Almost one-third of medical students report having experienced public humiliation during their training, an Association of American Medical Colleges (AAMC) survey found. And nearly all students have witnessed unprofessional behavior demonstrated by faculty members, residents or other students. When these situations arise, how should a resident respond?
An article in the JAMA special issue on medical education details a hypothetical situation where a resident must choose how to respond to the mistreatment of a medical student.
The incident
An internal medicine attending and well-known physician-scientist has an aggressive teaching style, which includes questioning students on material that is beyond their educational level. He believes this motivates them to learn. Sometimes, he uses a sarcastic tone, mocks the students or continuously questions the students even when it is clear that they do not know the answer.
In class one day, a student is almost in tears after being repeatedly questioned about trivia from an article assigned to the class. The attending laughs at him when he cannot immediately answer.
Dr. Insley, the intern on the team, knows that the student read and understood the article because he had brought it to her and talked about it the previous night before leaving to study for final exams. Dr. Insley is upset that this student has been publicly humiliated.
What should the resident do?
- A: Alert the residency program director and expect that the director will handle it
- B: Interrupt the attending when she sees the student is upset and distract him by offering relevant information about the article
- C: Talk to the student after rounds and encourage him to ignore this attending’s style because he treats everyone in this way
- D: Talk to the attending directly and share her observations that the student appeared very uncomfortable
- E: Do what the senior resident has recommended she do—ignore the situation
Evaluating the choices
Mistreatment is one of the six categories of disrespect, as pointed out in a study examining the nature and causes of disrespectful behavior by physicians. So what are the consequences of each of Dr. Insley’s potential responses?
Option A: Alerting the program director would allow Dr. Insley to avoid confronting the attending while still helping the student in distress. While the attending has good intentions regarding student teaching, his approach may be counterproductive and intimidating, leading to inadequate learning. The program director may already be aware of this teaching style and may be in a better position to offer feedback to the attending.
This strategy may help in the long term, but may be suboptimal in the short term because other team members may not know that Dr. Insley has sought help and consider this unprofessional behavior unchallenged.
Option B: Distracting the attending may be the easiest approach because it truncates any further unprofessional behaviors and might protect the student. While Dr. Insley may be able to stop the behavior temporarily, this approach does not get to the root of the attending’s behavior.
An alternative approach is to address the problem more directly while supporting the student. Dr. Insley could interrupt and say, “I sometimes freeze up when being asked questions on rounds, even when I know the answers. When the medical student and I were talking about this article last evening, I remember he picked up on an important contradiction in the discussion.” This approach shows leadership, supports the student, acknowledges situational fear and gives the student opportunity to regroup.
Option C: Talking to the student in the presence of the team after rounds will help address his distress and provide immediate support. It shows the student that other team members recognize the abusive approach as a threat to students’ well-being and to the team’s ability to function.
This approach, however, does not go far enough because it may appear to condone the unprofessional behavior by not confronting it. Allowing faculty to abuse and continue unchallenged implies that mistreatment is acceptable and perhaps even expected.
Option D: It may be challenging and professionally risky for Dr. Insley to approach the attending directly because there is a power differential between them. Dr. Insley would be hopeful that her feedback would result in a change in teaching style, but it is more likely that the attending would reject her feedback and may even criticize her for discussing the issue.
If Dr. Insley decides to directly give feedback to the attending, she should seek coaching from more senior clinicians regarding how to best approach the conversation.
Option E: Ignoring the situation is not optimal, yet it is unfortunately common. Bystanders who observe bullying and do not intervene are tacitly condoning the behavior and contributing to a sense of isolation for the student being bullied.
How to resolve the matter
The recommended course of action combines several options listed above. Dr. Insley and other team members have a responsibility to take action, even if they do not feel directly affected by the abusive behaviors. She should offer personal support to the student after rounds, but also inform the residency program director about the attending’s abusive behavior. That information could allow the director to discuss the behavior directly with the attending physician.
Why address abuse?
These types of behavior are problematic on many levels, the article said. “They are unpleasant for the student who is the subject of belittling comments. These behaviors also affect the learning and patient care environment for all trainees, suggesting that it is not appropriate to speak up, ask questions or feel comfortable as a learner or as a member of the health care team.”
If inappropriate behaviors are not addressed, team members assume that being aggressive and offensive is acceptable. And that type of atmosphere does not grant students the best possible learning environment.
Listen to an audio program on how to respond to bullying and take this quiz to earn continuing medical education credit. Included are interviews with a recent medical school graduate who was abused as a student and the authors of the JAMA article. In addition, Geoffrey Young, MD, senior director for student affairs and programs at the AAMC, and Thomas J. Nasca, MD, CEO of the Accreditation Council for Graduate Medical Education, explain how they expect institutions to respond to medical student and resident abuse.
