• Cause and Affect – ctd.

    I’ve written previously about how I feel like residency can often dampen empathy. But that’s after graduation. Medical school is no picnic either. I remember that we used to joke that if someone didn’t make you cry on your surgery rotation, then you must be doing something wrong.

    As I get older, that seems less and less funny. Then I saw this. “Medical students still suffer mistreatment by faculty, resident doctors, and nurses, US report says“:

    More than half of medical students reported some mistreatment during their third year, when they began clinical clerkships and to work with residents, attending physicians, medical school faculty, nurses, and patients, and family members, found the study, published in Academic Medicine, the journal of the Association of American Medical Colleges.

    Categories of mistreatment included physical, verbal, and sexual harassment and ethnic and power abuse problems, which were categorized as mild, moderate, and severe.

    This piece reports on efforts at the David Geffen School of Medicine of the University of California, Los Angeles to curb mistreatment:
    The study reviewed medical students’ reports of mistreatment during four periods: 1996-8 (before the implementation of interventions); 1999-2000 (the two years immediately after reporting initiatives were introduced); 2001-5 (during which the school’s gender and power abuse committee established a formal reporting and investigation system); and 2006-8 (the period after the California legislature required all state employed supervisors, including university faculty and staff, to complete a two hour online sexual harassment training course every two years and during which the medical school introduced a session on mistreatment for students).
    The surveys had a response rate of more than 90%, which is just insanely high. Here’s the depressing bit: More than half of medical students reported mistreatment. Most of it was verbal or power related, but 5% was physical. That’s horrifying. Women were more likely to be mistreated than men. Few students reported it or looked for assistance.

    The levels and types of mistreatment didn’t change in any of the study periods. In other words, the efforts to make things better didn’t seem to work.

    According to the story, when the doctors were notified of these results, they were shocked. I don’t know why. I remember medical school. I saw some terrible behavior then, and I still hear about some now.

    People wonder why doctors can sometimes seem uncaring or disconnected. They sometimes blame it on the constant exposure to pain or suffering. But I think we, as a profession, are somewhat to blame for fostering an atmosphere we would find repugnant in any other setting. I’ve written about it before. Perhaps it’s time we remember that our trainees are people too, and just as worthy of respect and empathy as patients.



    • Is this unique to medical profession or all human behavior? Any ideas about law clerks, paralegals? Same question can be asked of financial world and young investment bankers or traders as well?

    • I think there is a cultural ideal of harsh behavior in medicine such that mistreatment is an important proof of personal ability and support for quality in others. Abuse — the grand rant, at any rate, with histrionic gestures and foul language — is seen as a way to call someone out, to assert the ethic of personal responsibility that is in some sense at the core of these professions. The abuser can imagine that he or she is doing the abused a favor; the abused has earned the abuse by some flicker or more of indifference. There is almost an obligation to abuse. It is part of a pre-IOM notion of quality. I abuse because I’m good and I want you to be good … or gone. It’s very destructive.

    • This may be a good time to introduce the sociological concept of dominant professions: professions where there’s a significant amount of social respect, they typically self-regulate to a large extent, and they typically supervise others rather than get supervised. Physicians are obviously one, and other examples are airline pilots, the military, the clergy, lawyers and judges.

      Of course, done the wrong way, professional dominance can also lead to bastions of unaccountability and abusive behavior.

      Nobody’s perfect, but if physicians are interested in combating abusive culture, they might want to see what the pilots are doing. My understanding is that the culture is a lot more collegial. Atul Gawande’s already proposed a checklist manifesto, based on what pilots do … maybe physicians could take some pages from the culture as well.

      And it’s worth asking if physicians should be more willing to submit to external authority. Balance of powers and all that. Maybe hospitals should be more aggressive about revoking admission privileges for physicians who act abusively, or cover up an error, or something. It’s worth asking if dominant professions need to be taken down a notch.

      • How close is this professional dominance to the position of Catholic priests and Boy Scout troop leaders? I’m not implying that doctors are guilty of child molestation however I wonder if the same sociological phenomenon is happening, to different degrees in these various settings with significant power differentials.

        This discussion makes me glad that I got an MPH. In my experience my teachers, classmates, and now my colleagues have all been nice. We work together and support each other. Of course public health, with the possible exception of hotshot epidemiologists investigating emerging diseases, has a culture of collaboration since we all recognize one can’t influence population health all by oneself.

    • It is common in the nursing profession too. The common experssion in nursing is, “nurses eat their young.”