By James N. Woodruff, MD
Mistreatment continues to be a problem in the education of medical students. Despite efforts across the country, data from last year’s AAMC Medical Student Graduation Questionnaire found that 17 percent of students across all schools indicated they had been mistreated. This number has remained relatively stable over the past six years. Very appropriately, student mistreatment has increasingly become a focus of attention for the Liaison Committee on Medical Education, the accrediting authority for medical degree programs in the United States.
Like many institutions around the country, the University of Chicago Pritzker School of Medicine takes this problem seriously. We began a medical center-wide initiative about 10 years ago to address our mistreatment problem. It started with careful data collection and analysis to understand the problem better. In addition to the annual AAMC questionnaire, we began collecting data directly from the students as they completed each of their clinical rotations during their third year clerkships. This allowed us to get more immediate feedback and to identify areas of our curriculum that deserved particular attention.
Once we had data, our leadership made a number of interventions. It established a new ombudsman system, through which students and residents can get confidential assistance and advice when they found themselves in uncomfortable situations. Starting in 2006, robust educational interventions were also made. Faculty and residents in departments that demonstrated higher levels of mistreatment received annual mandatory workshops on the topic of mistreatment.
More general education also took place. A dedicated retreat for the University of Chicago’s clerkship and program directors was held to ensure that those in charge of our curriculum were prepared to address the issue in a coordinated team approach. In addition, each of our clinical departments was visited by our Dean of Medical Education to review the department’s strengths and weaknesses. Each of these Grand Rounds presentations had a section dedicated to mistreatment.
Significant effort was made in educating our students as well. As students make the transition from class work to an activity that more closely resembles “on the job training,” it is very important to outline for them what constitutes mistreatment and also how to respond when mistreatment takes place. Quick reference tools such as the acronym “MISTREAT” have been particularly useful:
Intimidation on purpose
Threatening verbal or physical behavior
Racism or other discrimination
Excessive or unrealistic expectations
Trading for grades.
Student education on mistreatment is a standard part of our curriculum and has been for several years now.
A very important final element of our initiative was to build a robust curricular element on professionalism within our medical school. This effort began with the creation of a Roadmap to Professionalism Steering Committee. Out of this committee have come exceptionally useful rubrics for teaching about mistreatment and positive role modeling. In addition, mechanisms for publicly recognizing outstanding teachers and professionals at our medical center were created.
We have been very pleased with the results of our efforts. Mistreatment reported by our students through the AAMC graduation questionnaire has dropped by more than 50 percent over the past few years, and last year mistreatment was reported at about half the rate of the national average. It is important to state, however, that while we have seen improvements in reported mistreatment at our institution, mistreatment still occurs. This is not acceptable.
We have recognized several large challenges to addressing mistreatment in the medical training environment:
1) Parties on both sides of the issue, faculty /residents on one hand and students on the other, need constant reminding about what mistreatment is and how best to address it. We can never consider the problem “solved.”
2) The clinical environments through which our students rotate are intense, high-stakes venues that are likely to become more so as medical centers continue efforts to control costs and our patient population ages.
3) There is an inevitable clash of cultures between the younger students and seasoned physicians that includes both the natural and expected evolution of personal and professional development, but also includes clear generational differences in expectations and communication styles.
4) Popular culture (ex. television) has reinforced mistreatment’s place as an element of our profession’s mystique.
Overall, we believe that our focus on both education and positive role modeling has been the major contributor to our progress with mistreatment. Consistent messaging in orientations and educational workshops by our institution’s leadership addresses turnover of personnel and raises awareness. Performance data promotes ownership of the problem. Consistent and very public acknowledgement of our most professional and humanistic faculty members, residents, and students helps promote a culture of professional behavior and inspires individuals to excel.
—James N. Woodruff, MD, is Associate Dean of Students at the Pritzker School of Medicine, The University of Chicago. He can be reached at firstname.lastname@example.org