on the degree of mistreatment often varied. In the “aggressive questioning” scenario about the patient with a possible DVT, for example, surgeons and OB-GYNs rated the severity of student mistreatment lower than internists, pediatricians, and family medicine doctors did.
O’Brien thinks some of these differences are related to behavioral norms within each specialty. “The aggressive questioning, where you get asked a bunch of questions, and there’s a hierarchical nature of things — I think that’s more enculturated in surgery and OB-GYN.”
In other cases, he suspects generational divides may be at play, spurred by swift changes in societal norms. In the ethnic-insensitivity scenario, “when residents rated it compared to attendings, they rated it much more severely,” O‘Brien says.
Many of medicine’s aging cultural norms can have adverse long-term effects on students’ career decisions and their mental health, says Cynthia Ledford, MD, a senior associate dean for medical education at Northeast Ohio Medical University and a co-author of the Academic Medicine study. Studies of the effects of toxic stress show that even seemingly small incidents of mistreatment, or microaggressions, can take a cumulative toll on students.
“What the data does show is that the more episodes you experience, you internalize that,” O’Brien says. “You’re at higher risk for anxiety, depression, substance misuse, suicidality, and leaving medicine entirely.”
“It’s a Rite of Passage”
Residents and other doctors said they weren’t surprised at the results of the study — especially the finding that specialists in surgery-related fields, including OB-GYN, were often less sensitive to student mistreatment. “If you had made me guess which attendings would be less likely to find scenarios abusive, I would guess it would be the surgical specialties,” Tulenko says.
She and others suspect this finding partially stems from the unique demands of specialties that involve doing high-stakes procedures. Physicians in these disciplines often work more hours a week than family doctors or internists, and the work they do during those hours — whether performing C-sections or excising inflamed gallbladders — requires precise focus.
In settings like the operating room, where blunders can kill a patient, “learner feedback may be much more direct and perceived as aggressive by those not familiar with these settings,” says Marina Haque, MD, an anesthesiology resident at Detroit Medical Center. “There is a lot of pressure on physicians to perform in a certain way. Sometimes that means seniors may assert their presence in an unbecoming way or feel it necessary to put learners in their place.”
In addition, Tulenko says, some specialties may attract people who are more comfortable with aggressive communication and less attuned to its downsides, making them less likely to perceive mistreatment. “The difference of experience, expectation, and personality causes the difference in results.”
Student mistreatment is accepted or encouraged in some surgical programs, says Gregory Peck, DO, an assistant professor of surgery at Rutgers’ Robert Wood Johnson Medical School. “Without a doubt, my own personal experience in surgery [is] these kinds of actions are glorified. It’s a rite of passage, so to speak.” He’s seen surgeons get tripped up when they fail to adapt their communication style to mentoring situations.
“What you need in order to be successful in saving a life, for example, is good in one context,” he says — but that same blunt approach can backfire in conversations with students. “We don’t have a whole lot of guidance on being able to keep it under wraps and know the proper context.”
Peck thinks some programs have made real progress toward nurturing a healthy culture for students in surgery. But in other programs, he sees leaders failing to address persistent mistreatment. “Folks that are unhealthy — and drive unhealthy environments, cultures and behaviors — sort of stay in control. They’re continually able to manipulate those environments and those cultures.”
Both Peck and Haque, however, stress that student mistreatment is also a serious problem in nonsurgical disciplines. At Haque’s alma mater, faculty in internal and family medicine were known for treating students worse than mentors in surgery. “The tactics they used to bring students down and make them feel horrible about themselves were more subtle,” she says, “but most definitely felt.”
Part of the challenge in identifying student mistreatment — and getting doctors on the same page about what it looks like — is that many doctors see blunt statements and pointed questioning as essential in getting students up to speed. “[If] I have someone that’s got a gunshot wound to the chest,” Peck says, “everyone sort of understands aggressive communication, because someone’s bleeding to death in front of you.” However, he adds, program directors do not always communicate well with faculty about when such feedback crosses over into verbal browbeating.
Physician mentors must prepare students for the daily rigors of the job and approach them directly when they do something wrong. However, if senior physicians convey this feedback in a combative way, they need to adjust their approach to avoid causing undue harm, Tulenko says. “If the purpose of aggressive questioning is building emotional toughness, it would be better to teach people tools of emotional toughness rather than abusing them and hoping they learn the tools on their own.”
To shift doctors’ communication styles, it’s also important to shift the culture that surrounds those doctors, Ledford says. That starts with encouraging conversations within each discipline about which lines shouldn’t be crossed — and how to respond if other doctors start crossing them. At Ledford’s school, “we’re starting to develop the skills of stepping in, calling in, being able to have the conversations about what are the unintended impacts of people’s words or behaviors and how they’re being interpreted,” she says. “I think research like this is a way of getting us to those complicated conversations.”
O’Brien thinks having physicians watch videos about mistreatment scenarios as a group, with other members of the same specialty, can be a powerful tool to drive cultural change.
“What you don’t want is a talk where people say, ‘Oh, here’s the statistics of mistreatment. Here are the consequences of mistreatment,’ ” he says. “When you do sessions, and you show videos, people start telling stories about what happened to them as students. It’s getting buy-in from the culture that they all have skin in the game. That’s where I think you can change behaviors.”
Ultimately, O’Brien hopes that greater awareness of how other doctors view student mistreatment — as well as knowledge of how that mistreatment affects students’ careers — will motivate more program directors and attendings to rethink old cultural norms. The goal in all mentoring programs, Ledford says, should be “to get to a high level of psychological safety, so that you can comfortably speak up and say, ‘This isn‘t right.’ “
Elizabeth Svoboda is a science writer in San Jose, California. Her work has appeared in the Washington Post, Discover, and elsewhere. She is also the author of What Makes a Hero?: The Surprising Science of Selflessness.