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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