Medical student mistreatment

Although students are reporting fewer incidents of abuse by faculty members, residents and nurses, experts believe ongoing mistreatment affects the learning environment.

By Jay Greene, amednews staff. Feb. 14, 2000.

Mistreatment of medical students appears to have declined during the past six years, according to surveys of fourth-year students by the Assn. of American Medical Colleges.

But medical education experts believe statistics are misleading and that students continue to be subject to unacceptable levels of public belittlement, humiliation, and physical and sexual abuse, and have been denied opportunities for advancement because of gender or ethnicity.

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"If you think abuse is gone, it is not," said Harry Jonas, MD, co-secretary of the Liaison Committee on Medical Education. LCME accredits the nation's 125 medical schools.

In a survey of 12,734 seniors conducted last year, the AAMC found that 26.7% had been occasionally belittled or humiliated compared with 28.1% in 1998. Slightly more than half, 51.1%, said they had never been subject to such abuse during their four years compared with 48.1% in 1998 and 61.7% in 1996.

As in past surveys, women and minority students recorded more incidents of sexual, physical and mental abuse than white men, the AAMC survey found.

"The abuse of students is ingrained in medical education and has shown little amelioration despite numerous publications and righteous declarations by the academic community over the past decade," wrote Donald G. Kassebaum, MD, vice president in the AAMC's division of medical school standards and assessment, in the November 1998 issue of Academic Medicine.

Undertrained in practice management

Other findings in the 1999 "Medical School Graduation Survey" indicate that students were generally satisfied with the quality of their medical school experience. Only 6.7% reported being dissatisfied in 1999 compared with 7.1% in 1998.

Students overwhelmingly rated as appropriate the time spent on diagnosis of disease (92%), patient interviewing skills (89%), care of hospitalized patients (88%), communication skills (87%), teamwork with other health professionals (84%), physician-patient relations (84%), primary care (77%) and care of ambulatory patients (76%).

But students rated as inadequate the time spent on nutrition (64%), alternative medicine (63%), pain management (62%), geriatrics (44%) and clinical pharmacology (28%).

More than half the students also gave inadequate ratings to a whole list of medical-economic topics, including practice management (72%), managed care (60%), medical care cost control (57%), quality assurance (57%), law and medicine (55%) and medical record-keeping (52%).

"When half the students say time spent on a topic is inadequate, that should raise a red flag for all schools that these are topics that need to be addressed," said Michael Whitcomb, MD, AAMC's senior vice president of medical education.

On the issue of medical student abuse, however, Dr. Whitcomb said schools are doing a better job at combating a long-term problem that reaches into teaching hospitals and ambulatory clerkships.

"Abuse used to be very common," Dr. Whitcomb said. "It is less so now, but it is something we need to monitor very closely and not take lightly. It affects the educational quality of our students' learning experiences and can lead to a cycle of abuse."

Residents more abusive than faculty

To address abuse at the institutional level, the LCME approved new rules last year intended to ensure that schools develop written procedures that encourage students to report instances of abuse without fear of retribution.

In addition, schools must state how complaints will be handled in a timely manner and develop methods to prevent student mistreatment.

"Now we have a specific standard we can use when we visit schools," Dr. Jonas said. "If they don't have a policy, we can ask them to develop one."

Dr. Jonas said one violation would not be enough to place a school on probation or withdraw accreditation. He said schools had been warned about failing to implement abuse-reporting mechanisms but that none had been sanctioned or put on probation.

"There need to be violations in a number of standards before we invoke probation," Dr. Jonas said. "At one school there were three suicides in 18 months. First-year residents don't understand how to handle depression in students. We saw a problem and asked the school to beef up student support services."

Because residents interact more often with students at the hospital than do faculty, Dr. Jonas said programs also need to address student abuse by residents.

The survey found residents accounted for more instances of abuse than did clinical faculty or nurses. Some 37% of students said residents and interns had mistreated them in 1999 compared with 33.5% who said so in 1998. Clinical faculty accounted for 33% of instances of student abuse in 1999 compared with 32% in 1998. Nurses accounted for 26% of complaints in 1999 compared with 20% in 1998.

"Some schools with problems do not have a mechanism in place for reporting abuse," said Samir Mehta, a student representative on the AMA's Council on Medical Education. "On the other hand, some students take advantage of the issue and report reprimands as a form of abuse. Perception is a part of it."

But statistics on abuse downplay the actual numbers of incidents, because most students fear repercussions if they speak out, according to Mehta, a senior at Temple University School of Medicine, Philadelphia.

"Students just tolerate a certain level of abuse, especially in the clinical setting," said Jason Schneider, an LCME student representative and a senior at New York University School of Medicine, New York City.

"LCME's new standard and an AAMC poster project that showed vignettes of incidents of student abuse are making students more aware that the behavior is not being tolerated," he said.

Fear of retribution still an obstacle

Efforts by the AAMC and the American Medical Association over the past 10 years to shed light on the problem have reduced instances of abuse, Dr. Jonas said. But data showing declines must be taken with a grain of salt, he added.

"When I go to medical schools and ask students about abuse, they are reluctant to talk about it much," Dr. Jonas said. "I ask them how many have been subject to sexual or verbal abuse or harassment. Most students sit there and don't say anything. I find that puzzling, and that tells me it still goes on, that students are worried about retribution."

Gender discrimination also is an issue at some residency programs, Dr. Jonas said.

The AAMC survey found an increase in gender, racial and sexual orientation discrimination in 1999. For example, 2.4% of students said they occasionally received lower evaluations or grades solely because of their race or ethnicity in 1999 compared with 1.9% in 1999.

"We talk with women who have interviewed for residencies in orthopedic surgery. They tell us that doctors interviewing them flatly say they don't take women," Dr. Jonas said.

Medical schools routinely use the results of AAMC's student and faculty surveys in annual planning to make changes, Dr. Whitcomb said.

LCME also reviews individual school reports and narrative summaries from students in accreditation reviews, Dr. Jonas said.

"The surveys are just another source of information we can tap into to make judgments on problems that need to be corrected," he said. "Usually the reports are not of great surprise to deans. They get the same complaints until they solve the problem."

At the University of Washington School of Medicine in Seattle, D. Daniel Hunt, MD, a psychiatrist and associate dean for academic affairs, said surveys like AAMC's have helped the school stay on the cutting edge compared with other schools.

"There is no other way we can see how we or other schools are doing," Dr. Hunt said. "We sometimes find areas of concern we were not aware of. Some things we beat ourselves on the head about for no reason."

For example, Washington put much effort into improving computer information education, he said.

"When we compare ourselves with other schools, we are doing significantly better. Everybody is having problems," Dr. Hunt said. "It puts it in perspective."

Another ongoing issue has been how much to teach clinical pharmacology at the medical school level, he said. Nationally, 28% of students feel clinical pharmacology is inadequately taught.

"How do we move from teaching basic molecular biology, in which students need a foundation, to the actual side effects a drug has on a patient?" Dr. Hunt asked. "We are looking into that issue now. It may be best taught at the residency level."

What to teach at medical schools is an age-old problem, Dr. Jonas said.

"Students always complain about the curriculum," he said. "Curricula are in a constant state of flux at schools.

"There just is not enough time to cover every topic satisfactorily."