A Culture of Fear and Intimidation: Reforming Medical Education

Even as we set out to reform U.S. health care, we continue to train medical students as if they were going to work in the old, broken system. Today, everything about medical education needs to be re-thought, from how we select students for admission to med schools to what we teach them about how to provide safe, patient-centered care.

A shocking new report from the  Lucien Institute at the National Patient Safety Foundation reveals how today’s medical schools fail their students as it lifts the curtain on a culture of  “abuse, shame and blame”  that undermines professional morale, inhibits teamwork– and ultimately puts patient safety at risk.   (Thanks to Dr. Diane Meier for calling attention to this report on Twitter.)

“Achieving  safety in the work environment requires much more than implementing new rules and procedures,” the report observes. “It requires developing and sustaining  cultures of safety that engender trust and embrace reporting , transparency, and disciplined practices. It also requires anatmosphere of respect among the health care disciplines  and a fundamental ability of all practitioners to work together in teams.”

The white paper, entitled “Unmet Needs: Teaching Physicians to Provide Safe Patient Care”  was prepared by an  “Expert Roundtable on Reforming Medical Education” that included a broad array of medical education leaders, students, patients, representatives from key organizations, experts from related fields, and members of the Institute. The Roundtable met in extended in-depth sessions in Boston in October 2008 and June 2009 before reaching a consensus regarding the current state of medical education—and  what medical education should ideally become.

The Roundtable participants acknowledge that med school students frequently are abused and demeaned and that this behavior is widespread. Each year, the Association of American Medical Colleges conducts a survey of medical students asking questions such as have you been “publicly belittled or humiliated?”  From 2004 to 2008, 12.7%  to 16.7%  of students answered “yes,” with “female respondents reporting higher rates” of abuse. Most often, students were humiliated by clinical faculty and residents (66% and 67%, respectively), followed by smaller but significant percentages of nurses and patients.

“Abusive behavior can be as subtle as making a student feel foolish for asking a question or as overt as throwing surgical instruments in the operating room,” the report explains. “Some may argue that an overall 12–17% rate of abusive and disrespectful behavior over the four-year medical school experience is not so extraordinary, but the rate ranges far higher in some schools.  . . . it is hard to  imagine any successful industry or company that tolerates abusive behavior” at this level.

In order to capture some examples of the problem a medical student member of the Roundtable solicited anonymous stories from medical students who had been humiliated.

A Third-year Medical Student on a OB/GYN Rotation Tells Her Story

“I was instructed to observe a hysterectomy, but when I arrived to the OR, the doctor looked at me with disdain and told me to stand in the far corner and not mess anything up. So, I perched myself atop a small step-stool in the back corner of the room, and I spent the next 3 hours squinting from across the room, completely unable to see anything except for blue-gowned backs.

“Suddenly, the doctor called out, ‘You, over there!’ I looked over in surprise—me? Apparently, there was no one available to pullout the catheter, and they beckoned for me to approach the table. I cautiously approached, and before I could even begin, the doctor sharply barked, ‘DON’T mess this up for me!’ Shaking, I  followed her instructions, and managed to remove the catheter without contaminating the sterile field.

“‘Now, GET OUT of the way!’ she yelled. I couldn’t see behind me, and in a small tremulous voice, I asked, ‘Is it okay to move backwards, I can’t see anything behind me…?’ Raising her voice up a notch, she yelled, ‘Just GET OUT!’ I took several hasty steps backwards, and my arm grazed lightly against the side of a table holding sterile instruments—mind you, nowhere near the table-top, where the instruments lay, but just on the side curtain—and a nurse shrieked ‘She contaminated the whole sterile field!’ With fury, the doctor looked up and spat, ‘Fuck you!’

“I blinked, and stared right back at her—really, did she just actually say that? Although I didn’t feel sad at all—only mad as hell—tears rushed to my eyes in a visceral response to all of the shouting. The instant that the curse left her lips, I could tell that she regretted it, but you can’t take back something like that, so the words hung awkwardly in the air, hovering over all of our heads for the rest of the procedure. She tried to make up for it, sending arbitrary irrelevant compliments in my direction, and the nurse patted me on the shoulder several times and tried to appear motherly and compassionate. But, what I remember most strongly from the experience— what I still cannot believe—is the fact, despite their palpable remorse, no one ever said, I’m sorry.”

Coping with Medical Mistakes

Learning to say “I’m Sorry” is part of what physicians need to do if they are going to cope with medical mistakes.

“Students need support in learning how to manage stress and conflict resolution when they are involved in an adverse event,” the report  observes. A medical education should prepare them to deal with the inevitable feelings of doubt, fear and uncertainty that any physician will experience more than once in his or her career. Medicine is a science fraught with ambiguities and unknowns. Doctors and nurses are fallible. This presents an excruciating dilemma that a physician can deal with in one of two ways. She can admit to medical errors, apologize to the patient, analyze the event,  and talk to other members of her team about how they might re-design the process to avoid such slip-ups in the future. This takes courage, confidence, and respect for your colleagues. Alternatively, she can deny medical errors, and lash out at others when a mistake is made.

Unfortunately, the med school culture can make it  “psychologically  impossible for the doctors who graduate from these programs to  . . . diagnose failed  patient care,” the report warns. A doctor who has been traumatized by a med school culture of shame and blame may find that she “has little insight into
‘what really happened’ ” and be “unable to empathize and communicate effectively with the injured and frightened patient.”  She may also “lack the knowledge and skills necessary to work with other team members to investigate the occurrence.”

If students are going to learn about patient safety they must feel comfortable (“safe”) in  reporting and discussing  preventable adverse events and other patient safety problems with their peers and the faculty. But this will happen only if faculty provide a receptive, concerned and supportive environment.

Here, the report suggests that medical schools should provide more reward to outstanding mentors in the form of higher salaries, more staff resources and promotion pathways that recognize teaching skills. Those who are particularly skilled at teaching how to keep patients safe should be named master teachers.
Professional Behavior and Professional Ethics

Ultimately, the report suggests that unprofessional behavior may undermine professional ethics.

Often, physicians who don’t act like professionals may never have taken the values of the profession to heart. Ego stands in the way of putting patients first. Doctors who demean medical students also are likely to look down on their patient.  They lack the imagination to identify with someone who is learning—or to sympathize with someone who is suffering

Here is the tragedy: when students are exposed to unprofessional behaviors and values, over time, they tend to accept them.

“Simply put, students assimilate the values, behaviors and attitudes of their mentors.” The report notes, pointing to a survey of third-year medical students, which demonstrates that “student observation of and accommodation to unprofessional behaviors progressively increased during the first five months of clerkships. Initially critical of these behaviors, students increasingly perceived them to be appropriate as training progressed, and steadily began to emulate them.”

A second anonymous survey of 1,853 third- and fourth-year medical students in 1992 and 1993 at six Pennsylvania medical schools also sounded a warning. “Ninety-eight percent of students had heard physicians refer derogatorily to patients; 61% had witnessed what they believed to be unethical behavior by other medical team members and, of these students, 54% felt like accomplices. Many students reported dissatisfaction with their actions and ethical development: 67% had felt badly or guilty about something they had done as clinical clerks, and 62% believed that at least some of their ethical principles had been eroded or lost. Controlling for other factors, students who had witnessed an episode of unethical behavior were more likely to have acted improperly themselves for fear of poor evaluations. Finally, students were twice as likely to report erosion of their ethical principles if they had behaved unethically for fear of poor evaluation or to fit in with ‘the team.’”

In Part 2 of this post, I’ll talk about the report’s recommendations for changing the way we select students for medical school, changing medical school curriculum , teaching teamwork, weeding out students who display  unprofessional or maladaptive behavior, and why “see one, do one, teach one” is antithetical to patient-centered care.

Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, her work has appeared in the New York Times, Barron’s and Institutional Investor. She is the author of “Money-Driven Medicine: The Real Reason Why Healthcare Costs So Much,” an examination of the economic forces driving the health care system. A fellow at the Century Foundation, Maggie is also the author the increasingly influential HealthBeat blog, one of our favorite health care reads, where this piece first appeared.

21 replies »

  1. I have been writing about and teaching physician and other healthcare audiences on these issues for the past twenty years. This article is right on target. The issue ultimately is one of making sure that physicians and others act in line with organizational values which typically include safety,quality patient care, respect,and dignity. All of these values are designed,in part, to help maximize outcomes and the level of care provided. Organizations need to set and enforce a few clear standards of behavior. Leaders must practice them, teach them and hold others accountable for applying them. This is the process by which culture will change so the kinds of events addressed above do not occur as they are recognized as unprofessional and, ultimately, a hazardous, unacceptable threat to patient care.


  3. You listen to all this criticism of how terrible doctors are, and yet, at the end of the day, who is going to do the best at treating medical problems? Your dentist? Your vet? Ok, I’ll keep it more realistic, your nurse practitioner, your physicians assistant, your accupuncturist, your masseuse, your therapist?
    Yeah, medical care can be better, but, is it so terrible on a whole that doctors are the primary villians here?
    We do a shitty job of policing ourselves, I am the first to say it, as I have tried to be one to make a difference in past years. But, and here is where the hierarchy of my profession will squirm and knash their teeth in painful agony of this opinion, the leaders of health care are just like the politicians putting this garbage into motion tonight: the status quo, as long as it benefits them first, will not change.
    The old guard, as a whole, have sold us out who are the workers in the trenches, and not just out, but are standing next to those non-clinicians who are eager to push us off the cliff and tell America, “hey, you don’t need health care in the end, ’cause you’re just gonna die anyway”. Just watch how these demonizers have their own personal physician behind the curtain.
    Hey, don’t believe me. Your House representative and Senator know better than I do.
    Again, just wait and find out in 2014. If you can hold out from your preexisting conditions that won’t get covered until then!!!

  4. …and now back to the subject.
    I was appalled by the ethical environment of my training in medical school. More among my peers and my supervising residents than among attendings.
    I eventually discussed many instances of shocking behavior I’d experienced in clinical rotations with the Dean of Medical Education. I was invited as a fourth-year to present “The Tar Baby Chronicles” to at a retreat entitled “Professionalism in the New Health Care Environment.” It was politely received.
    I also put together another presentation “Strong Work!” for the Medical Education Committee on the meaning of information technology advances on the priorities and processes of medical education and practice.
    I have been further appalled by graduate medical training, and largely stand by my earlier reflections and analyses.
    If interested, I have converted the powerpoint presentations I gave into Quicktime videos, and posted them on http://www.youtube.com/user/brimcmike

  5. With stories like the above, medical care will deteriorate in this country because these politicians just want to stay in office FOREVER. Today, one congressman was talking about one big California Private insurer was going to decrease dramatically the number of visits of hypertensive patients by using a program that will identify the best medication for you. They will not need doctors anymore!! But who will get sued? The doctors, not the insurance company and certainly never, if its the government.

  6. Socialized medicine will degrade coverage for all. I had a friend who retired from a good job in the USA and went to Canada so he could avoid having to pay a contribution for health care. He became a Canadian citizen. A couple of years ago he developed pancreatic cancer and could not get timely effective treatment in Canada. He was offered pain pills. So, he came back to the USA and paid for treatment.
    Our system of health services s not broken by any means, but could be improved. Let’s improve it together and not unilaterally destroy it.

    ” .. It’s actually about doctors and patients. As e patient Dave says, “your time will come.”
    Posted by: bev M.D.
    Check back when Obama’s IRS demands your patient records for regulatory compliance, Einstein.
    Good luck, connecting with reality. You need it.

  8. PalMD is a horrible blogger. No one reads his stuff. No one comments. He doesn’t write well and I think he knows he’s not so good at it. Sort of sad.

  9. Suli said “Unfortunately, change is often frustratingly slow because those who have the power to enact it are often resistant.”
    Wrong. The people in power maintain their power (and their $ multimillion compensation) by not changing it.

  10. F. (Frank1?)
    Congrats on only one capitalized word today. Too bad today’s post isn’t on politics, your one and only subject. It’s actually about doctors and patients. As e patient Dave says, “your time will come.”

  11. BORING
    Isn’t this MESS-iah’s job? Making the world perfect? Without any first-hand knowledge or experience?
    And under Obama-care — who are you, to question your government-approved provider? All those stories in “The Daily Telegraph” about how terrible the UK NHS is — just made-up, right? That’s why the USA needs single-payer, right?
    USA medicine isn’t perfect, as is academia or health IT 2.0.
    But at least you can fire your MD. Try that under socialism.
    BTW: do you really want a thumb-sucker to do your heart-bypass?

  12. I fully appreciate the culture of fear and intimidation that pervades medical institutions. As a senior veterinary student, I can attest to the fact that it certainly exists in veterinary schools as well. Unfortunately, change is often frustratingly slow because those who have the power to enact it are often resistant.

  13. Funny that the focus is on medical students who are reportedly abused.
    If the similar surveys were given to attending physicians, there would be spine tingling responses pertaining to the hospital administrators’ intimidation of and retaliation against senior physicians.
    It is commonplace for senior physicians who complain about hazards that place patients at risk to be sham peer reviewed at the behest of hospital administrators.
    The charges are “disruptive physician”.

  14. Just as in families, the abused become the abusers.
    I think the most important part of this report,however, addresses the lack of formal training in systems thinking and improvement science in medical schools. Physicians are unable to effectively participate in error root cause analysis teams and better design of hospital processes, defects which underly many errors, because they fail to appreciate that they have been trained in the wrong thing – individual, human effort – well intentioned but prone to failure. I hope this comes in part 2!

  15. I hope that my Dental students feel that dental education is very different from medical. I think that we support our students and take ownership of poor treatment results and errors.

  16. Exhausted MD:
    You write: “Non clinicians just don’t get it, letting politicians set the rules for clinical care is like, well, asking doctors to write laws.”
    I totally agree.
    This is why I an so glad that in the newest (reconciliation) bill let Medicare and a Medicare panel made up of doctors and medical experts make very impt. decisions about what Medicare pay for and how it pay for it Without Going Through Congress. This gives the panel great protection from lobbyists.

  17. I absolutely agree with your position. We need to teach our future colleagues a new oath, starting with “first do no harm if you want to practice medicine, but be prepared you will do lots of harm if you work for the American Meddling Association, ie the way medicine will be forced to practice by intruding, money focused politicians.”
    Non clinicians just don’t get it, letting politicians set the rules for clinical care is like, well, asking doctors to write laws. We just don’t know how to do it, outside laws regarding care. But, hey, america seems ready for the rules to be changed.
    Just wait until they find out how much politicians do not know how to run examination rooms and hospital wards. It’s just, what, yours or a significant others’ life here?!

  18. I am disturbed by the recent reluctance of our legislative representatives in the House and Senate to consider the real day to day crisis of individuals and families as they face the health issues that can destroy them without adequate coverage. We need coverage for each person in our country without consideration of the special interest groups that are attempting to prevent such solutions.