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This is the full text of a speech given to the Australian Medical Association’s National Conference by Alex Farrell, president of the Australian Medical Students’ Association, in Canberra on Sunday, 27 May 2018. Reprinted with permission.
ON my first day of medical school, we were asked to look on either side of us. It was a fun guessing game – which of us three would develop mental illnesses as part of our course.
A few months later, I first became involved in AMSA [Australian Medical Students’ Association] because, as a student starting to see the broken parts of our system, it seemed to be where stuff got done. Doctors, and by extension medical students, hold a trusted place in society, and I saw AMSA bringing us together so we could use our collective political capital for actual outcomes. Realising that students’ voices mattered in the conversation, and that, through groups such as AMSA and the AMA [Australian Medical Association], I could contribute to real change, was incredibly empowering. It was also daunting, because we still have a lot to work on.
When our organisations speak out, people listen. Students will remember the AMA joining us in the fight for marriage equality for a long time to come. It was a powerful signal to the Australian community that doctors support our queer patients and peers, at a time when many were hurting. It mattered.
The AMA speaking out on the health of refugees on Manus and Nauru mattered.
That is quite the responsibility. Here in this room, you are the people who will continue to set the AMA’s vision and messages going forward. Often, that will be on issues affecting the health of all Australians. For today, I want to look a little closer to home, at medical culture.
I am often told that when it comes to changing culture, students are the way forward. This year, I’ve sat in countless meetings where reassurances have been given that our problems will be solved, because the younger generation will eventually reach the top, and we have the mindset to create “the change”.
The medical students of Australia are extraordinary. But that is a huge burden to place on our shoulders alone, without the structures to support us. We have the least power, and often the most to lose.
“Generational change” is a myth when the problems lie in a system to which the upcoming generations are still trained to conform. They will continue to perpetuate that culture, unless it is actively disrupted.
We need support from you, doctors who have power in the system to help us change it.
I’ve been lucky enough to spend this year listening to students and hearing their stories. I’m here representing an exceptional group with diverse backgrounds and experiences.
Medical school has never been without its difficulties. While some things may have shifted for the better since your training years, in other ways we face new challenges, and old challenges we hoped would have disappeared – challenges in gender equity and diversity in leadership, in mental health and mistreatment in medical education, and in the growing training pressures that we’ll face on graduation.
Gender inequity is alive and well in medicine today. It covers a spectrum of sexist behaviour, from well meaning but gendered comments, to clearly abhorrent harassment and assault. You heard yesterday about the very real barriers women in medicine face on a daily basis – the invasive interview questions, the pregnancy discrimination, the pay gap.
This starts in medical school. Every female student will recall a time they were told to avoid specialties that aren’t “family friendly”. I’ve spoken to students who have been told that “there’s no point teaching them how to suture, because they are just going to become a GP anyway”. To a student whose supervisor was well known to either bully or flirt with their female students, and told she was lucky to be picked for the latter.
It’s what we call unconscious bias. Women and men alike, not meaning to, doubt women’s abilities just that much more. Women need to work harder to prove themselves, because they don’t fit the leadership image we all expect to see, whether that’s in an operating theatre or hospital boardroom. It’s not really about gender or sex, it is about power and authority, and who we see holding it.
Women are under-represented in nearly every position of medical leadership. They are far less likely to be medical school deans, chief executives of hospitals, receive research grants, or be AMA presidents. They are less quickly promoted, and less well paid.
The truth is, most doctors involved in the lower levels of sexism and harassment aren’t malicious. They may think they are being helpful, or flattering, or telling a harmless joke. Many never actually receive feedback that they are being inappropriate. And so, the behaviour builds, and the lack of accountability builds, and for the few with bad intentions, the opportunities to abuse power also build up.
When we tolerate less confronting comments, we pave the way for them to escalate unchecked.
Everyday sexism looks benign, but it has shaped what medicine looks like, from our first year university students all the way up to the people here today.
In the past couple of years, medicine in Australia has been rocked by the revelation of endemic harassment. I don’t think anyone will be truly surprised when the next horrible event breaks. We haven’t changed enough to expect them to stop. But it’s not enough to wait till then to be shocked back into action. There’s no more room for apathy in this space.
The same goes for all vulnerable population groups. There are exceptional Aboriginal and Torres Strait Islander medical students, but compared with other students, the barriers to graduating can pile up.
Earlier this year, I was able to speak to the student representatives of the Australian Indigenous Doctors’ Association (AIDA) and hear their stories of daily stereotyping and racist comments, of being regularly told they had taken the place of someone who actually deserved to be in medicine.
A survey by AIDA has found that nearly 50% of our Aboriginal and Torres Strait Islander doctors face bullying, racism or violence a few times a month, or even daily.
While more and more, the make-up of medical students reflects our population, this isn’t reaching the tiers of leadership where the ability to really create change lies.
The hurdles to being leaders and advocates are only made higher when certain groups are less valued and protected in the medical sphere.
For students and doctors in training, the health industry is hierarchical and rigid. Challenging norms simply isn’t safe territory.
We know that most students who are mistreated during their medical training don’t report it, for two key reasons: they don’t know how, and they’re afraid of what might happen if they do speak up.
When asked to elaborate, these are their responses:
“We are taught from our first year that whistle-blowing in medicine is career suicide”; “My supervisor could be my examiner”; “I tried — the university told me it was the hospital’s responsibility, the hospital directed me back to the university”; “It doesn’t look good for getting into a specialty program.”
Even as someone who has spent this year speaking out on this issue, when I go back into clinical rotations next year, I can’t say with confidence that I’ll report bullying or harassment if it happens to me. I am worried, as so many students are, about what might happen on the wards, but I’m even more worried about what might happen with a report.
Which means that responsibility to speak up lies with you. To take colleagues aside if they might be crossing lines. To create systems in hospitals where reporting doesn’t put students and staff at risk. To demand tangible consequences.
We can change the structure that drives medical culture. We need only look at the issue of mental health, to see this community rally, and say “enough is enough”.
The promises from COAG [Council of Australian Governments] to change mandatory reporting laws to remove barriers for health professionals to seek appropriate treatment for mental health are proof of that. That came from sustained and powerful advocacy, from students and the AMA.
The work is far from done, but as a start, I’m hoping I can look forward to not hearing any more stories of students being told that seeing a GP will end their career.
It won’t solve all the reasons behind poor student mental health. As students, we are staring down the barrel of the building pressure of vocational training – there are far more of us graduating than there are specialty training places, and by the time it is our turn to apply, it will be reaching crisis point.
Knowing that is the future for us, it should come as no surprise that students are doing anything we can to get ahead. Research projects in the holidays, master’s degrees in parallel with full-time medicine and part-time jobs. We can talk about work–life balance as much as we like, but while this is the status quo, mental health will suffer.
Once out in the workforce, many of us will take years off from clinical practice for PhDs or other pieces of paper to make us better candidates, but not necessarily better doctors. We will follow the signals that colleges and the profession send us – for a focus on clinical education and service, like so many of you yesterday placed as a priority, they need to be recognised accordingly.
When it comes to mental health, there is one area where students and senior doctors still seem too often not see eye-to-eye – resilience.
For us, resilience has become a dirty word. That’s not because we don’t believe in prioritising mental wellness. It’s a word that has been overused, at the worst times. Resilience is a suicidal friend pointed towards mindfulness courses. It takes students at the darkest point, and tells them that they just should have been stronger. It acknowledges that the medical training environment is flawed, but at the same time says that the answer is fixing students, rather than seeking larger change. That is what students hear.
So, instead, let’s talk about what they are being resilient against.
Sixty percent of medical students have witnessed mistreatment in medical education. That’s Three in every five. Most of the time, this comes as belittlement, condescension or humiliation.
Women are more likely to be mistreated in medical education than men, queer students more than heterosexual, clinical students more than pre-clinical. Consultants are the main offenders in half of the cases.
In the medical world, we are expected to teach and lead as a core part of our work. Doctors spend years learning to practise medicine, but are expected to teach with no training at all.
Your actions matter to the students in front of you in that moment, but also for what they model going forward. We replicate the examples that were shown to us in our training – so the way you teach now will shape what the medical profession will look like in 20 years. If you want to see things change, that is the first place to start.
As a teacher, model safe practice, good communication, work–life balance. A positive culture is a safe culture.
I know it is not always easy. As students, we take time away from your busy days. Sometimes we don’t know how to help, and we know that our gaps in knowledge fall short of your expectations. All students know the feeling of being a burden on their team. But to learn, we need to be in the room, and we need to be able to ask those questions.
Medical students want to work hard, and to be good, safe doctors.
You hold the power to [have an] impact [on] the lives of your students each and every day. That’s not to say they need to be your first priority. Your patients always come first. But it doesn’t have to be one or the other. It only takes a moment to say good job, or to answer a question, or explain how to improve next time.
That moment can make your student’s day. It can keep their love for medicine going through all the other parts of this profession that may otherwise leave us disillusioned far too soon.
Thank you to all of you who make that effort to be positive mentors and teachers. You are appreciated.
I believe that we can build a medical culture that is safe and nurturing. But it can’t wait 20 more years, when my peers are filling your seats. It has to start now, and it has to come from the top – in the way that you teach, in the way that you lead, and in the systems that you influence, be part of that change, and I promise, we will do you proud.
Alex Farrell is the 2018 President of the Australian Medical Students’ Association, the peak representative body for Australia’s 17 000 medical students. She is a medical student at the University of New South Wales. She can be found on Twitter @YourAMSA and Alex’s personal account is @AlexLFarrell.
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Thanks Louise.
A meta-analysis.
Not original source material.
No uniform definition of harassment.
Verbal ‘harassment’ was most common.
34% by consultants (with patients or families second commonest)
Harassment? Or sometimes feedback which was not positive to someone who lacks resilience?
Just asking.
But that paper can’t answer.
Marcus the best evidence is:
Fnais N, Soobiah C, Chen MH, Lillie E, Perrier L, Tashkhandi M, et al. Harassment and discrimination in medical training: a systematic review and meta-analysis. Academic medicine : journal of the Association of American Medical Colleges. 2014;89(5):817-27.
Internationally, 59% of trainees have experienced bullying and harassment, and 33% have experienced sexual harassment. The RACS inquiry found similar numbers locally
Sure Ignatius, let’s say “rampant”, particularly without any facts to back it up.
Maybe we could do a study like the University sponsored one into to rape culture on campus which found…. well, not much really.
Thank you for your work on this very important issue. I’m just adding my support for you here.
Also voicing my dismay at some of the “anonymous” comments made by others who seem to have no insight at the problem that is rampant in the medical profession.
I suppose the fact that they have chosen to remain “anonymous” says something as well.
Again thank you for the good work. We do need to take better care of our medical students and junior doctors. The culture of bullying in medicine needs to stop. And if out requires a generational change to do it, then so be it.
Thank you for your speech, Alex. I hope that this is shared far and wide, and please know that you have a lot of support for what you have said. Your anonymous detractors are those who, more than anyone else, need to really read, not just see, your words. I hope that all the medical students who come through my practice leave with a positive view of workplace interaction and teaching, and I would be aghast if they said ‘it was great to help build resilience!’
As a Med student over 40yrs ago I was lucky to never really be treated any differently than the boys ( apart from the expectation that I would wash up the coffee cups!) though I know some of my friends were not so lucky. None of the girls applied for surgical, orthopaedic jobs (nochance of an interview) or even to the Professorial medical unit. One brave very talented friend jdid aced the interview and was told “ we’ll take a chance on you Dearie!!. She said she was treated like a second class citizen ,left in six months and became a formidably good GP instead.
Things have improved- my medical mother lost her hospital job the day she go married. No choice in these days.
We now have women in virtually all areas but things still need to improve so yes keep fighting girls. We need more people like Alex and we need to support them.
Well said Alex. Older correspondents do sometimes wonder at what is now considered inappropriate, however so much (not all) of what passed for banter when I was a student in the 1980s was completely inappropriate and cringe worthy. I stand with you.
Older correspondents might be a bit more empathic if they recognised that these days the party game pass-the-parcel has a prize at every layer.
Thank you for raising this important issue so eloquently, Alex. It is amazing how much inequity is around, especially noticeable when your attention is drawn from it. Regarding the anonymous comments, i’d like to leave a quote here:
“It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat.”
Theodore Roosevelt
Hi, Alex. Thanks for a great article. Im sure as a speech is gave people lots to think about.
Remember the leaders youre looking at now also trained in a toxic environment. Some of them will not have been direct vicims, but the majority will have either suffered or witnessed suffering. Some of those will have been expertly gaslighted, blaming themselves and not the system, and will be invested in maintaining that premise until the bitter end. But many, many more of us will resonate with what you’re saying.
Comments are going to come at you from all over. The kind and open sharing ones might seem to prove your point, but also the hard and bitter and angry ones might be the ones who prove it better… that the ones who went without leadership, protection, examples, and inspiration really needed the help youre describing.
“When the axe came into the forest, the trees said, ‘Look, the handle… it’s one of us.'”
Here’s to a better world. Cheers.
Alex, you have articulated beautifully the issues so many of us have faced & continue to face in medicine. I am proud to have you as one of our leaders now & in the future, paving the way for real change.
Congratulations, Alex, on a eloquent and powerful speech. Some of the anonymous comments prove your point nicely, especially as the poster/s have chosen to not put their name/s to their unkind and disrespectful remarks.
I am saddened that resilience has become a dirty word. I think the concept of resilience is incredibly important but it should never be used as an excuse for system failures/ pressures and destructive behaviour by individuals.
I wish you all the best in your career, and please keep being brave through speaking up so publicly.
I am so over this discrimination garbage in all its forms. Australia would have to be one of the least discriminatory countries in the world, and that includes countries of all types, colours and religions. Those who rave on about discrimination generally only want to wave some kind of ‘victim’ card in their own interests.
“I’ve never been mistreated, so no one must have been mistreated.” Impeccable logic there. I also was never mistreated as a medical student or a junior doctor. It was definitely present where I trained (Flinders in Adelaide), and where I worked as a JMO in Canberra. Senior doctors develop reputations for behaviour – both positive and negative.
I have been harassed by registrars with narcissistic personality traits, sat in rooms with male (surgical) colleagues verbally bashing their female counterparts, and a consultant with the intent of “building resilience”. This consultant’s words were along the lines of “at least you don’t have a mental health problem”, “or that you are pregnant”, “or that you have a drug or alcohol problem”. (This said to a mid-thirties married woman, from a low socioeconomic background (siblings and father living in public housing), and family situation including alcoholism, drug problems and attempted suicide (not myself, but family member, after death of mother/wife from cancer). Though considering his specialty, he can be forgiven for completely misunderstanding another’s situation. His idea of why I demonstrated a “perfectionistic personality” was because “you’ve never failed at anything” (painting a picture of a “wallflower”, I might “appear” young and naiive). I can only assume he had good intentions when he was “advising” me. His lack of understanding from where perfectionistic traits may have arisen, eg. protecting oneself from the adversity they had faced. At the time I noted his words and brought them up with HR. This was met with futility, as HR did not even acknowledge this.
I have since left the medical profession. A waste of economic resources both for myself and the community. Having had a number of “resilence building” life experiences, as well a deep empathy for people – sadly, medicine and I just didn’t work out. Yes, I “failed” medicine, but no regrets about the life I am living.
In terms of the poster talking negatively about “positive psychology”. Perhaps just start with not being a jerk, in other words “be kind”, and don’t make assumptions about people.
Hi Alex.
Thank you for the important work that you are doing. I’m sure that the comments here are not the only backlash you will have received, medical culture being what it is. I wanted you to know from a senior colleague that it’s people like you who will be the change we all wish to see and despite the fact that the dinosaurs are vocal they are NOT the majority.
Best wishes.
Dr Gillian Riley.
Just apropos the Anonymous comments: if you trace the timeline from Geoffrey Blainey to Peter Ridd to see how academia deals with the freedom to express a contrary opinion, you might understand why some people don’t feel this is a big enough problem over which to put their jobs and careers on the line.
That the interchange of ideas has come to that – in institutions that are supposed to foster free inquiry – truly IS sad.
What a great speech. Keep up the good work. Ignore as much as you can the backlash. Hope you have lots of support. Well done.
Alex.
I stand with you. The treatment of medical students and junior doctors is not good enough.
The anonymous comments make me really sad – not only are they wrong, dismissing real lived experience, but they don’t even have the courage to put their name to the comment. Perhaps they realise they are wrong on some level.
Keep fighting the good fight. The standard we walk past is the standard we accept. Speak for those who are unable, raise up those who can find the voice.
Let me know how I can help.
Thank you for such a brilliant speech Alex. Louise Stone, who has commented above, flagged this to the GPs Down Under facebook group. You’ve raised some incredibly important points, amongst which the one that really struck a chord is that we simply can’t wait for, and expect, our future leaders to effect a cultural change that is desperately needed right now. I know Louise does some amazing work in this space so it may be worth you both connecting. But know that a great many of us support what you’ve said, stand by you, and will take your call to action to heart in a deliberate and concerted effort to stand up for what is right, and push for the changes that you’ve outlined. Well done and keep up the fight! Oh, and we are definitely not going to throw criticism at our colleagues behind a veil of secrecy and anonymity.
Hi Alex
Thank you for this important work. In the last four years I’ve been doing a study interviewing doctors who have been sexually assaulted by their senior colleagues. I did this work because as a GP I cared for a junior colleague who had been raped by her consultant and helping her manage this trauma was devastating.
I disagree with some of the earlier comments. Just because you have not experienced harassment and abuse doesn’t mean others share your good fortune. After a couple of years of this work, I’ve become used to distressed colleagues seeking me out and discussing their own trauma that occurred anywhere from last week to last century. I am a senior GP, and this has never happened to me. I’ve been very fortunate. But given community prevalence of harassment and abuse, it would be pretty strange if medicine was immune.
If you’re interested in the study, you can find more at ofdoctors.bydoctors.com
or contact me at ANU. Keep speaking up about what you see Alex, many of us support you
60% of Medical students have experienced “mistreatment”. Really? What exactly constitutes mistreatment? Does everything in medical education have to be delivered with “positive reinforcement” or else we feel we are being mistreated. Perhaps if resilience was not considered a dirty word, but rather something to build into our character, this so-called “mistreatment” perhaps should be recognised for what it is -senior specialists driving you to be better and safer doctors. I find it interesting when I read of gender inequity and pay gaps in medicine. I have never seen a hospital award, nor have I noted in the MBS any mention of rates or item numbers that vary depending on whether you are a female or a male doctor. That’s because they do not exist. Any “pay gap” exists because more hours have been worked, or more procedures performed. When you compare apples with apples, GPs with GPs, specialists with specialists, male and female doctors have no pay gap. I have worked in medicine for well over 20years, and I am a female GP – i have never been mistreated, never witnessed mistreatment, my superiors always encouraged me to be the best I could be. The notion that I wouldn’t be taught suturing because I would only be a GP is an absolute nonsense – what GP is not suturing? And if that comment had ever been made to me, it would have been dealt with appropriately by calling it for what it is – an absolute nonsense! I have never felt I am somehow less of a doctor because I am female, nor that I have somehow had to prove myself more. In fact in general practice, I have generally found that patients seek me out because I am a “female GP”. The simple fact is men and women are different. Personally I think it’s about time we celebrate and enjoy those differences. I look forward to the day I can again enjoy a joke and a laugh with my colleagues, rather than worry that every little thing out of my mouth will be judged and evaluated, and I will receive the inevitable labels we are so quick to use.
Some correspondents seem to have taken a big swig of the Kool-Aid, and embraced the “white male from a middle class background” narrative. Also interested to know about these “students of all types”: what are the ‘types’ that are hypothesized?
If one really believes that there are people (men) in medicine who set out to obstruct the progress of ‘minority’ or female students, you might take a look at the demography and see that they are now as likely to be Asian males as white males.
Interestingly, those males seem to have climbed the ladder despite being in a minority.
Wonder if they’re just good at what they do?
But one should never let facts get in the way of a good story.
A great article. Wow, the last comment was a key example of the denial of many of the issues students of all types can face- they are told they are imagining it! This draws to mind the attitude of the residential colleges in Adelaide as seen on 60 Minutes last night, and how one brave young woman has been extensively abused for telling her truth. Anyone who is not a white male from a middle class background is likely to have seen or experienced some discrimination or harassment, whether or not this affects their career. I remember some surgeons at Med school telling “hilarious” dirty jokes in theatre, likely partly with the aim of making any female students uncomfortable! And a male consultant who enjoyed interrogating female students alone in his office, not sure how well students in this situation would perform! Of course no one complained ever. Hopefully this doesn’t still happen much any more but behaviour may be more subtle. It is very much not visible (perhaps especially not to those involved in the discrimination etc) if you’re not looking for it or experiencing it. And many white males do see some bullying and of course individual discrimination for other reasons!
Please don’t complain about hierarchies, in medicine or anywhere else. There is a reason we don’t make medical students Professors. As you become more able, so will you ascend.
For all the talk of discrimination, there is actually very little proven (as opposed to the many claims from those who don a victimhood mantle and then allege it, when they fail to make the grade).
Study hard and be the best that you can.
In my first year exams in 1998 we had a day of OSCE type stations. One of the stations was on reporting a lecturer who was displaying inappropriate behavior to another student, and the correct way to notify the medical school. We were told at UQ this was expected of use, on campus and in the hospitals. Do the schools down south not reinforce this in the curriculum? I note a couple of years later the vice chancellor at UQ was sacked when it was found his daughter had been given an advantage in the selection process for medicine. Some one reported this. They were not afraid because they knew the school would have to practice as it preached.