Appendix 16 - Medical Student Abuse

by Michael Greger, MD and United Progressive Alumni

[ Medical School Resources | Appendices | Discussion ]


Nature is cruel; therefore we are also entitled to be cruel - Himmler

An Association of American Medical Colleges panel called medical education, "a brutal academic experience." Quoting from Mother Jones, "Men and women becoming doctors experience eight to ten years of relative social isolation, receiving almost no feedback from the nonmedical world. Conservative male faculty members dominate most medical schools, many of them emotionally brutalized by the same profession they are teaching."[218]

New England Journal of Medicine: "Too often our top leaders in academic medicine, the deans and the department chairs, manage through fear and intimidation."[219] Where else could people get away with this? What other professional context would sanction this behavior? Writes one physician, "Before embarking on medical study, I had a career in college teaching. If, as a professor, I had treated students the way I was treated as an MD student, I would have been quickly summoned before my department chair or dean to account for myself."[220]

Commentary from the New Physician:

Everyone in the healthcare field feels threatened these days. This disquiet accounts... for most of the tension, demoralization, aggressiveness, apathy and insecurity among trainees and their supervisors.... Very few perpetrators are boors or sadists. But many are out of date, ill-informed, awkward at teaching, socially inept and deeply insecure....[221]

A passage quoting Robert H. Coombs, Ph.D., a UCLA psychologist who interviewed hundreds of physicians and physicians-in-training and wrote numerous books about the social and emotional development of physicians:

Medical student mistreatment persists partly because of 'A subset of doctors that come from emotionally impaired families....' Because of their dysfunctional upbringing... these people tend to be caregivers as well as perfectionists who are emotionally inexpressive and have little sense of self. 'They think medicine is the perfect career choice for them... especially a specialty like surgery, where they don't have to talk to people much, they don't have to deal with emotions, and they feel really in charge,' Coombs says. 'These doctors,' he says, 'are the major perpetrators of abuse.'[222]

"Teachers should treat students as they wish students to treat patients."[223]

Quoting from a JAMA article "Membership has its Costs," "To gain entrance and acceptance within the guild [of medicine] one has to go through a series of hidden, punitive rituals.... The use of humiliation, rejection, and alienation in these punitive hazing rituals is readily observed by... [medical students] during training."[224] From the Journal of General Internal Medicine: "Psychological abuse, gender discrimination, sexual harassment, physical abuse, homophobia, and racial discrimination are prevalent problems during... training."[225]

Abuse - defined to students as unnecessarily harmful, injurious or offensive treatment inflicted by one person upon another. In one survey, fifty medical students were instructed to confine answers to personal abuse by doctors and to exclude other stressful issues like long hours, excessive work, etc. How many reported being personally abused and humiliated by residents or faculty members? 100 percent.

The largest survey of its kind, covering more than 80% of graduating medical students in 1996, offers a more conservative estimate: "Forty-eight percent of the 13,168 respondents experienced at least one episode of mistreatment while in medical school."[226]

The literature starts in 1982 when a landmark study in JAMA pointed out striking parallels between changes that occurred in children who had been abused and changes that occurred in medical students, both having suffered largely ignored and/or unrecognized abusive episodes.[227] The gradual transformation from eagerness and enthusiasm to depression and fear.

The most compelling use of this metaphor can be found in an article published in Family Medicine in 1989 entitled "Medical Education: A Neglectful and Abusive Family System." Like neglectful and abusive families, the article asserts, medical training is often characterized by unrealistic expectations, denial, indirect communication patterns, rigidity and isolation.

As reported in Academic Medicine, "The abuse of students is ingrained in medical education, and has shown little amelioration despite numerous publications and righteous declarations of the academic community over the past decade."[228] According to Donald Kassebaum, Secretary of the Liaison Committee on Medical Education (the accrediting body for U.S. medical school programs), medical schools have tended to, "issue policy statements out of the provost offices that declare they won't be beastly toward each other, and that's it."[229]

'God knows what scars we'll all end up with.'[230]

Medical student abuse leads to significant student psychopathology.[231] In one study in which 80% of the hundreds of medical students sampled claimed they were abused in medical school - particularly during third year - more than two thirds describe the experience as being very upsetting and of major importance. Half said they were adversely affected for over a month. Fifteen percent said the abusive experience would always affect them.[232]

A third of students report mistreatment from residents and attendings having adverse effects on their actual physical health. More than a third seriously considered dropping out and one out of four report they would have chosen a different profession if they had known in advance about the extent of mistreatment they would experience.

Cutting Edge

Not surprisingly, studies find that the frequency of abuse was greatest during the surgical rotation.[233] In one study, eight percent of students were threatened with bodily harm, assault, or assault with a weapon.[234] Perpetrators were most often surgeons.[235]

From the trade journal Medical Economics:

For the most spectacular tantrums, it's hard to match the lords of the operating room. While most surgeons mind their manners, a minority go absolutely bonkers - flinging scalpels, threatening to throw scrub nurses against the wall, kicking equipment, fistfighting with anesthesiologists... 'The throwing of scalpels goes on, but not as much as it used to,' says... a former medical director. 'Maybe one guy out of 30 does it now. It used to be one out of 10.'[236]

In a pilot study, ten percent of students report actually being physically abused (slapped, kicked, or hit) by residents or faculty. Examples were given:

In the OR I was being taught to suture. When I held the forceps improperly I was hit on the knuckles with another instrument by my chief. When I inadvertently did it again I was hit in the same place. After the operation, my knuckles were bleeding and I now have a scar on the back of my right hand.[237]

One student reported he had been kicked in the testicular region by an attending physician and required medical attention for his injury.[238]

Medical student testimonials: "'The abuse felt like someone shoved a vacuum cleaner hose down my throat and sucked everything out of me.' As far as I'm concerned it's been three years of constant abuse and humiliation, and I view it as a time to forget - a sacrifice of 4 years of my life."[239] "My third year experience so completely soured my ideals of medicine that I am now considering becoming a malpractice consultant." Me too damn it. Maybe I'll just get a law degree and sue doctors. Watch them untouchably squirm on the stand.

Perceived Mistreatment

Skeptics of the medical student abuse literature would rather the term "perceived mistreatment" and believe that, "Pre-existing psychopathology, such as depressed mood states, may predispose students to negatively distort medical school experiences."[240],[241] Interestingly, those faculty who disagreed that there was such a thing as medical student abuse were almost all men, and a significantly larger number from the group thought that women students were, "oversensitive to faculty sexual humor (p<.0001)."[242]

 
 

[218] Mother Jones 1983(January):21.

[219] Conley, FK. "Toward a More Perfect World." New England Journal of Medicine 328(1993):351-352.

[220] Holly, J. "Medical Student Abuse." Humanist 58(1998):3.

[221] James, D. "Deep Impact." New Physician 48(1999):16-25.

[222] Ibid.

[223] Reiser, SJ. "The Ethics of Learning and Teaching Medicine." Academic Medicine 67(1994):872-876.

[224] Lee, FS. "Membership has its Costs." Journal of the American Medical Association 271(1994):1048-1049.

[225] van Ineveld, CHM. et al. "Discrimination and Abuse in Internal Medicine Residency." Journal of General Internal Medicine 11(1996):401-405.

[226] Mangus, RS, CE Hawkings and MJ Miller. "Prevalence of Harassment and Discrimination Among 1996 Medical School Graduates." Journal of the American Medical Association 280(1998):851-853.

[227] Silver, HK. "Medical Students and Medical School." Journal of the American Medical Association 247(1982):309-310.

[228] Kassebaum, DG and ER Cutler. "On the Culture of Student Abuse in Medical School." Academic Medicine 73(1998):1149-1158.

[229] James, D. "Deep Impact." New Physician 48(1999):16-25.

[230] Silver, HK and AD Glicken. "Medical Student Abuse." Journal of the American Medical Association 263(1990):527-532.

[231] Lubitz, RM, DD Nguyen and RS Dittus. "Medical Student Abuse." Journal Of General Internal Medicine 10(1995):91.

[232] Silver, HK and AD Glicken. "Medical Student Abuse." Journal of the American Medical Association 263(1990):527-532.

[233] Luitz, RM. and DD Nguyen. "Medical Student Abuse During Third-Year Clerkships." Journal of the American Medical Association 275(1996):414-416.

[234] Wolf, TM, et al. "Perceived Mistreatment and Attitude Change by Graduating Medical Students." Medical Education 25(1991):182-190.

[235] Margittai KJ, R Moscarello and M F Rossi. "Forensic Aspects of Medical Student Abuse: A Canadian Perspective." Bulletin American Academy Psychiatry and the Law 24(1996)377-385.

[236] Lowes, R. "Taming the Disruptive Doctor." Medical Economics 5 October 1998:67-80.

[237] Silver, HK and AD Glicken. "Medical Student Abuse." Journal of the American Medical Association 263(1990):527-532.

[238] Wolf, TM, et al. "Perceived Mistreatment and Attitude Change by Graduating Medical Students." Medical Education 25(1991):182-190.

[239] Rosenberg, DA and HK Silver. "Medical Student Abuse." Journal of the American Medical Association 251(1984):739-742.

[240] Baldwin, DC and SR Daugherty. "Do Residents Also Feel 'Abused'?" Academic Medicine 72(1997):S51-53.

[241] Richman, JA, et al. "Mental Health Consequences and Correlates of Reported Medical Student Abuse." Journal of the American Medical Association 267(1992):692-694.

[242] Kane, FJ. "Faculty Views of Medical Student Abuse." Academic Medicine 70(1995):563-564.

 
 
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