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 an atmosphere 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 mento
rs.” 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.