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Rude Medicine

Are hazing, harassment and abuse an inevitable part of training?

The New Physician May-June 2007
Bullying surgeons. Power-pimping attendings. Boorish residents. Medical students are warned at the outset that these characters are fact, not fiction, on the wards, and trainees need to grow thick skins. Bad-mannered behavior seems more accepted in the medical education community than in other forms of professional training, and hazing so ingrained that it has become part of the didactic experience. But is it really necessary to strip down student egos to create tough, capable physicians? To a point, yes, say both
students and their teachers.


PIMP CULTURE


Take the tradition of pimping, described in British medical literature as early as 1628. The rapid-fire questions posed by attendings to catch interns or students off-guard were termed “Puempfrage” in 1889 by German surgeon Dr. Walter Karl Koch, who loved to use the technique on his rounds in Heidelberg. Dr. Abraham Flexner, on his visit to Johns Hopkins University in 1916, wrote admiringly of rounding with the famed Dr. William Osler, who “riddles house officers with questions. Like a Gatling gun…. [S]tudents call it ‘pimping.’ Delightful.”


But today, the concept of pimping often carries connotations of a fearful and humiliating, if necessary, rite of passage for physicians-in-training. In his now-legendary 1989 tongue-in-cheek essay, “The Art of Pimping,” published in the Journal of the American Medical Association, Dr. Frederick L. Brancati wrote: “On the surface, the aim of pimping appears to be Socratic instruction. The deeper motivation, however, is political. Proper pimping inculcates the intern with a profound and abiding respect for his attending physician while ridding the intern of needless self-esteem…. Pimping welds the hierarchy of academics in place, so the edifice of medicine may be erected securely, generation upon generation. Of course, being hammered, wrought and welded may, at times, be somewhat unpleasant for the intern. Still, he enjoys the attention and comes to equate his initial anguish with the aches and pains an athlete suffers during a period of intense conditioning.”


While “unpleasant” perhaps, pimping is typically harmless, and is recognized by students as an important element of pedagogy and of “the socialization process into the medical community,” according to researchers in the department of behavioral sciences at Northeastern Ohio Universities College of Medicine. Their interviews with a cohort of fourth-year medical students in 2005 revealed that students note the hierarchical nature of pimping, viewing it as a tool for attendings or residents to assess students’ levels of knowledge. Although some respondents experienced so-called “malignant pimping”—humiliation by incessant questioning or questions inappropriate to their level of training—students in the sample were overwhelmingly positive about the practice and its effectiveness as a teaching tool.


“In my experience, even the most brutal pimping experience was not unjust in the information that was being requested, only in the method of delivery,” says Victoria Wong, a fourth-year at the John A. Burns School of Medicine, University of Hawaii at Manoa. “As for the psychological effects of such sessions, I must say that they toughened my skin, and I have often been grateful for such character building because it comes in handy when dealing with patients who are bullies.”


Still, overbearing behaviors commonly cross over into the darker territory of belittlement and harassment, according to students responding anonymously to the Association of American Medical Colleges’ (AAMC) annual Graduation Questionnaire (GQ). The AAMC has been asking graduates about experiences of mistreatment for the past several years. In its 2006 GQ, more than two-thirds of respondents (68 percent) said they had been mistreated by hospital clinical faculty, and more than 70 percent by interns and residents. Only 36 percent reported these incidents to their schools, however. Those who kept quiet often did so because the incident “did not seem serious enough to report” (40.7 percent), they did not know what to do about it (20.9 percent) or they were afraid of reprisals (54.2 percent). See chart below.





Interestingly, the GQ has shown that far more students today are saying they have experienced mistreatment than just a few years ago: In 1998, only 31.8 percent said they had been mistreated by hospital clinical faculty, and only 33.5 by interns or residents.


So are incidents on the rise, or are today’s students just a more sensitive bunch?


Dr. Jordan Safirstein, an interventional cardiology fellow at Saint Vincent’s Medical Center in New York City and editor-in-chief of the online housestaff community www.StopPaging Me.com, thinks it’s the latter: Most medical students today “are cry babies,” he says. “For the most part—and I am speaking in massive generalities and from personal experience—most of them have never played team sports or been subjected to authoritative figures other than their parents. Whenever I’ve heard residents repetitively complaining about their superiors’ behavior, it was usually as much the fault of the complainant. Sometimes interns and juniors need to know that they are not doing things well or well enough. And not everyone delivers teaching in a hold-your-hand way.”


A SUCK-IT-UP STATE OF MIND


Undoubtedly for many medical students, enduring humiliation or mistreatment—from verbal insults to running menial personal errands for residents—is just the price of pursuing a demanding career. Whenever specific claims of superiors going over the line come up on student discussion forums and listservs, complainants are inevitably bombarded with exhortations to suck it up and stop whining. Didn’t they know what they were in for when they signed up for the exalted calling of medicine?


More general forum discussions of medical student abuse prompt plenty of dismissive comments as well, like these from the Student Doctor Network: “In no way are students the victims; they knew what they were getting into when they signed up”; and, “Perhaps [it is] because this is a job that an immature, wimpy little brat won’t be able to handle…. So, the hazing is sort of like a boot camp to prepare you for what is ahead.”


And this comment, from a teaching resident: “You only get harassed if you let yourself get harassed. Treat everyone in a forthright manner, look them in the eye, and be respectful without being obsequious and nobody is going to harass you.”


After four years of medical school, Wong’s perspective is this: “I believe it is a myth that medical students are belittled or mistreated by those who are teaching them. Certainly, having to ‘suck it up’ is a common part of a medical student’s education. In fact, it is a perpetual state of mind, rather than intermittent endurance of specific occurrences of injustice and annoyance. The obstacles of the medical student…have more to do with physician egos and scut work, rather than outright mistreatment. It is difficult to determine what behaviors of superiors are uncalled for.”


Certainly, defining what constitutes real abuse is challenging, since it deals in the gray areas of individual behaviors and perceptions. Both victims and tormentors may subscribe to the imprecise notion that “I know it when I see it.”


Determining if a student has been mistreated “is a very fuzzy line, because it’s in the eye of the beholder,” says Dr. Leslie Kahl, professor of medicine and associate dean of student affairs at Washington University School of Medicine in St. Louis (WUSL). Her office is in charge of handling incidents of student abuse, but she notes that she receives very few formal complaints. “Occasionally a student reports that a line has been crossed and we investigate, then get five other stories from five other people who were present.”


This is understandable, she says, because these incidents typically occur in a stressful, fast-moving setting. “Someone gets shoved, but to other observers, the person was just being moved out of the way.”


Although WUSL takes student mistreatment very seriously, publishing a detailed policy on its Web site defining medical student abuse and channels for reporting it, Kahl still encourages students to handle all but the most egregious incidents themselves before involving administrators. “We advise our students during orientation that often the best way to deal with it is [to talk to the offender] right at the time, making sure to deal with the facts and their own feelings, and not to attribute emotions or motivations to the person who offended them—not to pass judgment.”


This approach “almost always leads to immediate resolution,” she notes. But when students don’t feel comfortable dealing directly with the individual involved, “we tell them they can talk to that person’s supervisor, and so on up the line, all the way to me. We offer many pathways, since different situations require different responses. So we try to be flexible in our response.”


Consequently, her office rarely gets involved, she says. “They usually deal with their feelings by talking it out with their friends or resolving it directly with the transgressor or a superior.”


Kahl does acknowledge how shocking it can be for a student the first time he or she is sharply criticized or knocked aside during a procedure. “It may sound stereotypical, but the way [physicians] behave differs from rotation to rotation, which can be difficult for the novice student. He or she may have just come from pediatrics and into surgery where expectations and behaviors are different. As a senior clinician, I know this, but students can be caught off-guard.”


THE REAL DEAL


But for one medical student, an attending’s role-playing lesson in dealing with unpredictable psychiatric patients suddenly turned into a terrifying threat. “Basically, my attending…pulled a Bowie knife on me.” Another student, also speaking anonymously, says that when she politely and repeatedly declined her attending’s efforts to get her into a residency program he favored, he angrily spit on her.


As these and many other documented instances show, serious medical student abuse can and does occur, and educators agree it should not be tolerated.


The Liaison Committee on Medical Education, which accredits medical schools, leaves it to institutions themselves to establish standards of conduct “in the teacher–learner experience” and how infractions will be handled. However, the American Medical Women’s Association offers more specific guidance for members in a detailed position statement delineating examples of abuse. They include:


  • Verbal comments of a derogatory or a demeaning nature that do not contribute to a constructive learning environment
  • Physical violence of any nature
  • Physical threats or punishments
  • Sexual harassment
  • Degrading comments or discrimination based on gender, nationality, age, religion, ethnicity, sexual orientation or physical characteristics
  • Grading or threats of grading used to punish a student rather than to objectively evaluate academic or clinical performance
  • Attempts at deception concerning credit for the work of others or mistreatment in the care of patients
  • Request for the performance of personal services
  • Requiring the performance of hazardous medical procedures without sound medical indication or without proper protective equipment


Mistreatment of students can become institutionalized, says Kahl, and occurs when a malignant training culture has been accepted for too long. Typically, “the more senior offenders are simply left alone” with no consequences, and the tradition marches on.


According to the American College of Physician Executives’ 2004 physician behavior survey, more than 95 percent of responding members said they encountered disruptive and even dangerous physician behaviors on a regular basis.


The operating room is where some of the worst offenders can be found, ruling military-style, and commonly acting on the assumption—sometimes accurately—that doing something wrong or too slow is not an option.


“In surgery, there’s a culture where a surgeon is in charge and that culture exists for a lot of reasons,” says Brian Hurley, a fourth-year at the University of Southern California Keck School of Medicine and vice president of the American Medical Student Association. “Sometimes surgeons will run their OR like a king would run a kingdom.”


One surgeon he worked with recently was generally “mild-mannered” through every facet of his demanding day—patient visits, student interactions, policy meetings. But when he stepped into the glare of an operating room, Mr. Hyde turned into Dr. Jekyll. “It was just a stream of negative; anything he saw that was wrong, he would be very vocal about,” Hurley says. “Feelings didn’t matter.”



THE PRICE OF ARROGANCE


So, what’s the big deal if a student’s or nurse’s feelings get bruised by a particular physician with a perpetually sour attitude?


“It is patient safety,” says Hedy Cohen, vice president of the Institute for Safe Medication Practices, a nonprofit organization that reviews and provides education on medication errors and adverse events for the health-care industry. A constantly prickly physician is less easily approached than a friendly one. And without open communication, patient safety is compromised.


“If you have a nurse or pharmacist or another physician who gets an order or sees something they want to discuss with [someone who] is consistently rude or doesn’t listen,” she points out, then he or she might attempt to bypass the physician, and errors occur. The argument for team-oriented medicine was never more clearly asserted than in the Institute of Medicine’s 1999 report, “To Err Is Human: Building a Safer Health System,” which listed medical accidents as one of the leading causes of preventable deaths in the United States, estimated at 44,000 to 98,000 per year.


Indeed, agrees Dr. Luis T. Sanchez, director of Physician Health Services for the Massachusetts Medical Society, what is the point of having qualified students, nurses, technicians and residents around if you intimidate them into not speaking freely? “We probably need to be often authoritative, but we should never be authoritarian,” he says.


Optimists about the future of medical education point to hopeful shifts toward teaching a team approach to care. Old-school docs, initiated by their own hazing rotations years ago, now have patients who research their illnesses on the Internet and are sometimes better informed than they are. Physicians are now on care teams that include “the nurse, the secretary, the janitor,” Sanchez jokes. “We have to get along with the parking attendants, the licensing boards, [and] managed-care people.” He adds, “From my point of view, equally important as learning about cardiac exams and how to treat a broken leg is to learn how to behave correctly when under stress.”


At the University of Southern California, for example, “teamwork is a big push,” Hurley says. In many classes, “students get together in teams instead of learning by lecture, so you’re taught in an integrated manner.” Still, “business schools are head and shoulders above medical schools” in teaching teamwork and leadership, adds Hurley, who also holds a business degree.


INTERVENTION


Pamela Rowland, director of the office of professional development at Dartmouth Medical School, has been rescuing doctors from themselves for almost 20 years. She might get a call from a licensing review board, an attorney, the American College of Physicians or a hospital administrator looking for help for a doctor who has lost it too many times. “I go into some difficult situations, where somebody is on their last chance. In other words, if I can’t turn it around, they’re in real trouble,” she says.


Rowland is part of a heightened response to behavioral issues in medicine that includes hotlines for medical students; coordinated responses from nurses to rise up and help, rather than combat the physician who acts out of line; and wellness programs for difficult doctors themselves.


The good news is that when physicians turn their intelligence, goal-setting and other inherent powers toward self-improvement, the results are almost always successful, she says. The bad news is that they usually won’t make the first appointment unless given a serious nudge.


And that nudge may be coming more readily: In April, the Joint Commission on Accreditation of Healthcare Organizations approved a new standard on physician behavior that will require hospitals to bring professionalism policies up to code, including what to do when someone crosses the line.


Kahl has found that there is a lot schools can do to protect the student– preceptor relationship. “One thing institutions can do is to specifically define the expectations teachers and learners have for each other.” Another is to have a method for identifying problem preceptors and then either weed them out or ensure they adapt their behaviors.


She recommends that schools “have an evaluation process that allows students to give feedback about specific individuals they had trouble with. Repeated citations of the same person will show a clear pattern, so that it should be possible for a course director to address the problem, or lay it at the feet of the department head.” The problem physician might then “get a talking-to, or undergo sensitivity training, or just no longer have students assigned to him or her.”


Kahl notes that while students want the process to be completely anonymous, faculty members don’t, and she doesn’t blame them. “The stakes are very high for the accused,” she says. But one school she knows of came up with a “very clever solution”: It started having students at the end of each rotation complete the portion of the AAMC’s GQ that deals with mistreatment. The data were collected over a period and then shared with faculty and section heads. “[Physicians] are a very data-driven group, so when they gathered [information] over time, they could identify the outliers; it wasn’t a matter of we-said-they-said.” And once everyone had the data in front of them, “the problems self-corrected very quickly.”


Still, for most medical students, offensive remarks or harsh criticism at the hands of rude residents or impatient physicians won’t be remediated by administrators, so the only comfort they can take comes from those who have been there before them: “The concept of ‘sucking it up’ while in training is a necessity in any field,” says Wong. “It just seems more prevalent in medical education because the learning curve is steeper, the expectations are higher and the learning is endless.”


Safirstein agrees: “Sometimes [in life] you have to work with people you don’t like, and you don’t have a choice about it. Put your head down, read your medicine, open your ears and close your mouth. The best way to shut someone up is know more than them.”
Martha Frase-Blunt is editor of The New Physician. Anthony C. Hall is a freelance writer in Dryden, New York. Direct comments about this article to tnp@amsa.org.