All due respect

Nathaniel Morris, MD, well remembers being humiliated by a supervisor during his first days of surgery training as a medical student on the East Coast. Morris was learning how to stitch closed an open wound. “The surgeon told me, ‘You suture like Helen Keller,’” says Morris, who is now a resident in psychiatry at Stanford. “Then he kind of laughed.”

Far from a hidden problem, the reality is that students are routinely humiliated, belittled and harassed by supervisors while in medical school, according to data collected annually by the American Association of Medical Colleges.

“It is something that most medical students experience at some point,” Morris says.

Doctors will tell you it’s a tradition perpetuated by the profession’s hierarchical structure — attending physicians above residents above interns. And medical students, who are at the bottom, often face social pressure to “appear strong” and just deal with mistreatment. Though the humiliation is decried, it continues.

“Once the learners become the teachers, the cycle of mistreatment often repeats with residents and physicians treating students as they were treated,” wrote a group of Stanford educators in an article published in Academic Psychiatry last spring.

In 2009, notes the article, the dean of Stanford’s medical school saw that the rate of mistreatment reported by Stanford’s graduating medical students had increased above the national average, leading him to heighten efforts to break the cycle. New programs included receiving monthly feedback from students about problems, and educating students on ways to report problems without fear of reprisal.

“When we started this mistreatment initiative in 2010 it was a program ahead of what other medical schools were doing,” says Rebecca Smith-Coggins, MD, lead author of the paper and associate dean for medical student life advising. “We wanted other schools to have an example of a program to help develop their own.”

The authors report that the program is making progress, citing data collected from the AAMC medical school graduation questionnaire.

The study reports that by 2014, students were half as likely to cite fear of reprisal as the reason they failed to report an episode of mistreatment.

In addition, from 2012 to 2014, smaller percentages of students reported experiencing mistreatment, according to the study. In 2012, 55 percent of the 63 students who responded reported experiencing mistreatment; in 2013, the figure dropped to 52 percent of the 64 students who responded; and in 2014, it dropped again to 34 percent of the 48 students who responded, Smith-Coggins says.

“It’s been our goal to help our educators find respectful ways to teach, and to help our students understand the culture of medicine, and to make sure issues are addressed without fear of reprisal for the student,” says Smith-Coggins.

Additional efforts include a policy for addressing claims of mistreatment that includes disciplinary action if necessary, and a series of educational videos depicting behavior that students may interpret as mistreatment.

Since the study was published, representatives from about a dozen medical schools have asked Smith-Coggins for advice on how to set up similar programs, she says.

“We are focusing on this so intently in medical school so our future residents and attending physicians will change,” Smith-Coggins says. “Culture change is such a difficult beast. But that’s the hope.”