By David Acosta, MD, FAAFP, and Paul G. Cunningham, MD, FACS
Hospital behaviors that may have been tolerated in the past are clearly viewed differently now, and can no longer be accepted in the future. Any form of mistreatment negatively affects the culture and climate of medical schools and teaching hospitals.
The Association of American Medical Colleges (AAMC) Council of Deans and the leadership of our academic medical institutions have placed a high priority on eliminating all forms of mistreatment toward students during medical education, emphasizing that students need to learn in a supportive environment.
Recent efforts by the AAMC have focused on competency-based medical education and the development of entrustable professional activities (EPA), a common core of behaviors that should be expected of all medical school graduates. For example, EPA 9 cites demonstrated competency of appropriate behaviors expected of the ideal professional in the learning and workplace environment: “work with other health professionals to establish and maintain a climate of mutual respect, dignity, diversity, ethical integrity, and trust…” Although it might be intended, avoidance of mistreatment is not explicitly mentioned.
The Accreditation Council for Graduate Education has clearly moved competency-based training forward by implementing the Clinical Learning Environment Review Program, and is intending to focus on the learning environment. Of the six focus areas, “professionalism” is assessed with regard to the behavior of residents and faculty. Mistreatment is not specifically mentioned.
Mistreatment remains critically in need of reasonable performance standards and meaningful methods of redress. Efforts to date have focused on defining mistreatment, and on educating our faculty, residents and students on what constitutes mistreatment and what doesn’t.Many institutions have implemented targeted activities, programs, and policies to reduce if not eliminate mistreatment. In 2012, theAAMC revised the Graduate Questionnaire with hopes of getting a more comprehensive picture of the culture and climate at medical schools and teaching hospitals. Unfortunately, as Fried et al have demonstrated after more than 10 years of best efforts, there has not been a significant decline in mistreatment.
One problem with our collective approach in dealing with learner mistreatment is that it has solely focused on the victim. Little has been published regarding the approach in dealing with the perpetrator of mistreatment and the remediation process. Students most frequently report being mistreated by residents, clinical faculty, and nurses; residents report being mistreated by attending physicians, higher level residents, and nurses. Not much attention has addressed the impact of witnessed mistreatment on the wider medical community (other students, residents, faculty, and staff). The concept, principles, and process of restorative justice provide a values-based alternative approach to addressing mistreatment that targets resolving conflict and building community.
Restorative justice has a set of principles and practices grounded in the values of showing respect, accountability, and strengthening relationships. The model encourages the participation of all the people affected by the offense in problem resolution and in damage reparation. The practice becomes a way to build community within the academic institution and helps students, residents, fellows, staff, faculty, and leadership develop a meaningful process to deal with mistreatment. The process works in harmony with the norms, values, and culture of the institution and seeks to restore relationships and community.
This method requires students to speak up and accept increased responsibility for institutional discipline and community building. Institution personnel (faculty, residents, and staff) accustomed to more authoritarian relationships between teachers and students may have difficulty giving students the respect they need to effectively practice restorative justice. Nevertheless, this shift in power is critical to the success of institutional restorative justice and may lead to benefits over time. This calls for institutional investment and the provision of professional development for all institution personnel.
Restorative justice is best known for its use of a community circle. This idea brings together (under the guidance of a facilitator) the harmed, those who caused the harm, and the community in which the harm occurred to respectfully share their perspectives, feelings, and concerns. The community circles have many functions, including fostering understanding of the harm resulting from an offense, establishing agreement about what should be done to repair that damage, and building a cohesive community.
We need to change the culture of our academic medical institutions and to make explicitly clear to faculty, residents, and staff several guidelines:
1) It is our expectation that our medical students, residents, faculty, and staff will respond to any forms of perceived mistreatment in a professional manner.
2) Appropriate confrontation and negotiation skills will be taught to all faculty, residents, students, and staff that will enable us to safely have high-stakes conversations without the fear of retribution.
3) Collectively, we will learn how to best respond when confronted by a concerned victim of mistreatment: exhibit openness, be non-judgmental, use humility, and interrupt behavior associated with our own personal implicit biases.
Ultimately, it is likely that the best approach to creating the most effective conversations will involve peer-to-peer interactions. Credibility for the process is dependent on authenticity. When the caregiving profession as a whole is prepared to champion compassion and inclusiveness to the highest, the expected positive change in behaviors will occur.
David A. Acosta, MD, is Associate Vice Chancellor for Diversity and Inclusion and Chief Diversity Officer for the University of California Davis Health System. He can be reached at firstname.lastname@example.org.
Paul R. G. Cunningham, MD, is Dean, Brody School of Medicine, and Senior Associate Vice Chancellor for Medical Affairs at East Carolina University. He can be reached at CUNNNINGHAMP@ecu.edu.