Medical student mistreatment

Medical student abuse is a major problem in medical education. The Association of American Medical Colleges' (AAMC) yearly Graduate Questionnaire from 2011 found that 16.8% of medical students report being personally mistreated during medical school.  This number has been pretty much the same for the past five years (16.6 to 17.0%). The most common form of mistreatment is public belittling or humiliation which happens occasionally to 46.8% of medical students and frequently to 4.2%. The scary part is that there are only 18.3% to whom it never happens. 8.1% of students were physically harmed or physically punished. The examples given included being hit, slapped, or kicked. Wow!

Other forms of mistreatment are less common but not non-existent. Of those who reported mistreatment, almost one percent were asked for sexual favors in exchange for grades or awards, eight percent were subjected to unwanted sexual advances, and 20% were subjected to offensive sexist remarks. Fourteen percent were subjected to racially or ethnically offensive remarks. The mistreatment of medical students comes from a wide variety of sources-clinical faculty, residents and interns, nurses, and even patients. This is scary!  These students are highly educated, highly motivated, and paying a lot of money for the opportunity to become doctors.

A article published in AcademicMedicine, details the efforts of one medical school to eliminate medical student mistreatment.  The article, by Fried and colleagues (1), describes a 13-year study in which their school (the David Geffen School of Medicine at UCLA) sought to change the culture of medical education. The school convened a group of faculty, administrators, and mental health professionals to develop school-wide interventions that could address the problem of student mistreatment. These interventions included policies, reporting mechanisms, as well as resources for discourse among students, faculty, nurses and residents.  In addition, they surveyed all of their medical students at the end of the third year. Now, this is after they finished their clinical clerkships. They asked questions that were similar to the AAMC's GQ-how often have you experienced mistreatment which included physical, verbal, sexual, and ethnic categories. They also asked how often there was power mistreatment defined as feeling intimidated, dehumanized, or had a threat made against you.

As an aside at this point. If you are wondering why these definitions are so specific, you only have to understand how often students are made to feel this way. It is so much the norm, that the researchers have to explicitly state what they consider abnormal or students will not even identify it as abnormal.

The authors included data from 1,946 medical students between 1996 and 2008. In this study, the authors found that an average of 57% of students had some form of mistreatment and there was no improvement in this number after the school instituted mandatory mistreatment education or sexual harassment prevention training.  Women were significantly more likely to experience sexual harassment than men over the period from 1996-2008. Students often did not report mistreatment. They were least likely to report to report incidents of ethnic mistreatment (only 7% were reported).

The authors' final comment was "despite the proactive approach taken by our institution to eradicate student mistreatment over this period, we found that the majority of our students continued to report some form of mistreatment at least once during their third-year clerkships." They also admitted that "we find it disconcerting that students continued to report incidents of all categories of mistreatment at these rates."

References

(1)  Fried JM, Vermillion M, Parker NH, Uijtdehaage, S.  Eradicating Medical Student Mistreatment: A Longitudinal Study of One Institution’s Efforts.  Academic Medicine  2012; 87(9): 1191–1198.

Self-regulated learning and performance in medical school

We are always worrying about medical student performance. Measures of performance, including grades and standardized test scores, are monitored and discussed regularly. After sitting on an academic performance committee for several years, I have noticed that some students that struggle are a surprise to the faculty. Oh sure, there are some students who have lower pre-matriculant variables (undergraduate science GPA, MCAT, performance in upper level science courses) prior to starting medical school. In those students we might expect a lower performance in medical school. But there are regularly, students who did well during undergraduate studies, they have MCAT scores that are fine, and they are coming before the academic committee because of poor performance-usually failing a course or multiple courses.  Why does this happen?

Educational researchers in the Netherlands (ErasmusUniversity Medical Centre) and the Centre for Research and Innovation in Medical Education) have tried to tackle this question. (1) Their research question was: what is the relationship between motivation, learning strategies, participation, and performance in medical school. They are interested in the concept of self-regulated learning (SRL) which can be thought of as a learner that uses meta-cognition, motivation, and behavioral proactivity to improve their own learning. Several things that can be seen in self-regulated learners (and I would say in high-performing medical students): they monitor their progress towards their own goals; they are interested in learning for the sake of learning; and they develop and utilize effective learning behaviors.

This study was done in a medical school in Rotterdam, the Netherlands which has a six-year medical curriculum. First year students in 2008 and 2009 were included in the study. There were 303 students in 2008 (32% male) and 369 students in 2009 (37% male). Students were given a questionnaire that was about their study techniques and were given immediate feedback and recommendations for ways to improve. An 81 item survey with six motivation subscales and nine strategies subscales was given to measure their Self-regulated Learning. The survey used a Likert scale (1=not at all true of me to 7=very true of me). The questions were things like “understanding the subject matter of this course is very important to me” and “I ask myself questions to make sure I understand the material I have been studying for this course” and “I make sure I keep up with the weekly readings and assignments for this course.” Students also rated their attendance in lecture, clinical skills training, and assignments

The authors found that Participation (lecture attendance, completing study assignments, and skill training attendance) was positively associated with Year 1 Performance and improvements in the mean GPA. Deep learning strategies were negatively associated with Year 1 performance. So students who utilized deep learning strategies more frequently as their study method, had more difficulty in the preclinical (Year 1) curriculum.

So why does participation affect performance? Is it just because people that go to lecture are able to learn things and get explanations that are not in the available written information? Or is it because of the repetition of the material? They have heard it more times- a concept known as distributed practice (study effort is distributed over several study sessions). Or is it differential repetition? Material is presented in lecture, on-line modules, tutorials, small groups, skills training, and independent study which gives more opportunity to absorb and integrate the information into a structured knowledge base.

Is it just because people that go to lecture are more in tune with the material covered and how it will be tested? Since they go to lecture, they know what is going to be on the test based on the cues and clues from the faculty. This is an area that needs more research. We want students to utilize deep learning strategies because information that is learned this way are more likely to retain that information. We don’t want students that do better on the test just because they show up, unless showing up leads to deeper learning and retention of information.

References

(1) Stegers-Jager KM, Cohen-Schotanus J, Themmen APN. Motivation, learning strategies, participation and medical school performance. Medical Education 2012: 46: 678–688.