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Rapid Responses: Rapid Responses published:
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"Near peers" are different in clinical environment
- Vijay Rajput, Angela Dawn Frates, Huma Q Rana (19 September 2006)
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A dead horse, turned on its head
- Elliot B Tapper (20 September 2006)
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Family Medicine and Harassment
- David V Power (30 September 2006)
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What is being measured?
- Roger A Fisken (30 September 2006)
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Belittlement of medical students is a known problem, but still no solution.
- Jackie Y. W. Cheng (1 October 2006)
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Beware censoring our best teachers.
- David McKean (2 October 2006)
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Harassment and Belittlement: A Source of Medical Education
- Golnar Aref-Adib (4 October 2006)
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Belittlement and Harassment in US Medical Schools
- Heidi Lempp (9 October 2006)
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Medical student's belittlement
- Pralhad .S Patki (22 November 2006)
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Vijay Rajput, Associate Professor of Medicine UMDNJ- Robert Wood Johnson Medical School, Camden, NJ 08103, Angela Dawn Frates, Huma Q Rana
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In the first two preclinical years, you don't have a real supervisor or “near peers” to ridicule you in the day-to-day clinical environment. You're lucky if you have meaningful social interaction with faculty. In a clinical environment that is new to you have "near peers" and clinical faculty members supervising you and your near peers. In any successful workplace, the key is creating a culture that fosters team play and not moving up the ranks. Medicine fosters the latter culture starting with internship. It has traditionally been seen very much as hazing experience most of it by “ near peers”. 28% were belittled by residents and 32% by attending physicians initially while later in their training 71% were belittled by residents vs. 63% by attending physicians. We think it points to a problem with training of residents and perhaps their own concern with maintaining a structural hierarchy/insecurity. Study does not tell us which year of training has more Mental Illness/Breakdowns. If the majority occurs within the first two years, then the triggers would be very different from triggers that would cause breakdowns in the clinical years. One could blame the hospital culture/belittling by near peers. Traditionally many of this experiences are seen as enduring harsh hazing to gain acceptance in a fraternity, so the more likely you are to value your membership and minimize hardships on the way. Competing interests: None declared |
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Elliot B Tapper, Medical Student Emory Medical School, 30306
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When I read of this study's results in the popular press, I was worried. Turns out, I had every reason. The authors, despite their self- professed awareness of the subject's stale state, did little to divert their study from the tiresome methodological traps that consumed their predecessors. Three important points will be made in this response. First, there are two layers of reductionism, endemic to all studies of this sort, that enfeeble the conclusions. Second, these studies, by their construction and by ignoring the key – but inconvenient – dimension of subjective perception, are designed to elicit the conclusion presented. Let’s be honest, harassment and belittlement are merely impotent linguistic representations of the multiplicity of truly complex experiences, each fundamentally connected to a specific context and each inextricably linked to the particularized internal state of the perceiver. Simply integrating that spectrum into two woefully inadequate words would make a reasonable person blush. But collapsing "some" and "severe" harassment into one category, that takes gumption. These two levels of thorough reductionism combined with opt-in questionnaires, simple as they are - popular as they are (1,2), do not a meaningful study make (other studies went the binary exposure v. non exposure route {4}). Some methodological innovation was not only necessary to have energized this tired inquiry, but crucial for any of their conclusions to be taken seriously. The conclusions, themselves creaky echoes from ghosts of studies past, were preordained by the dogma from which the study sprang and guaranteed by their statistical slight of hand. Though perhaps most disappointing, the most interesting questions laid sadly fallow. Before we publish correlations, claiming significant link between experiences and emotional consequences, we ought to make a strong case for the mover in that relationship lest our musings languish in purgatorial dubiousness. Yet our authors have neglected to even consider that, beyond the possibility of being the figment of overzealous categorizing, what is identified as harassment or belittling may very well be the fault not of a crusty, old Doctor, but instead an oversensitive ego. Noting in passing but leaving undeveloped that there are significant differences between specialties is to ignore the interesting, and not overplayed possibility that, turning this dead horse (e.g.: 3) on its head, the disposition of the perceiver, evident in his particular choice of profession as it is in his characterization of treatment within asymmetric power dynamics, is an obligate first step in framing these results. Elliot B Tapper etapper@emory.edu 1 -Nagata-Kobayashi, Shizuko. Sekimoto, Miho. Koyama, Hiroshi. Yamamoto, Wari. Goto, Eiji. Fukushima, Osamu. Ino, Teruo. Shimada, Tomoe. Shimbo, Takuro. Asai, Atsushi. Koizumi, Shunzo. Fukui, Tsuguya. Medical student abuse during clinical clerkships in Japan. Journal of General Internal Medicine. 21(3):212-8, 2006 Mar. 2 - Wilkinson, Tim J. Gill, Denzil J. Fitzjohn, Julie. Palmer, Claire L. Mulder, Roger T. The impact on students of adverse experiences during medical school. Medical Teacher. 28(2):129-35, 2006 Mar. 3- Stratton, Terry D. PhD; McLaughlin, Margaret A. MD; Witte, Florence M. MA; Fosson, Sue E. MA; Nora, Lois Margaret MD, JD. Does Students' Exposure to Gender Discrimination and Sexual Harassment in Medical School Affect Specialty Choice and Residency Program Selection? Academic Medicine.Volume 80(4), April 2005, pp 400-408 4- Nora, Lois Margaret MD, JD; McLaughlin, Margaret A. MD; Fosson, Sue E. MA; Stratton, Terry D. PhD; Murphy-Spencer, Amy EdS; Fincher, Ruth- Marie E. MD; German, Deborah C. MD; Seiden, David PhD; Witzke, Donald B. PhD. Gender Discrimination and Sexual Harassment in Medical Education: Perspectives Gained by a 14-school Study. Academic Medicine. Volume 77(12, Part 1), December 2002, p 1226–1234 Competing interests: None declared |
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David V Power, Course Director, Primary Care Clerkship University of Minnesota Medical School
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That students embarking on careers in Family Medicine noted higher levels of harassment and belittlement may, as the authors note, be because such students are more attuned to issues of mistreatment or because Family Medicine has changed from being one of the least abusive of specialties. I'm confident that Family Physicians have not become less humane and more abusive. Instead what I not uncommonly hear from students choosing Family Medicine is that some other specialists belittle such a choice with comments like 'you're too smart to choose Family Medicine': the specialty choice is what provokes the belittlement. Competing interests: None declared |
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Roger A Fisken, Consultant physician Friarage Hospital, Northallerton, DL6 1JG
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I have read the methods section of this paper several times but I have failed to find any information about the questionnaires. What were these questionnaires? How were they validated? Were they measuring unfair and hostile treatment (labelled as harrassment or bellittlement) or only some aspect of the subject's preception of his/her treatment? Most importantly of all, what were the reviewers and the editor doing in passing this article for publication without asking these questions? Competing interests: None declared |
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Jackie Y. W. Cheng, Postgraduate research student MBBS, MRes University of Hong Kong
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Suicide and related behaviours (completed suicide once every few years) are problems in our medical school but seldom talked about. Suicide is also extremely common among mainland Chinese students (often said to be due to stress of studies). The study by Frank et al. is yet another replication study that tells us belittlement of medical students is a prevalent problem, and the authors attempted to analyse associations with gender, ethnicity, chosen specialty, depression, stress, alcohol consumption, ˇ§glad being a doctorˇ¨, and whether the ˇ§faculty cared about studentsˇ¨. Causal inference is difficult for this and other similar studies, and reverse causality is possible (e.g. whether being cared by the faculty is a cause or an effect [recall bias and thought distortion] of belittlement cannot be determined). Furthermore confounding is a huge problem since factors such as gender, racial, and socioeconomic disadvantage may confound the relationship between belittlement and depression/stress/alcohol. Social networks, unspoken power gradients, and psychological aggression within the profession are also important factors but are difficult to quantify, and are seldom researched or reported. I was rather disappointed by this and other similar articles (Wong, 2006; Richman, 1992) since not only did they fail to point out the full scale of the problem, whether the investigators lacked the perspective (unlikely) or the results were not reported due to political reasons, they also failed to provide solutions to solve them. I was dismayed when I read that these academically excellent students who are selected through the toughest selection processes ended up facing more belittlement than other students. I also disapprove of medical students who remained silent despite being harassed or belittled. I have worked in peer support groups for medical students, but I was appalled at the low participation rate (less than one call per month) despite huge publicity. My experience in these and other research projects tells me that many medical students are conditioned into silence and become receptive of belittlement and harassment (ˇ§nothing will change even if I complainedˇ¨). Much alike to other forms of abuses, medical students themselves sometimes become the cause for abuse since the perpetrators face no resistance or penalties. In the hierarchical system of clinical medicine, sadistic superiors may even praise students for remaining receptive to verbal and other types of abuses. Worse still, student may also face repercussions, directly or indirectly, for complaining about the perpetrator. In the worst scenario, the perpetrator of the worse abuses may be on the committee for ˇ§mental health and well-beingˇ¨ of medical students. Frank E, Carrera JS, Stratton T, Bickel J & Nora LM. Experiences of belittlement and harassment and their correlates among medical students in the United States: longitudinal survey. BMJ 2006; 333: 682 Richman JA, Flaherty JA, Rospenda KM, Christensen ML. Mental health consequences and correlates of reported medical student abuse. JAMA 1992; 267(5):692-4. Wong JG, Cheung EP, Chan KK, Ma KK, Tang SW. Web-based survey of depression, anxiety and stress in first-year tertiary education students in Hong Kong. Aust N Z J Psychiatry 2006 ;40(9):777-82. Competing interests: None declared |
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David McKean, Clinical Medical Student UK
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While no one would deny that severe bullying and harassment can have a negative effect on medical students, I cannot help but wonder where one draws the line between abrasive, if effective, teaching methods and outright bullying and whether the behaviour of my own consultants would constitute such objectionable behaviour? My fear being that concerns about such issues could be used to force the more intimidating, yet extremely effective, teachers into diluting their methods. For example, recently my Neurology consultant mimed shooting me in the head, in front of a patient I had clerked, for neglecting to perform Romberg’s Test (in my defence the patient had been in a wheelchair and the result was predictable from the diagnosis). The same consultant could be heard, on another ward round, asking a patient if I had been quite so tongue tied when we had spoken earlier, while discussing the potential benefits of sending me to some of boot camp! Worse still is the cold stare one recieves on delivering anything other than a perfectly recalled history (without notes, of course, as "you youngsters do have your memories"!) Should anyone feel the urge to leap to my defence I should say that while these and many other similar encounters undoubtedly made me feel rather a fool, I would consider them neither bullying nor harassment. Firstly because I have a robust sense of humour, but also because I realise that the consultant's only desire is to make me a better student, a goal I believed he achieved. Whether he might enjoy making students squirm a little is an entirely secondary, albeit psychologically intriguing, consideration. While few who have been taught by this consultant escape a pointed comment or wry smile, none would deny the quality of the teaching given, nor the motivational affect such encounters have. And so, while I wholeheartedly agree that action should be taken in genuine cases of bullying, I would urge against any overly enthusiastic action over the issue lest you censor the best, if the most intimidating, teachers medical students have the good fortune to meet. Competing interests: None declared |
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Golnar Aref-Adib, Medical Student University of Nottingham Medical School, Queen's Medical Centre, NG7 2UH
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EDITOR- From the moment a medical student wanders out of the cosy lecture theatre and is unleashed into the hospital the habitual embarrassment begins. Where we would be without the terrifying words “Student doctors? Don’t all look down, why don’t YOU report the xray?” or “Surgical sieve? Ring any bells?!” In reality the constant questioning does feel like harassment because that is what it is. Through this Socratic method of teaching, they are wearing us down, exhausting us until our thoughts are clarified and any faulty reasoning is exposed.(1) This enforces us to think systematically and act practically like ‘real’ doctors. Getting it wrong can make you feel belittled, but that is common place in life. My friends belittle me when I get something wrong in a pub quiz. It is the exposure and loss of certainty that we equate with humiliation, though this can simply arise from feeling inadequate. Unfortunately, as stated by Frank et al (2) , there is a minority of malicious doctors who use it as a forum to humiliate, upset and even torment medical students. While there is no place for bullying in the NHS, my overriding concern is that current bad press could censor current Socratic teaching methods and prevent invaluable education on the ward and in clinics. For how much would we learn and read round if we didn’t have that old -fashioned doctor on that terrifying ward round. It is a strange truth but you will never forget that elusive answer, you were desperately searching for in front of your consultant, the SPR, the registrar, the SHO and the F1. Like all things in medicine, there are a spectrum of teachers, however this dynamic, interactive teaching method can be very effective when done well. So to the depressed and belittled medical student, bear in mind: what doesn’t kill you may just stop you from killing the patient. 1 Socratic teaching. www.cutsinger.net/socratic.html. University of North Carolina. James Cutsinger’s Department of Religious Studies. 2 Frank E, Carrera JS, Stratton T, Bickel J & Nora LM. Experiences of belittlement and harassment and their correlates among medical students in the United States: longitudinal survey. BMJ 2006; 333: 682 Competing interests: None declared |
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Heidi Lempp, Senior Qulaitative Researcher King's College London, Rheumatology Department, SE5 9PJ
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Editor – this is a welcome paper and the first longitudinal and prospective survey from the US that further contributes to uncomfortable findings for the medical profession (1). It remains curious why so little has been reported from UK medical schools about this wide spread practice of belittlement and harassment. Our qualitative study (2) has provided broadly similar and more subtle findings in relation to the perpetrators and its cumulative emotional impact of bullying on students. There is now a trend to view such mistreatment of medical students not as incidents against individuals (3;4), but as a symptom of a wider systemic, institutional ‘closed’ culture. This I think is missing from the discussion of this important paper(1). At the heart of such public humiliation are psychological, educational and structural causes and expectations which appear deeply embedded in medical schools. If the medical profession wants to remove this curious contradiction of aiming on the one hand to educate ethically and clinically competent doctors ‘fit for practice’ and at the same time continues to tolerate disrespectful and unprofessional attention towards their future doctors by some colleagues, this requires firstly acknowledgement, personal accountability and redress to enhance rather than undermine the well being of doctors and ultimately patients. Reference List (1) Frank E, Carrera J, Stratton T, Bickel, J, Nora L. Experiences of belittlement and harassment and their correlates among medical students in the United States: longitudinal survey. BMJ 2006;333:682-7. (2) Lempp H, Seale C. The hidden curriculum in undergraduate medical education: qualitative study of medical students' perceptions of teaching. BMJ 2004;329:770-3. (3) Houghton A. Bullying in medicine. British Medical Journal Careers 2003;12 (April):s125-s126. (4) Hafferty F. Beyond curriculum reform: confronting medicine's hidden curriculum. Academic Medicine 1998;73(4):403-7. Competing interests: None declared |
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Pralhad .S Patki, Retired Professor B J Medical college.Pune-1, India
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I definitely agree with the findings of Erica Frank et al's observation that medical students feel that they are subjected to belittlement and harassment during their study period. In India, one can find similar situation, may be of a higher nature. This some times leads to higher incidence of depression and suicidal tendencies. Ragging is a professional malady in medical colleges especially in India, this further ad up to medical student’s problem. Professors and residents say things that make students feel not worthy, it is the reigning culture . Faculty to interact with students in an ethically appropriate and sensitive way .Student counseling, if done sincerely may reduce the complications of these problems. Medical teachers need to take special interest in lessening these problems in their medical institutes. Competing interests: None declared |
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