Subscribe
×

Preference: Education

190

‘Teaching by humiliation’ experienced by two thirds of medical students

A study has found that 74% of university medical students had been humiliated by their teachers during clinical rotations. 83% of students witnessed their peers being humiliated.

The research, published in the Medical Journal of Australia, featured an anonymous survey of 146 University of Sydney and University of Melbourne students.

According to the report, students considered humiliation to be teachers being nasty, rude or hostile, and when they belittled students. Less common behaviours were teachers yelling, shouting, cursing and swearing at students.

Some students were disgusted by the practice of teaching by humiliation, one writing: “The culture of bastardisation in the medical profession has to stop. Had I known it was like this, I never would have given up a good job that I loved to do medicine.”

Others, however, felt it was necessary for learning in the medical profession, with up to half of the survey responses saying teaching by humiliation was ‘useful to learning’.

“It is ‘humiliating’ to be put on the spot and have your knowledge and understanding tested publicly, but I find it to be a fantastic way to learn and consolidate. Rudeness and insults, however, should have no place in this method,” one student wrote.

Related: Changing education model key to stamping out bullying in medicine

Dr Karen Scott, Senior Lecturer at the University of Sydney, and her coauthors reported that it wasn’t just medical or surgery teachers being rude to students.

“The specific professional group most frequently named was nursing and midwifery, reported by 59% of University of Melbourne students and 35% of University of Sydney students. Administrative staff were also named”, the authors wrote.

The report concludes that there needs to be long term research and action to understand the complexity of the situation and identify ways to shift the culture.

“At the same time, current and future teachers deserve meaningful, ongoing support and professional development, and students deserve support to be assertive and resilient.”

Read the full report online at the Medical Journal of Australia.

AMA takes stand against racism, backs Indigenous constitutional recognition

The AMA has thrown its support behind constitutional recognition for Indigenous Australians and combating racism, condemning its insidious effects on social and emotional wellbeing.

As the on-field treatment of Indigenous AFL star Adam Goodes intensifies the focus on racism in the community, AMA President Professor Brian Owler said racist attacks were not only immoral but had all-too-real detrimental effects on the health of those who were its targets.

Professor Owler, who attended the Garma Festival at the Northern Territory town of Nhulunbuy in early this month, said the experience of Adam Goodes, who was badly shaken by the incessant booing directed at him by AFL crowds in recent weeks, showed that racism could have real consequences for individual mental health, as well as overall social and emotional wellbeing.

He said this was why the AMA viewed racism as a health issue and was committed to Indigenous constitutional recognition.

“The Aboriginal concept of ‘health’ centres on social and emotion wellbeing – a concept that applies to anyone,” the AMA President said. “Indigenous people face racism on a daily basis. The treatment of Adam Goodes raises an important questions for the nation, for non-Indigenous people, and our commitment to issues such as raising the standards of health, education, and economic outcomes of Indigenous people.”

“It comes back to social and emotional wellbeing. It is about respect for Indigenous culture and their place in the community being recognised and valued.”

In light of this, he questioned Prime Minister Tony Abbott’s decision not to support the development of a consensus Indigenous position on constitutional recognition to help inform a proposed referendum on the issue – a decision that deeply disappointed Indigenous leaders.

Professor Owler warned the Federal Government that its risks derailing its headline Indigenous Advancement Strategy and undermining recent progress in closing the gap by neglecting health issues and sidelining Indigenous leaders and communities.

The AMA President said that although Government efforts to improve school attendance, encourage young people to get a job and to make communities safer, were laudable, by themselves they would not bridge the big gap in wellbeing between Indigenous Australians and the rest of the community.

“Health is essential to learning, to going to school, for training and employment,” he said. “Health must underpin these strategies. The lack of focus on health is one of the reasons why I struggle to understand the Government’s Indigenous Advancement Strategy.”

Professor Owler said there had been real progress in addressing Indigenous disadvantage, including reducing infant mortality, but cautioned the disruption and uncertainty created by last year’s decision to slash $500 million from Indigenous services and programs put recent gains at risk.

“There is clearly a lot of good things that are being done, but we still have an enormous problem, and Indigenous health is one of those areas where you cannot take the foot off the pedal, because the moment you stop you can lose all the gains you have won,” he said.

Last year’s Budget cuts are continuing to resonate. An analysis of the 2015-16 Federal Budget by Menzies Centre for Public Policy Adjunct Associate Professor Dr Lesley Russell found that the share of total health funds being directed to Indigenous health programs will fall to 1.07 per cent this financial year before a minor improvement to 1.13 per cent in 2016-17.

Dr Russell said Commonwealth funding for Indigenous policies as a percentage of total outlays and of GDP was in decline, and that Indigenous organisations were losing out in the competition for funds to deliver Indigenous programs.

Adrian Rollins

 

Indigenous constitutional recognition – more than symbolism

The AMA takes its commitment to closing the gap in Indigenous health outcomes seriously, and this involves engaging regularly with Indigenous leaders and communities, and with others committed to addressing social disadvantage.

The Garma Festival, which is held in Arnhem Land each year, brings together a diverse group of people to discuss Indigenous rights and culture, including health, education, and other social issues. I was fortunate to attend this year.

Garma is an opportunity to engage with Australia’s Indigenous leaders and to hear from Indigenous peoples, in their own words, what is needed to improve the health and lives of Australia’s First people.

One of the most important features of the program is the key forum. Sitting in the traditional meeting place of the Yolngu clan, high on an escarpment looking out to the Arafura Sea, it seems a long way from Canberra or the SCG. However, topics of constitutional recognition and racism towards Indigenous people in our society, including footballers, were among those most discussed.

The Aboriginal concept of ‘health’ centres on social and emotion wellbeing – a concept that applies to anyone. Indigenous people face racism on a daily basis. The treatment of Adam Goodes raises an important questions for the nation, for non-Indigenous people, and our commitment to issues such as raising the standards of health, education, and economic outcomes of Indigenous people.

There was clearly anger, which was well articulated by Noel Pearson’s speech on the topic, in which he asked “how well do we know our fellow Australians”? He called on the better parts of ourselves and this nation to triumph over racism.

The AMA is a supporter of Recognise – the campaign for constitutional recognition of Australia’s First Peoples. This is more than about symbolism. It is an important part of reconciliation and about the value that this nation places on Indigenous members of the Australian community. While there is bipartisan support for this process, the next step is for Indigenous people to agree on what form the change should take, and subsequently the specific wording of the question that should be taken to any referendum.

There was palpable disappointment at Garma at the response from the Prime Minister in rejecting a proposal for a series of Indigenous meetings to come to an agreement before wider discussion. It was pointed out that Indigenous people are often asked to take responsibility. There was a significant consensus around the need for Indigenous people to take this role.

Perhaps there is concern about the results of that process, and the model that is offered. Whatever the reason, unless there is unity behind the proposal, the referendum risks failing – and that would be a grim day for all Australians.

Many of the most important legal battles for Aboriginal land rights involve Arnhem Land and the While at Garma, there was also time to discuss some of the more concrete health issues. I sat with Professor Alan Cass, Dr Paul Laughton, and Senator Nova Peris discussing the high rates of renal failure in the Northern Territory, the role of prevention in addressing chronic kidney disease, the impacts of dialysis on patients and their families, along with the need to increase the rate of kidney transplantation.

As most chronic kidney disease is preventable, our discussion again highlighted the need for good primary care, particularly in Indigenous health. The Aboriginal community controlled health system is so important, particularly in the Northern Territory. It is one of the reasons why the AMA campaigned so strongly on the Government proposals that threatened funding for primary health care, such as the co-payment proposals and the freeze on Medicare indexation. These proposals all effectively defund primary health care.

While there was time for discussing health, in line with the Government’s Indigenous Advancement Strategy, there was a lot of discussion around education and employment. There is good work being done but, as was highlighted in some of the conversations on the sidelines with people working in schools and communities, health has to underpin these strategies. There cannot be any relaxing of our commitment to Close the Gap.

 

Discrimination, bullying and sexual harassment: where next for medical leadership?

Sexual harassment, the perceived career damage that can result from reporting such behaviour, and inconsistent standards of response by medical colleges and health services hit the headlines in early 2015.1 A background briefing paper published by the Royal Australasian College of Surgeons (RACS) in June 2015,2 as well as several articles in this issue of the Journal3–6 confirm these concerns are real.

Discrimination, bullying and sexual harassment (DBSH) occur in many workplace environments internationally, despite having been prohibited by law for decades. Trainees, medical students and female staff and colleagues are identified as the most likely targets. Proceduralists are particularly likely to offend. Some offenders unwittingly reproduce behaviours they have learned from role models of previous generations. Others are more deliberate or determined perpetrators, often with a reputation for misbehaviour that frequently goes unchecked. Observers who are aware of such behaviour may be covictims or coperpetrators, or both. Hospitals and professional associations sometimes foster a culture of abuse through covert sanctions against complainers, or by providing tacit approval by failing to act or by discouraging change.

There is little doubt of the perception among medical students and trainees that complaining can damage a career because “the hierarchy is too high and too strong”.7 Underreporting of abuse is prevalent across the entire health sector.8 Despite explicit professional values being taught, these seem to be overlooked, and there is a perceived disconnection between organisations’ stated values and their responses in individual cases of alleged abuse.9,10

Significant cultural change is necessary to make perpetrators aware that their behaviour will no longer be tolerated. The leadership required includes the following:

  • understanding what constitutes DBSH;
  • taking responsibility for proactively improving workplace culture and eradicating DBSH;
  • providing training in appropriate behaviour, including resilience, performance under pressure and speaking up when DBSH occurs;
  • recognising the right of victims to be able to report abuse or complain without fear of retribution;
  • providing appropriate timely responses to allegations, that include various levels of sanction for perpetrators; and
  • providing confidential counselling and support for those who have been affected.

In March this year, the RACS established an Expert Advisory Group to provide well grounded, informed and independent advice. The college published the background briefing paper, above, reviewing the evidence,2 and an issues paper11 that will cover the areas described above as well as equity between the sexes. It has also commissioned a prevalence survey of college fellows, trainees and international medical graduates, and qualitative research that captures the stories, effects and outcomes of individual cases. On the recommendations of the Expert Advisory Group, the RACS mounted an improved complaints process, and partnered with an independent external agency to provide the RACS Support Program for those affected.

Medical colleges have a vital role to play in honouring the “societal contract” that exists between the profession and the public,12 ensuring that DBSH are never tolerated and championing professionalism and standards.

“Teaching by humiliation” and mistreatment of medical students in clinical rotations: a pilot study

The development of professionalism is currently a topic of interest in medical education research and often an explicit goal in medical curricula. Yet for over 25 years, research into the teaching of students and junior doctors has reported the presence of humiliation, intimidation, harassment and abuse,1 which undermine the teaching of professionalism.2 Early research identified forms of abuse ranging from subtle acts, such as derogatory remarks and undermining students’ abilities and motivation, to more overt behaviour, including verbal attacks, yelling and nasty or rude behaviour.3,4 Subsequent research reported that students were publicly belittled, humiliated or threatened with physical harm;2 had their reputation or career threatened; or experienced unjustified criticism, sarcasm and teasing.5 Some medical staff reportedly withheld necessary information, ignored students and set impossible deadlines.5

More recent research has identified practices including teaching by humiliation,6 contempt, belittlement,7 harassment, discrimination, assault,8 mocking and scorn,9 as well as offensive, intimidating, bullying10 and demeaning behaviour.11 Other subtle forms of abuse identified include refusal to answer questions, return calls or answer pagers, and use of condescending language.12 Reports have also described a misuse of the Socratic form of teaching, known as “pimping”,12 in which teachers ask questions aggressively, putting students on the spot and shaming them.6

To identify the extent of this problem, the annual North American survey of medical graduates has since 1991 included questions about mistreatment.13 There has been little research into the subject in Australia, although a South Australian study identified mistreatment of junior doctors by surgeons and emergency department staff.14

In our previous study of medical students’ expectations and experiences of paediatric rotations, students reported mistreatment.15 Our aim in this study was to generate a contemporary understanding of practices that medical teachers in the hospital setting have referred to as “teaching by humiliation”.16 Our research question was: what are the interpretations and experiences of teaching by humiliation among students from two Australian medical schools during their paediatric and adult clinical rotations?

Methods

We conducted this pilot study with medical students in the final, clinical-based stage of their degree at two Australian medical schools: at the end of Year 3 at the University of Sydney, and Year 4 at the University of Melbourne. We used convenience sampling, in which students were invited to voluntarily complete an anonymous survey at the end of their paediatric rotation in Semester 2 of 2013.

The research was approved by the University of Melbourne’s Human Research Ethics Committee (HREC protocol 1340653) and endorsed by the University of Sydney’s Human Research Ethics Committee.

Survey

The survey items were developed from factors studied in earlier research.2–5,17 The survey consisted of 19 questions: 17 binary yes/no questions, one question with provision for free text, and one open-response question. The first four items asked about teaching by humiliation, and subsequent items asked about specific practices or behaviours associated with it. Teaching by humiliation was deliberately undefined and left to the students to interpret; the students were given the opportunity to define and comment on the term in the open-response question. We conducted a paper-based survey because students in the previous cohort had recommended it over an online survey to obtain a higher participation rate.

Statistical analysis

Data were analysed in SAS version 9.3 (SAS Institute) to describe frequencies and proportions of binary item responses within and between groups. We used the McNemar test to compare agreement between responses for adult rotations (in medicine, surgery, general practice, etc) and the paediatric rotation. No adjustment was made for multiple statistical comparisons.

We analysed students’ free-text responses using a grounded theory approach.18 The initial analysis was conducted separately by two of us (J B and K S) using the constant comparison process to identify themes in the data. We then compared these analyses and modified the themes through discussion and agreement. One of the initial analysts (J B) then grouped the themes into categories, which the other (K S) reviewed and endorsed as valid.

Results

Of the 151 students invited to participate in the study, 146 (96.7%) completed the survey (68/73 in Sydney and 78/78 in Melbourne). Most participants reported having experienced (74.0%) or witnessed (83.6%) teaching by humiliation during their adult clinical rotations; smaller proportions had experienced (28.8%) or witnessed (45.1%) it during their paediatric clinical rotation (Box 1). There was strong evidence of a difference in responses between the adult and paediatric rotations for experiencing and witnessing teaching by humiliation (P< 0.001 for each).

When asked about specific behaviours students associated with teaching by humiliation, experiencing (71.2%) or witnessing (80.0%) intimidating questioning styles were the most prevalent during adult rotations. Smaller but still sizeable proportions of students referred to experiencing (43.4%) or witnessing (54.1%) intimidating questioning styles during their paediatric rotation (Box 1). There was strong evidence of a difference in responses between the adult and paediatric rotations for these (P < 0.001 for each).

Larger proportions of students had experienced or witnessed subtle rather than overt forms of teaching by humiliation. Subtle forms included teachers being nasty, rude or hostile, or belittling or humiliating students. There was strong evidence of differences between adult and paediatric rotations for experiencing and witnessing these behaviours (P < 0.001 for each) (Box 1).

The more overt behaviours associated with teaching by humiliation included teachers yelling, shouting, cursing or swearing at students. There were more reports of experiencing and witnessing these behaviours in adult than paediatric rotations, with moderate to strong statistical evidence for differences in all behaviours except experiencing cursing or swearing, which was infrequent (< 5%) in all rotations (Box 1).

Box 2 shows the proportions of students who had experienced and witnessed teaching by humiliation and an intimidating questioning style and considered them useful for learning. About 30%–50% of these students considered the mistreatment to be useful for learning.

Many students had seen or heard hospital staff other than medical or surgical teachers being rude to medical students (34.5% in paediatric rotations; 60.4% in adult rotations). The specific professional group most frequently named was nursing and midwifery, reported by 59.0% (46/78) of University of Melbourne students and 35.3% (24/68) of University of Sydney students. Administrative staff were also named. One student noted that the behaviours were “ubiquitous” and another said that “almost all [professional groups] on different occasions” exhibited these behaviours.

Analysis of students’ comments on the open-response question identified five main themes (Box 3):

  • Students responded differently to practices encompassed by teaching by humiliation, ranging from disgust to excusing or defending teachers’ practices that exposed a student’s poor knowledge.

  • Teaching by humiliation was understood to persist because it is a traditional practice in the culture of medicine and medical education, and an accepted way of enculturating the young, helping them to “toughen up” for medical practice.

  • Students noticed the aggressive ways in which medical teachers ask questions, sometimes explaining it as reflecting a lack of teaching expertise.

  • The reported victims and perpetrators of teaching by humiliation included junior medical staff, who were subjected to the practices as much as students; they were equally likely to be the perpetrators, alongside senior medical and nursing staff.

  • The intimidating and humiliating practices were experienced and witnessed more in some settings than others: urban rather than rural hospitals; adult more than paediatric rotations; and in surgery and emergency departments.

Discussion

Our study found that many students in two large Australian medical schools had experienced or witnessed teaching by humiliation during their paediatric and adult clinical rotations. Decades after first being reported and despite the belief of some that students invent or overstate the problem, teaching by humiliation and mistreatment of students persist, often in more subtle forms than those reported in the past.

Providing the survey in paper form enabled ease of completion, resulting in a high response rate. However, the generalisability of the findings from this pilot study may be limited due to the use of an unvalidated survey, influence of the recency effect on recall of paediatric compared with adult clinical rotations, our decision to leave open the definition of teaching by humiliation, and inclusion of only two metropolitan medical schools. A larger study may determine the effect size. Further, responses about witnessing teaching by humiliation may have been subjective, given that a student is projecting his or her own views into a scenario. However, for this exploratory study, we wanted to gauge the extent of these practices, whether experienced or witnessed. Despite these limitations, our findings suggest a contemporary understanding of teaching by humiliation in Australian medical education.

Our research was conducted amid concern in medical education about a culture of harassment and mistreatment in medical schools,1,13 medical teachers’ continued use of the term “teaching by humiliation”6 and students’ reports of negative experiences, such as being “constantly ignored and told to disappear”.15 A large proportion of the students in our survey reported experiencing and/or witnessing a range of behaviours that they associated with teaching by humiliation. Although the proportion was higher in adult rotations, there was considerable reporting of these practices in paediatric rotations.

Our results confirm the findings of decades of research with medical students, in which up to 95% reported having experiences of behaviour they associated with teaching by humiliation.2,3,6,7,14,17,19–22 Any suspicion that our findings reflect overreporting of teaching by humiliation by medical students is challenged by research that found senior staff underestimated the prevalence of this practice in the training of junior doctors.5 More recently, a review of the literature found that less than a third of victims report this type of abuse because of a lack of awareness of reporting procedures, suspicion the report would not be acted upon, and fear of retaliation.21 In other research, students said they were advised against reporting.10 We assume that the medical students who voluntarily completed our anonymous survey reported accurately.

Our study showed that in the contemporary medical education environment, teaching by humiliation is most often manifested in subtle rather than overt behaviour, consistent with other recent research.12 More students reported experiencing or witnessing rudeness and belittling behaviour; fewer experienced or witnessed explicit yelling and swearing. The study also highlights the widespread practice of aggressive questioning as a teaching technique, which shames some students and is regarded as an abuse of the Socratic method.12

Up to half of the students in our study who had experienced or witnessed mistreatment considered it to be useful for learning. In research from Canada, junior doctors rationalised their experience of mistreatment, believing it was useful if the content of the teaching was important or if the learner had not understood the content presented in other ways.22 In addition, some junior doctors believed public chastisement and intimidating behaviour was just “redirection” and “the natural socialisation of a good doctor”.22 Future research could seek to understand what is at play in these beliefs.

Our study also highlighted that physicians and surgeons are not the only hospital staff responsible for mistreating students. Nurses, midwives and administrative staff were commonly named as perpetrators. Thus, when thinking about abuse as a cultural matter, our attention must be directed toward the culture of hospitals and all health care professionals, not just medicine or medical education.

The findings of our study raise four concerns: the effect on the individual student’s learning and mental health, the dissonance with and subsequent undermining of the formal professionalism curriculum, characteristics of the medical profession, and the future medical teaching workforce. We note, too, the potential for negative effects on patients and families who witness abusive behaviour.

For optimal learning to occur, the environment should be free of fear and unnecessary anxiety.23 Previous research has found teaching by humiliation can affect students’ mental health, having an impact on their confidence, loyalty to the institution and care of patients.21 A study in the United States found that mistreated medical students were more likely to be stressed, depressed and suicidal, to binge drink and to believe their faculty did not care about them.20 A more recent study found associations with student burnout.19

Our findings are at odds with the current explicit teaching of professionalism in medical schools. Whether professionalism is thought of as desirable professional characteristics or a process wherein practitioners become trustworthy, practices that novices experience as humiliating undermine what is taught.2 Habitual denial or rationalisation of students’ experiences of humiliation as being oversensitivity to negative feedback is unlikely to advance the profession.

The mistreatment of students also affects the profession in other ways. Two students in our study commented that they would not have trained in medicine if they had known about the mistreatment. Other research found that about 30% of students who had been mistreated had considered dropping out of medicine or would have chosen a different profession if they had known about the extent of mistreatment.7 In attempting to explain why medical students are mistreated, the authors of that study explored the “different moral orders” that characterise professions and highlighted the influence of the medical and hospital hierarchy on the institutionalisation of abusive behaviour.7 Others point to the hierarchical and competitive medical education culture6 and the “dog-eat-dog culture of the medical workplace”.10 The medical culture accepts disrespectful behaviour towards patients, staff and students that would not be acceptable in other social interactions.12 In our study, students considered teaching by humiliation to be part of the culture of medicine: senior and junior doctors do what was done to them as students, and the culture of “toughening up” the young is perpetuated.

It has been suggested that physicians’ values and behaviours develop from the attitudes they adopt during university studies.7 The risk is that through teaching by humiliation, some medical students will accept their place in the medical hierarchy,24 align their values to those of their teachers and adjust their career plans to survive.6,9 By doing so, they maintain the dominant, hierarchical culture of medicine24 and sustain a cycle of abuse wherein victims become perpetrators.1,23

As in earlier research, some students in our study suggested the solution is to help teachers gain an understanding of safe learning environments and develop approaches to teaching that do not rely on mistreatment.7,22 However, we suspect that because the problem is cultural and institutionalised, leaving a “transgenerational legacy”,1 it is unlikely to transform through improved teaching expertise alone. Rather, as a deeply ingrained cultural practice, mistreatment of medical students requires focused action to interrupt the existing culture and replace it with “a culture of compassion, tolerance, and respect”.25

As a cultural matter, mistreatment of students requires multilevel and long-term action, especially if commitment of resources to the professionalism curricula is to be productive. The profession and the discipline of medical education would benefit from research to understand the complexity of factors that allows the cultural practices to be perpetuated and to identify ways to shift the culture. At the same time, current and future teachers deserve meaningful, ongoing support and professional development, and students deserve support to be assertive and resilient.

1 
Analysis of medical students’ survey data about teaching by humiliation (n = 146)

Survey item

Paediatric rotation*

Adult rotations*

P

1. Experience of teaching by humiliation

28.8% (42/146)

74.0% (108/146)

< 0.001

3. Witnessed other students being taught by humiliation

45.1% (64/142)

83.6% (122/146)

< 0.001

5. Experience of being yelled or shouted at by medical or surgical teaching staff

1.4% (2/146)

13.7% (20/146)

< 0.001

6. Witnessed medical or surgical teaching staff yelling or shouting at other students

4.8% (7/146)

30.1% (44/146)

< 0.001

7. Experience of medical or surgical teaching staff being nasty, rude or hostile

31.0% (45/145)

55.9% (81/145)

< 0.001

8. Witnessed medical or surgical teaching staff being nasty, rude or hostile to other students

29.2% (42/144)

58.2% (85/146)

< 0.001

9. Experience of being belittled or humiliated by medical or surgical teaching staff

19.2% (28/146)

40.7% (59/145)

< 0.001

10. Witnessed medical or surgical teaching staff belittling or humiliating other students

22.9% (33/144)

56.9% (82/144)

< 0.001

11. Experience of being cursed or sworn at by medical or surgical teaching staff

3.4% (5/146)

4.8% (7/146)

0.48

12. Witnessed medical or surgical teaching staff curse or swear at other students

2.8% (4/145)

10.3% (15/145)

0.002

13. Experience of medical or surgical teaching staff asking questions in intimidating way

43.4% (63/145)

71.2% (104/146)

< 0.001

15. Witnessed medical or surgical teaching staff ask questions in intimidating way to other students

54.1% (79/146)

80.0% (116/145)

< 0.001

17. Witnessed or heard other hospital staff being rude to students

34.5% (50/145)

60.4% (87/144)

< 0.001

* Data missing for some participants.

2 
Mistreatment considered useful for learning by medical students

Survey item

Paediatric rotation*

Adult rotations*

2. Experienced teaching by humiliation and considered it useful for learning

50.0% (21/42)

40.7% (44/108)

4. Witnessed teaching by humiliation and considered it useful for learning

42.2% (27/64)

32.0% (39/122)

14. Experienced intimidating questioning and considered it useful for learning

42.9% (27/63)

40.4% (42/104)

16. Witnessed intimidating questioning and considered it useful for learning

40.5% (32/79)

35.3% (41/116)

* Denominators represent number of students who reported experiencing or witnessing each instance of teaching by humiliation.

3 
Themes identified in medical students’ comments on the open-response question, with illustrative quotations

Theme

Example quotations

A spectrum of experiences, interpretations and explanations: devastating but acceptable

“Teaching by humiliation is despicable and does not help anyone.”“It is ‘humiliating’ to be put on the spot and have your knowledge and understanding tested publicly, but I find it to be a fantastic way to learn and consolidate. Rudeness and insults, however, should have no place in this method.”

Medical culture: necessary toughening up, transgenerational legacy; other effects: attendance, career choices

“I get the feeling it is culturally ingrained and perpetuated.”“I understand they think it’s good for character and learning but it just demoralises you and makes you feel defeated and disheartened and not want to show up.”“The culture of bastardisation in the medical profession has to stop. Had I known it was like this, I never would have given up a good job that I loved to do medicine.”

Teaching skills, questioning skills: the cause, the problem and a potential solution

“You learn a lot from someone who’s friendly, engaging and WANTS to teach. I don’t mind being asked questions, it’s just the manner in which they do it.”“This is still part of the medical culture, though I think it is reducing. I wonder whether it is the case of some do not know how to educate in any other way.”

Groups and contexts: victims and perpetrators, specialties, seniority

“Common for consultants to expect a large amount of knowledge from you in a specialist area and then say ‘you know nothing and are pathetic’ when you don’t.”“All consultants were excellent but I found some of the other members of the medical team (eg, Fellows, registrars) often neglected or belittled us.”

Different settings

“It is common for surgeons to teach [by] questioning you in front of your peers and humiliating or making fun of you if you get the wrong answer.”“I have recently come back from a rural term, where teaching and staff attitudes were excellent.”

Sexual equality, discrimination and harassment in medicine: it’s time to act

More enlightened teaching would go a long way towards solving these problems

Among entrants to Australian medical schools, women slightly outnumber men. Of a total of 14 384 domestic medical students enrolled in medicine in 2014, (51.3%) were women.1 By the time these women complete their training, significant gender imbalances will emerge in their fields of practice, with palliative medicine and sexual health being the only specialties with more women than men.

Redressing sexual inequalities in medicine will require more than increasing the numbers of women in male-dominated specialties; the changing roles of the sexes in society, learning styles, hospital-based training and the professional identities of women in a largely masculine medical hierarchy are all deeply relevant.

A 2015 United States study of women’s perceptions of discrimination during surgical training and practice found that most observed or experienced gender-based discrimination during medical school (87%), residency (88%) and practice (91%).2 These results suggest that bullying and discrimination are rife, and complaint mechanisms inadequate. Studies of women in North America show they experience greater levels of abuse than men, and that the high prevalence of harassment and discrimination has not diminished over time.3–5 A 2014 systematic review and meta-analysis of harassment and discrimination in medical training showed that verbal harassment was the most common type of abuse and that physical abuse was the least common.3 Abuse (verbal, physical, sexual, harassment, sex discrimination) affects performance and leads to stress and discomfort,4–6 which in turn affects how supervisors and teachers view particular students. Women in all stages of medical training have been subjected to harassment and discrimination — beginning as early as medical school. No area is untouched.

Medical school

Medical students, eager to assume a professional identity, absorb the medical culture. Many argue that this is necessary for success, but enculturation can lead students to believing that progression in medicine requires them to accept the status quo.5 Students quickly learn that conformity and complacency are crucial components of learning and professional advancement;7 complaining is not an option. An Australian study pointed out that a reluctance to report bad behaviour might relate to the legalistic framework for managing complaints, particularly immediate notification of the complaint to the perpetrator and identification and subsequent vilification of the whistleblower.8

In 2007, American medical students observed that unprofessional medical educators, who were protected by an established hierarchy of academic authority, did more to harm students’ virtue, confidence and ethics than was acknowledged.9 They said that students struggle to understand the disconnection between the explicit professional values they are taught and the implicit values of the hidden curriculum.9 A 2012 US longitudinal study of third-year female medical students showed that gender would play a substantial role in their future careers, and that inappropriate gendered behaviour was inevitable in medical training generally.3

Trainees

Clinical training in hospitals involves working in a hierarchical team structure headed by a consultant, with the least experienced intern at the bottom. This crucial phase — a time when the dynamics of hierarchy and interpersonal relationships enhance or impair learning — can influence career choices.4 Good supervisors can have positive influences on career choices; conversely, bad ones can quickly diminish aspirations. A 2005 US study of 4308 respondents (medical students, surgical residents, fellows and fully trained surgeons; 76% male) showed that men and women had similar reasons for choosing surgery, but for women, a significant factor was their positive clerkship (training) experience and availability of female role models.10 Women were less likely to agree that their surgical training experiences were comparable to those of their male peers.10 A 2012 Australian study of doctors’ preferences for choice of specialty reported that life balance and capacity to provide continuity of care with opportunities for academic or procedural work were highly influential.11 This study did not break down its findings for men and women, but 61.5% of respondents were women. The study concluded that doctors prefer fewer hours of work, control of their working hours, low level on-call responsibilities, academic opportunities and significant procedural work.11

Surgery

In March this year, the Royal Australasian College of Surgeons established an Expert Advisory Panel to examine its culture after complaints of bullying and harassment of female surgical trainees reached the media. Surgery is popular among medical students, but their enthusiasm diminishes significantly for both sexes, particularly for women, by the time they need to decide on a specialty. Reasons include the heavy workload and a desire to have children.12 Once they become surgeons, women are more positive about their career choice than female medical students contemplating such a career.13 A 2014 literature review on gender-based differences in surgical training found that the lack of role models and gender awareness were responsible for the low numbers of women training in surgery. Women were unlikely to meet a female surgical role model during their training, and were more likely to experience gender-based discrimination during their surgical rotation (P < 0.05), leaving them with a perception that surgery was incompatible with a rewarding family life, happy marriage, or having children.12

Only 10% of surgeons in Australia (539/5507) are female. The Box shows a breakdown of Australian medical practitioners by specialty and sex. Less than 3% of female doctors are surgeons and less than 1% of all doctors are female surgeons. Among surgical specialties, women are most highly represented in paediatric surgery (29%) and least highly represented in orthopaedic surgery (3%) (Appendix).

Role strain, harassment, career penalties associated with maternity leave, and gender-based pay differentials are common challenges faced by women in many workplaces. However, in medicine generally, and in surgery in particular, there is an additional constraint. The main difference from medical school learning is that service provision is a significant component of the learning contract between the trainee and the employer. While trainees are required to focus on both learning and providing a service, the hospital is focused on patient care. A Canadian study describes sexual stereotyping that classifies females as being concerned about the welfare of others and being motivated by stronger needs for nurturance, in contrast with males who are classified as striving to master, dominate and control the self and the environment.14 In hospitals, these attributes may lead women to prioritise patient safety ahead of their own learning needs.

US studies show that, while female medical students perform equally well on objective assessments, they consistently report less confidence in their abilities, and experience significantly more anxiety about their performance.15 When making the transition to the workplace, female doctors, who are often more cautious, will worry about their inexperience, while many male doctors (with the same experience) will emphasise their skills and present as being ready for the clinical challenge. A supervisor responsible for patient care is likely to select the more confident trainee because of their work schedule and their assumptions (founded or unfounded) about trainees’ competence. Hesitating and underconfident women miss out on opportunities because of their fear of not being good enough. This is particularly the case in procedural medicine.

All of this means that women gain experience at a slower rate than men; at the same time, the culture of “can do” prejudices them against specialties such as surgery. Surgery, with its roots in the male apprenticeship model, may underappreciate female learning styles, which can lead supervisors to think female trainees lack commitment or are not cut out for the job, leading to women being belittled, excluded and bypassed on the basis of incorrect assumptions about skills and knowledge. A Finnish study found that male medical students were exposed to and performed surgical procedures significantly more often than female students.16 This is where women may be at a disadvantage — their learning approaches and styles may not be as suited to the opportunistic supervision learning method used in hospitals that requires an assertive personality and a “can do” attitude that are not necessarily the best for patient care, but are best for progress in specialty training.

What can we do?

We need to heed the prevailing belief held by students that the medical culture is resolute. Governance structures for complaints about the behaviour of teachers should be transparent and accessible to medical students. Token attention to grievance processes without removing teachers who behave badly reinforces the belief that nothing can or should change. Targeted education is required, with accountable and transparent processes in place to ensure that zero tolerance of harassment and bullying is the norm.

Surgery is one area where the experience of women is well documented and consistently found wanting. If the surgical culture were reformed to accommodate gender differences in training, it may become a template for other areas of medicine. Recent research shows there is a generational shift among both men and women in relation to the balance between personal and professional lives, with participants saying that their priorities are radically different from those of their senior colleagues.17 Given the increasing role played by women in medicine, it is time to reflect on the models underpinning specialty training and to look to methods shown to enhance learning for both sexes. Nurturing female surgeons to become clinical supervisors and encouraging female surgeons to teach and be involved in mentoring programs would help.

College policies and guidelines about harassment and discrimination alone will not change the culture — these must be accompanied by swift and strong action by college representatives when instances are brought to their attention. That men and women have inherently different characteristics and learning styles is now well established; the next step is to explicitly acknowledge these differences in the design of medical education. A failure to do this will maintain the status quo and perpetuate discrimination against women in medical training. Allowing a supervisor who is known to be sexist or discriminatory to teach brings into question the sincerity of a college in dealing with bad behaviour. Colleges need to have zero tolerance for harassment and discrimination.

Acknowledging the powerful influence of supervisors on learning outcomes for trainees is crucial. In addition to excellent knowledge in their disciplines, clinical supervisors need to have knowledge and skills in the areas of teaching methods, different learning styles, ethics, patient safety and sexual stereotyping. Being a senior doctor is not a qualification for teaching in itself, and the assumption that it is exposes medical education to the risk of nothing changing. Clinical supervisors need to be accredited. Accredited supervisors can reinforce the potential of all trainees rather than acting as a de-facto barrier to women’s entry into male-dominated specialties.

Medical practitioners registered in Australia at 28 February 2015 by specialty, and proportions by sex

Specialty

Total number

Proportion

Female

Male

Addiction medicine

165

24%

76%

Anaesthesia

4 579

28%

72%

Dermatology

504

44%

56%

Emergency medicine

1 649

32%

68%

General practice

23 759

40%

60%

Intensive care medicine

808

16%

84%

Medical administration

329

32%

68%

Obstetrics and gynaecology

1 834

40%

60%

Occupational and environmental medicine

301

17%

83%

Ophthalmology

951

20%

80%

Paediatrics and child health

2 408

46%

54%

Pain medicine

251

22%

78%

Palliative medicine

293

55%

45%

Pathology

1 985

39%

61%

Physician

9 325

27%

73%

Psychiatry

3 385

38%

62%

Public health medicine

432

39%

61%

Radiation oncology

361

40%

60%

Radiology

2 255

24%

76%

Rehabilitation medicine

468

42%

58%

Sexual health medicine

116

55%

45%

Sport and exercise medicine

119

22%

78%

Surgery

5 507

10%

90%

Total

61 784

33%

67%

Source: Australian Health Practitioner Regulation Agency’s Public Register of Medical Practitioners.

Intern system needs upgrade, not overhaul

Calls to dump the current medical intern training system and replace it with a two-year prevocational program or absorb it in the final year of medical school are ill-considered and unnecessary, the AMA has told a Government inquiry.

In a submission to the Council of Australian Governments’ Health Council National Review of Medical Intern Training, the AMA argued that although aspects of the current intern system could be improved, any changes should be incremental and underpinned by evidence.

AMA President Professor Brian Owler and AMA Council of Doctors in Training Chair Dr Danika Thiemt told the review there was nothing to show that a wholesale overhaul of existing arrangements was warranted.

“It is hard for us to agree that the current internship model is flawed when there is so much variety and flexibility across Australia, and when the calibre of doctors in training emerging are world-class and are regarded as such,” they said. “That is not to say there is no room for improvement, but we do not believe this has to take the shape of frame-breaking change, and any change should be informed by a strong evidence base.”

More from Australian Medicine: Plan for the future, no more piecemeal cuts: Owler

The COAG review is being conducted amid expectations a growing number of medical graduates will miss out on an internship place this year as Federal and State governments squabble over funding and responsibility.

A national audit found that there was a shortfall of 366 intern places this year, and Australian Medical Students’ Association President James Lawler said anecdotal reports indicated there would not be enough places in 2016.

“This is a bittersweet time for medical students around the country, with excitement at their internship offers conflicting with the fact that they are now competing for training places in a system that is already overwhelmed,” Mr Lawler said.

The review has been asked to examine four options, ranging from leaving the system as-is, to increasing intern term periods, establishing a two-year UK-style prevocational training program or drawing internship-like duties back into the final year of medical school.

In their submission, Professor Owler and Dr Thiemt argued strongly against the latter two options.

“The AMA believes there is no evidence to support radical changes to the structure of the internship along the lines suggested in [these] options,” they wrote. “These options are unrealistic, would require a significant investment of resources, including cost and additional supervisor input, and may result in unintended negative consequences. In any case, it is unlikely that cash-strapped jurisdictions would be in any position to fund them.”

The AMA leaders said the UK-style model might be superficially attractive, but there was no evidence that it would deliver any improvement on current arrangements, while the type of learning gained through university education was “very different” from that provided in a workplace, where interns are required to make decisions about care, albeit under supervision.

More from Australian Medicine: IT investment key to health savings

“There is no evidence to show that the current model of internship in Australia is ‘broken’, or that radical changes to its structure are required,” Professor Owler said. “The current model of intern training in Australia has served the community well. Instead of sweeping changes, we need to build on what works.”

But he said the review had highlighted a lack of data surrounding the quality and effectiveness of the intern year in preparing junior doctors for independent practice, and the AMA has proposed that remedying this be a priority.

“The AMA believes the review must propose new systems to provide better information on the quality of medical intern training, the transition from medical school to intern training, and in the remaining prevocational and vocational training years,” the AMA President said.

The AMA has recommended there be a national survey of medical training, similar to the survey that the General Medical Council undertakes in the United Kingdom.

Adrian Rollins

Foreign aid cuts a health disaster for many

As a final-year medical student, I am the first person to admit that I’ve been very fortunate so far in life.

Most of these blessings are facets of our rich, first-world society – free, high-quality health care and cheap tertiary education, not to mention the basics that I take for granted every day like somewhere to live, food and clean water.

Sometimes, though, it can become easy to forget two things. Firstly, I did nothing to deserve these blessings. Secondly, billions of people around the world are less privileged than I am. For these reasons, I am thoroughly disappointed in the $1 billion cuts to foreign aid announced in the recent Federal Budget.

Under the previous Labor government, Australia had a bipartisan commitment to contribute 0.5 per cent of its Gross National Income (GNI) to foreign aid, though this was delayed several times.

Little did we know at the time that the 0.38 per cent of GNI level reached at the time Labor left office would be the peak.

Since then, a succession of major Budget cuts by the Coalition Government have driven to our foreign aid contribution down to the point where we are now only giving 0.22 per cent of our GNI.

These cuts fly in the face of the 0.7 per cent of GNI commitment Australia agreed to at the UN in 1970, and which has been repeatedly reaffirmed ever since.

Meanwhile, our counterparts in the UK have recently passed a Bill legally ensuring that they will continue to give at least 0.7 per cent of GNI as aid.

Doctors and medical students alike should be unequivocally outraged.

Our profession is one in which we are privileged to have the opportunity to help people each and every day.

In medical school, we are taught that it is essential to be an advocate for our patients, especially those who have no voice. We must apply this principle to the people of the developing world and fight for effective altruism.

The recipients of Australia’s development assistance have no real means by which to communicate their needs with our government, but doctors can take up this mantle. Of course, various advocacy groups are already doing this. However, it is clear that current efforts are inadequate.

We need to face the facts – these aid cuts will equate to lives lost. Real people with families will die. Australia’s foreign aid provides vital health services in developing countries, as well as emergency assistance to other countries when disasters strike, such as the recent earthquakes in Nepal.

If Australia, one of the most economically developed countries in the world, refuses to provide these funds to countries in our region, who will?

We tend to forget it, but giving aid also benefits us.

Along with the obvious advantages of diplomatic relations associated with generous aid, Australia should leverage its expertise as a leader in tropical diseases to fight the epidemic of tuberculosis in Papua New Guinea, or else the consequences might spread to our shores. Instead of diverting our aid money to offshore detention programmes for refugees, we should invest in developing countries to alleviate poverty and assist displaced people whose lives have been torn apart.

It is the responsibility of doctors to advocate for not only the health outcomes of Australian citizens, but those individuals without the good fortune to be born within our sunny borders. Foreign aid is an essential component of Australia’s contribution to global health and wellbeing, and must be consolidated rather than compromised.

Nicky Betts is a final year medical student at the University of Western Sydney, and Vice-Chair External of AMSA Global Health.[1] [2] [3] [4] [5] 

We’re overdosing on medicine – it’s time to embrace life’s uncertainty

The more we learn about the problem of too much medicine and what’s driving it, the harder it seems to imagine effective solutions. Winding back unnecessary tests and treatments will require a raft of reforms across medical research, education and regulation.

But to enable those reforms to take root, we may need to cultivate a fundamental shift in our thinking about the limits of medicine. It’s time to free ourselves from the dangerous fantasy that medical technology can deliver us from the realities of uncertainty, ageing and death.

We’re all ill now

A growing body of evidence shows that when it comes to health care, we may simply be getting too much of a good thing. In the United States, it’s estimated that more than US$200 billion a year is squandered on unnecessary tests and treatments. In the United Kingdom, senior medical groups are calling on doctors to reduce all the wasteful things they do. And in Australia, the Choosing Wisely campaign recently kicked off with lists of unnecessary and harmful health care.

Not only are we overusing pills and procedures, we’re creating even more problems with “overdiagnosis” by labelling more and more healthy people with diseases that will never harm them.

Screening programs targeting the healthy can detect potentially deadly cancers and extend lives. But they can also find many early abnormalities that are then treated as cancers, even though they would never have caused anyone any symptoms if left undetected.

The common ups and downs of our sex lives are often re-labelled as medical dysfunctions. Older people who are simply at risk of future illness – those with high cholesterol, for instance, or reduced kidney function, or low bone mineral density – are portrayed as if they were diseased.

The doctors expanding disease definitions and lowering the thresholds at which diagnoses are made are often being paid directly by the companies that stand to benefit from turning millions more people into patients.

We're overdosing on medicine – it's time to embrace life's uncertainty - Featured Image

What’s driving all this excess is a toxic combination of good intentions, wishful thinking and vested interests – fuelled by sophisticated diagnostic technology that often offers the illusion of more certainty about the causes of our suffering. It’s as if we’re seeking technical fixes for the fundamental reality of human existence – uncertainty, ageing and death.

Fundamental shifts in thinking

Indeed, intolerance of uncertainty has been suggested as among the most important drivers of medical excess. Doctors order ever more tests to try, often in vain, to be sure about what they’re seeing – to be more certain. But disease and the benefits and harms of treating it are inevitably fraught with uncertainty because we’re trying to apply knowledge derived from populations to unique individuals.

More broadly, uncertainty is the basis of all scientific creativity, intellectual freedom and political resistance. We should nurture uncertainty, treasure it and teach its value, rather than be afraid of it.

No matter how much the marketers of medicines try to make us feel broken by the mere passing of time, ageing is not a disease. Disease definitions that equate “normal” with being young are fundamentally flawed and require urgent review.

The doctors who defined osteoporosis, for instance, arbitrarily decided the bones of a young woman were normal, automatically classifying millions of older women as “diseased”. Similarly, those who defined “chronic kidney disease” have classified the normal changes in kidney function that happen as many of us age as somehow abnormal. Brace yourself for the impending arrival of pre-dementia, the latest attempt to medicalise the ageing process.

In all cases, the people who wrote these definitions included those with ties to pharmaceutical companies – reinforcing the need for much greater independence between doctors and the industries that benefit from expanding medical empires.

Rays of hope

Everyone must die and everyone, patients and doctors alike, is more or less fearful of dying. So, it’s perhaps not surprising that we so often turn to biotechnical approaches rather than paying real attention to the care of the dying – a core purpose of medicine.

We're overdosing on medicine – it's time to embrace life's uncertainty - Featured Image

 

What we tend to forget is that medicine cannot save lives – it can only postpone death. Yet we persuade ourselves it might somehow keep extending our lives, and we come to view almost every death as a failure of medicine.

Doctors persist with treatments for the dying well after these have become obviously futile, often with the support of patients or their families. Deep, difficult and necessary conversations about death and dying are only possible in a context of trust, which becomes increasingly difficult as health-care systems are ever more fragmented.

But, there are many positive signs of change within medicine. The Choosing Wisely campaign mentioned above is a partnership between doctors and wider civil society. And it’s now an international movement to wind back excess medicine.

A new approach called shared decision making is promoting much more honest conversations between doctors and the people they care for, embracing uncertainty about benefits and harms, rather than peddling false hopes. Another new approach among GPs called quaternary prevention is urging doctors to protect people from unnecessary medical labels and unwarranted tests and treatments.

Perhaps all these new movements will re-establish doctor-patient trust, helping us reduce fear and embrace uncertainty, and end the pretence that medicine can cure ageing and even death. Biomedical science has made our lives immeasurably better, but it’s time to accept that too much medicine can be as harmful as too little.

Former president of the UK Royal College of General Practitioners, Dr Iona Heath, co-authored this article. Dr Heath will deliver a free public lecture on the problem of “Too Much Medicine” at the University of Sydney this Wednesday night, August 5.

The Conversation

Ray Moynihan is Senior Research Fellow at Bond University.

This article was originally published on The Conversation.
Read the original article.

Some truths about the “low” childhood vaccination coverage in Sydney’s eastern suburbs

Among the hype and controversy prompted by the Australian Government’s recent announcement that conscientious objectors to childhood vaccination would lose childcare subsidies and part of the family tax benefit,1 including the accompanying media rancour,2 it is worth noting that published vaccination coverage figures based on the Australian Childhood Immunisation Register (the Register) are only an estimate of the extent of coverage. In the case of the eastern suburbs of Sydney, they significantly underestimate the true coverage.

In January 2002, we studied a cohort of children aged between 12 and less than 15 months residing in south-eastern Sydney; according to the Register, 81% had received all vaccination doses scheduled for the first year of life. Systematic follow-up — by contacting providers and/or parents — of one-third of the children recorded by the Register as being overdue for one or more do ses established that the overall proportion of children who were up-to-date with their vaccinations was, in fact, at least 91%.3

In March 2013, we undertook a similar follow-up survey, on this occasion focusing on children aged between 12 and less than 15 months who resided in the Waverley and Sydney City local government areas, where the Register-based coverage level was reported as being 87%. These areas were targeted because this figure was significantly lower than the overall south-eastern Sydney figure of 91%. Of 112 children recorded as being overdue for one or more vaccinations and whose records were checked with providers and parents, 37 (33%) were actually up-to-date, leading to an increase of 4% in the estimated total coverage, to at least 91%.

Although there is evidence of underreporting of childhood vaccinations in urban areas,4 the purportedly low childhood vaccination coverage in parts of Sydney has been cited critically on a number of occasions, including in the New South Wales parliament.5 On the basis of our follow-up surveys, which we have continued since 2013 in collaboration with Medicare Locals, we have established that published coverage rates based on Register data are significantly underestimated.

Discussions with medical practice staff and support officers suggest that in many instances where children have been incorrectly recorded in the Register as being overdue for vaccinations, it is because general practitioners do not understand the reporting process, data have been entered incorrectly, or there are technical problems in the practice software that transmits encounter data to the Register.

In some localities, including ours, the true level of coverage is higher than that reflected in the Register. It then becomes a public health priority to identify those populations where coverage is genuinely low, so that education and other appropriate efforts can be properly focused. To obtain a more accurate picture of variations in coverage, investment is required to provide ongoing support to general practice staff and to ensure that practice software interfaces seamlessly with the Register.