A Culture of Fear and Intimidation: Reforming Medical Education

Even as we set out to reform U.S. health care, we continue to train medical students as if they were going to work in the old, broken system. Today, everything about medical education needs to be re-thought, from how we select students for admission to med schools to what we teach them about how to provide safe, patient-centered care.

A shocking new report from the  Lucien Institute at the National Patient Safety Foundation reveals how today’s medical schools fail their students as it lifts the curtain on a culture of  “abuse, shame and blame”  that undermines professional morale, inhibits teamwork– and ultimately puts patient safety at risk.   (Thanks to Dr. Diane Meier for calling attention to this report on Twitter.)

“Achieving safety in the work environment requires much more than implementing new rules and procedures,” the report observes. “It requires developing and sustaining cultures of safety that engender trust and embrace reporting, transparency, and disciplined practices. It also requires an atmosphere of respect among the health care disciplines and a fundamental ability of all practitioners to work together in teams.”

The white paper, entitled “Unmet Needs: Teaching Physicians to Provide Safe Patient Care”  was prepared by an  “Expert Roundtable on Reforming Medical Education” that included a broad array of medical education leaders, students, patients, representatives from key organizations, experts from related fields, and members of the Institute. The Roundtable met in extended in-depth sessions in Boston in October 2008 and June 2009 before reaching a consensus regarding the current state of medical education—and  what medical education should ideally become.

The Roundtable participants acknowledge that med school students frequently are abused and demeaned and that this behavior is widespread. Each year, the Association of American Medical Colleges conducts a survey of medical students asking questions such as have you been “publicly belittled or humiliated?”  From 2004 to 2008, 12.7%  to 16.7%  of students answered “yes,” with “female respondents reporting higher rates” of abuse. Most often, students were humiliated by clinical faculty and residents (66% and 67%, respectively), followed by smaller but significant percentages of nurses and patients.

“Abusive behavior can be as subtle as making a student feel foolish for asking a question or as overt as throwing surgical instruments in the operating room,” the report explains. “Some may argue that an overall 12–17% rate of abusive and disrespectful behavior over the four-year medical school experience is not so extraordinary, but the rate ranges far higher in some schools.  . . . it is hard to  imagine any successful industry or company that tolerates abusive behavior” at this level. 

In order to capture some examples of the problem a medical student member of the Roundtable solicited anonymous stories from medical students who had been humiliated.

A Third-year Medical Student on a OB/GYN Rotation Tells Her Story

“I was instructed to observe a hysterectomy, but when I arrived to the OR, the doctor looked at me with disdain and told me to stand in the far corner and not mess anything up. So, I perched myself atop a small step-stool in the back corner of the room, and I spent the next 3 hours squinting from across the room, completely unable to see anything except for blue-gowned backs.

“Suddenly, the doctor called out, ‘You, over there!’ I looked over in surprise—me? Apparently, there was no one available to pullout the catheter, and they beckoned for me to approach the table. I cautiously approached, and before I could even begin, the doctor sharply barked, ‘DON’T mess this up for me!’ Shaking, I  followed her instructions, and managed to remove the catheter without contaminating the sterile field.

“‘Now, GET OUT of the way!’ she yelled. I couldn’t see behind me, and in a small tremulous voice, I asked, ‘Is it okay to move backwards, I can’t see anything behind me…?’ Raising her voice up a notch, she yelled, ‘Just GET OUT!’ I took several hasty steps backwards, and my arm grazed lightly against the side of a table holding sterile instruments—mind you, nowhere near the table-top, where the instruments lay, but just on the side curtain—and a nurse shrieked ‘She contaminated the whole sterile field!’ With fury, the doctor looked up and spat, ‘Fuck you!’

“I blinked, and stared right back at her—really, did she just actually say that? Although I didn’t feel sad at all—only mad as hell—tears rushed to my eyes in a visceral response to all of the shouting. The instant that the curse left her lips, I could tell that she regretted it, but you can’t take back something like that, so the words hung awkwardly in the air, hovering over all of our heads for the rest of the procedure. She tried to make up for it, sending arbitrary irrelevant compliments in my direction, and the nurse patted me on the shoulder several times and tried to appear motherly and compassionate. But, what I remember most strongly from the experience— what I still cannot believe—is the fact, despite their palpable remorse, no one ever said, I’m sorry.”                                  

  Coping with Medical Mistakes

Learning to say “I’m Sorry” is part of what physicians need to do if they are going to cope with medical mistakes.

“Students need support in learning how to manage stress and conflict resolution when they are involved in an adverse event,” the report  observes. A medical education should prepare them to deal with the inevitable feelings of doubt, fear and uncertainty that any physician will experience more than once in his or her career. Medicine is a science fraught with ambiguities and unknowns. Doctors and nurses are fallible. This presents an excruciating dilemma that a physician can deal with in one of two ways. She can admit to medical errors, apologize to the patient, analyze the event,  and talk to other members of her team about how they might re-design the process to avoid such slip-ups in the future. This takes courage, confidence, and respect for your colleagues. Alternatively, she can deny medical errors, and lash out at others when a mistake is made.

Unfortunately, the med school culture can make it  “psychologically  impossible for the doctors who graduate from these programs to  . . . diagnose failed  patient care,” the report warns. A doctor who has been traumatized by a med school culture of shame and blame may find that she “has little insight into
‘what really happened’ ” and be “unable to empathize and communicate effectively with the injured and frightened patient.”  She may also “lack the knowledge and skills necessary to work with other team members to investigate the occurrence.”

If students are going to learn about patient safety they must feel comfortable (“safe”) in  reporting and discussing  preventable adverse events and other patient safety problems with their peers and the faculty. But this will happen only if faculty provide a receptive, concerned and supportive environment.

Here, the report suggests that medical schools should provide more reward to outstanding mentors in the form of higher salaries, more staff resources and promotion pathways that recognize teaching skills. Those who are particularly skilled at teaching how to keep patients safe should be named master teachers.            

Professional Behavior and Professional Ethics

Ultimately, the report suggests that unprofessional behavior may undermine professional ethics.  Often, physicians who don’t act like professionals may never have taken the values of the profession to heart. Ego stands in the way of putting patients first. Doctors who demean medical students also are likely to look down on their patient.  They lack the imagination to identify with someone who is learning—or to sympathize with someone who is suffering

Here is the tragedy: when students are exposed to unprofessional behaviors and values, over time, they tend to accept them.

“Simply put, students assimilate the values, behaviors and attitudes of their mento
rs.” The report notes, pointing to a survey of third-year medical students, which demonstrates that “student observation of and accommodation to unprofessional behaviors progressively increased during the first five months of clerkships. Initially critical of these behaviors, students increasingly perceived them to be appropriate as training progressed, and steadily began to emulate them.”

A second anonymous survey of 1,853 third- and fourth-year medical students in 1992 and 1993 at six Pennsylvania medical schools also sounded a warning. “Ninety-eight percent of students had heard physicians refer derogatorily to patients; 61% had witnessed what they believed to be unethical behavior by other medical team members and, of these students, 54% felt like accomplices. Many students reported dissatisfaction with their actions and ethical development: 67% had felt badly or guilty about something they had done as clinical clerks, and 62% believed that at least some of their ethical principles had been eroded or lost. Controlling for other factors, students who had witnessed an episode of unethical behavior were more likely to have acted improperly themselves for fear of poor evaluations. Finally, students were twice as likely to report erosion of their ethical principles if they had behaved unethically for fear of poor evaluation or to fit in with ‘the team.’”

In Part 2 of this post, I’ll talk about the report’s recommendations for changing the way we select students for medical school, changing medical school curriculum , teaching teamwork, weeding out students who display  unprofessional or maladaptive behavior, and why “see one, do one, teach one” is antithetical to patient-centered care. 

14 thoughts on “A Culture of Fear and Intimidation: Reforming Medical Education

  1. Having seen it from the inside, it’s way worse than what you write here. Patients die because of some MDs arrogance and, yes, greed.

  2. It is astonishingly difficult to change a culture, especially when we point out how those controlling the culture are a major reason it continues. One reason I went into pediatrics is that I saw much, much less of that sort of behavior among my pediatric mentors. But even with them it happened now and then. Still, I do think it has improved over when I went to medical school in the mid-1970s. We’re making headway, yet we all know it still goes on.
    I know of at least one large community hospital that has taken a strong, proactive stand against the kind of behavior you describe. It first promulgated a well-publicized and clear policy that such behavior would not be tolerated. When the crunch came, as all knew it would — a surgeon behaved abusively to a nurse — the hospital vice-president for medical affairs (an intensive care physician) was notified and he responded by sending security into the OR suite later that day. (They had to change into scrubs to do so.) The security guards then escorted the physician out of the hospital. And he couldn’t come back because the physician had his privileges temporarily suspended until he agreed to change his ways. Now, that’s pretty extreme. And many hospitals would never do this because they want doctors, especially procedural specialists, to bring their business to them and not to the hospital across town. But when this VP told me the story, he added that the incident wasn’t a signal to the staff — it was a bombshell. And, after the obligatory howls, no similar episode has happened for the following two years and counting. Tough love from one doc to another.

  3. I have been reading about how medical education and the medical culture should be reformed for at least 30 years – there are very few new ideas out there.
    Old Idea Number 1: Medicine is a Male Dominated Hierarchy and the inclusion of more women will fix it. Please note that the anecdote involved a female doctor and medical student.
    Old Idea Number 2: Requiring Pre-Med Students to study the “humanities” (literature, art, etc.) will make them better, more compassionate physicians. Evidence – Zero. Proponents – mostly teachers and other practitioners of the humanities.
    Old Idea Number 3: Encourage a culture in which mistakes are discussed openly and learned from – except don’t do anything to rein in malpractice – Catch 22.
    Obviously, nobody can defend abusive behavior. Is such behavior more common in Medicine than in the Law, Business and the Military (How sensitive are drill instructors ?) Who knows.
    My experience in Medical School and Residency was that there was a mix of different types of people – some were clearly a**holes, most were average, and some were truly inspirational. Hopefully medical students today are able to distinguish between them.

  4. Chris, Legacy–
    Chris :
    Recently, when I screened the film, a young med student came up to me afterwards and said, in essence “what can I do to avoid the money-driven trap of corporate medicine?”
    I told him: “while in school, pick your mentors carefully. And hour friends. Look for like-minded people.”
    “And then go into the specialty where you find the best mentor(s).”
    Usually med students really aren’t in a position to know which specialty they would like most. They haven’t yet practiced medicine. But they probably do know which mentors they like and respect..
    This is an important clue.
    If you want to be in a humane patient-centreed profession, choose mentors are who humane and patient-centered .
    And then learn as much as you can from them.
    As I read your comment –before I even scrolled down– I thought,
    “This has to be Legacy.”
    It’s the cynicism. But at the same time, the flip side–the idealism. Barely detectable, but there.
    Yes med school is much like the military–I plan to talk about that in part 2.
    And there is some of the same hazing in law school, but law students spend far fewer hours in class than med students spend in classes and training.
    The training of lawyers becomes much more like med school once they become associates at a major firm.
    That is when the really begin to be abused, humiliated, cursed and blamed for any mistake and every loss.
    On distinguishing among mentors –see my reply to Chris.
    I agree, this is what students need to do.

  5. I had a “dirty” (ie bloody) scalpel thrown at me during my surgery rotation. I opted not to report the incident because other students who had lodged complaints against the surgeon had found that their grade in the rotation was unexpectedly low. Although we were assured confidentiality, the details required to lodge a complaint made the complainant easily identifiable. The fact that the school’s administration was well aware of this kind of dangerous behavior (if the scalpel had hit me and the patient had HIV or hepatitis C, I could have been infected), and chose to do nothing about it, speaks to the entrenched culture in medical education.
    Thanks for sharing this. I look forward to reading Part 2.

  6. Sharon MD and Ed
    Sharon MD–
    Hearing this from you (and I have been reading your extremely intelligent and level-headed comments for some time)helps peruade me that the report is not exaggerating.
    There is something dysfunctional going on in our medical schools. From what I ave heard this is tue in almost all med schools, but as the report indicates, some are much worse than others . .

  7. Just about everything said here about Medical schools/medical education is also true (maybe more true) of dental education in the US. With a history of little proof of community improvement interest as the norm in most dental schools, the University of Arizona started a new dental school in about 2000 which was going to try a different approach to both selecting students and educating them for community improvement. Under Dean Jack Dillenburg the experiment was begun, but it will take a while to know if different types of dental provider attitudes and actions come about from those who go/went there. The website below tells some of the story:
    I hope this kind of educational attitude works and catches on, but the cost of dental education will have to be made much more affordable for all if this ever has a chance to work out.

  8. Hate to have to say this, but problems in health care education are not limited to medicine.
    Similar behaviors occur from nursing instructors to nursing students.
    I once listened to a colleague rip a student apart during a physical assessment check off (in lab, not clinic no less). The student had actually been doing just fine, but this instructor found the need to nitpick every flaw, real or perceived.
    Every time I would stand up to come over and put a stop to it, the instructor would cool it off, then start up again when I went back to working with another student.
    I complained to my department chair, but nothing was done.
    Abuse towards students just isn’t taken seriously. Given that both physicians and nurses are supposed to be caring professions, I am just . . . overwhelmed by how I see students treated.

  9. Panacea– I can well imagine that this happens in nursing schools too.
    Things must change.
    askdoctoronline: please feel free to repost.
    NG: I can well believe than dental schools also follow this military model . .

  10. I was looking for a lawyer to speak to in regarding a situation with a doctor that disrespected.humiliated.
    and embarrassed .I was very hurting because of the way he treated me was wrong amd I still feel hurt.and I have to see these nurses every day I am here.and I am embarrassed because of that.thank you
    Sincerely your:
    Ernestine young

    • Probably a lawyer is not going to take the case unless you were physically harmed. Being disrespected and humiliated just
      isn’t usually the bias for a lawsuit. And since the lawyer has to spend quite a bit of money out of his own pocket just to bring a case, he’s not likely to do it unless he sees a substantial award on the horizon.

      But I would suggest that you talk to someone at the hospital. Ask to see the attending physician. Call the administrative offices and
      ask if there is someone that patients should call if they been treated in an embarrassing and humiliating way. Is one of your
      nurses friendly? If so, ask her.

      Best of luck