“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.