The participant sample comprised ten current or recently graduated medical students (three men and seven women) of metropolitan, rural and international backgrounds.
Table 1: Participant Demographics
Participant Pseudonym
|
Age
|
Gender
|
Ethnicity
|
University
|
Year of Study
|
Geographic Origin
|
Colette
|
28
|
Female
|
Caucasian
|
University of Sydney
|
Three
|
Metro
|
Alice
|
21
|
Female
|
Caucasian
|
UNSW
|
Four
|
Metro
|
Theo
|
21
|
Male
|
Caucasian
|
UNSW
|
Four
|
Metro
|
Sanjna
|
24
|
Female
|
Indian
|
UNSW
|
Graduated 2018
|
Metro
|
Arosh
|
24
|
Male
|
Sri Lankan
|
UNSW
|
Six
|
International
|
Peter
|
21
|
Male
|
Caucasian
|
UNSW
|
Four
|
Rural
|
Abby
|
23
|
Female
|
Caucasian
|
UNSW
|
Five
|
Metro
|
Lily
|
23
|
Female
|
Caucasian
|
University of Sydney
|
Two
|
Metro
|
Jarra
|
22
|
Female
|
Caucasian
|
UNSW
|
Four
|
Rural
|
Lauren
|
23
|
Female
|
Caucasian
|
University of Sydney
|
Two
|
Metro
|
All participants described the ‘hierarchy’ as a prominent feature of medical culture. Most participants stated the hierarchy was necessary to an extent, providing a chain of command in which junior defers to senior in complex medical decisions. Most participants respected consultants for their superior knowledge.
‘You do need a hierarchy, or at least an identifiable person who is overall responsible… You’re there for the patients, and the patient’s deteriorating… You do need someone who’s like, “This is what we’re going to do”.’ (Peter)
However, many participants noted a toxic workplace culture from abuse of the hierarchy. Participants described ‘servant’ demands of medical students and trainees, including: demanding coffee (then complaining it’s not right); not allowing students to microwave their food; and forcing one student to carry handwash rather than taking notes, which made that student feel ‘completely disrespected’ (Arosh).
Participants said they did not feel able to report issues because of the hierarchy. Senior doctors were overwhelmingly considered unapproachable because they were ‘self-important’, sexist, uninterested, too busy, or participants feared verbal abuse. All three male participants, but only one female participant, while intimidated, stated they overcame this and asserted their right to approach seniors.
Participants felt that underreporting contributed to lack of intergenerational change. They suggested more ‘top-down’ methods of intervention were necessary to challenge the cyclical nature of mistreatment, currently a ‘rite of passage’, whereby the bullied become the bullies.
Four key themes were generated in the discussion of medical culture. The first overarching theme identified by in all transcripts was the concept that self-sacrifice was a value inherent to the medical profession. Doctors and, to a lesser extent, medical students are expected to compromise their personal lives, including having children, in order to progress in their careers. Participants articulated an expectation for medicine to consume practitioners’ identities, and that sacrifice, often manifesting as overworking and underreporting, is a ‘rite of passage’ (Alice).
‘The culture is to put medicine before everything in your life… probably from experiencing medicine, from the competitive nature of getting into medicine, the type of people who therefore get in.’ (Alice)
There was some discord between how problematic participants viewed this issue. Some considered it outrageous, and that medicine should be considered ‘just a job’ (Peter and Sanjna), while others (Theo and Abby) said self-sacrifice may be necessary to maximise patient care.
‘There’s always the aspect of, “If you leave early, patients don’t get care”, and if your hospital doesn’t find a way for you to be paid overtime, you still have to do it because otherwise there are very real, tangible consequences.’ (Abby)
The second theme highlighted was when participants were asked what qualities pervade medical culture, resilience being one of the most commonly conceptualised values instilled in medical training, six participants discussing this theme.
‘You need to shrug off, you need to compartmentalise these things, and I think we’re taught that a lot in med.’ (Arosh)
The third theme generated was ‘imposter syndrome’: many participants identified that they valued humility and said they were unwilling to ask questions or request help for fear of appearing ‘incompetent’. This was often accredited to the type of people admitted to medical school: high achievers with competitive ambitions.
‘If you feel like you’re asking a stupid question and wasting their time… that might reflect on you, you might look stupid, you might look like you don’t know what you’re doing.’ (Lauren)
‘I just feel like a lot of people in medicine have imposter syndrome and are constantly like, “I’m not good enough” and “I didn’t deserve to get in”.’ (Jarra)
The fourth theme generated was the cultural practice of deference to senior doctors, and was raised when participants were asked what they thought about their clinical teachers and if they found them approachable. Recognition of their own limitations, and respect for consultants’ experience and knowledge, made participants feel like they had to go out of their way to ‘be nice’ (Alice) to senior clinicans.
‘Whenever the registrar called the consultant, they’d always be like, “I’m so sorry for calling you, just a really quick question.” They’d apologise so profusely and I was like, “That is literally [the consultant’s] job”… and the fact that you had to hesitate that much before calling them is so bad.’ (Sanjna)
This is one example of the excessive deference described by participants. Another was the practice of addressing the consultant as ‘Doctor’, as opposed to their name, which participants thought was outdated.
Seven participants felt uncertain about the avenues of recourse available to them. Barriers to reporting included insufficient assurance of confidentiality; lack of clarity regarding whether incidents fell under the university or hospital’s purview, meaning grievance escalation policies were unclear; and outcomes were characterised as inadequate.
The perceived lack of anonymity prevented reporting because of the commonly cited problem of dependency on senior doctors to ‘sign off’ on trainees and students in order to progress through their training, as well as identified whistleblowers struggling to find future employment.
‘It’s a constantly picking game of keeping people who are important to your future on your side.’ (Abby)
Regarding outcomes, of the four participants who had reported an incident or knew someone who had, none had experienced desired outcomes. This included ‘sexist behaviour from one of the surgeons’ (Peter), on which the clinical school had insufficient authority to act. A further five participants said that if they did experience bullying or harassment, they would not come forward because they do not believe any action would be taken, the clinical school does not have enough power to act, or the hospital/clinical school does not invite criticism. The remaining participant said he only believed there would be outcomes if the person reporting made enough of an ‘uproar’ (Theo).
‘There’s a huge amount of fear and stigma about taking things to the university, also just general disillusionment that the university, that the hospitals, that the structures that are supposed to be there to support us, have failed pretty consistently, and people aren’t willing to put themselves in danger to have another go at it.’ (Abby)
Lily: I like to think they’d be spoken to about it in a confidential manner, and then given a warning, and then if it continues to happen, then they’d be removed from that position.
Interviewer: Do you think that’s actually what would happen?
Lily: No… I think they’re very rarely removed from that position, to the point that if they are it gets in the Sydney Morning Herald.
Furthermore, the networking culture within the hierarchy of clinical teaching settings made participants fear acquiring a reputation of being sensitive, a troublemaker, or difficult to work with if they did not comply with demands of senior doctors, as this could have direct repercussions on academic marks or career progression.
‘No matter how valid your complaint is, hospital management, I think, will tend to see you as the person who is a bit of a troublemaker, or caused a fuss… There might be retribution.’ (Sanjna)
For these reasons, participants overwhelmingly said that they would only come forward when they had nothing to lose, such as if they had no interest in pursuing the specialty in which they experienced the abuse; if they could provide concrete evidence, a high burden of proof existing for medical students; or they were willing to stake their career.
'[It] couldn’t be interpreted as something where I was just a bit sensitive about it. It would have to be, “This is clearly not okay”.’ (Colette)
To remedy these obstacles, many participants suggested implementation of a formal grievance escalation policy, such as the Vanderbilt Coworker Observation Reporting System (CORS).
- Pressures on Medical Students
Five main factors were identified as causing stress to medical students. The first was academic pressure, with eight participants stating how difficult it was to learn huge amounts of content in short periods of time, on top of unrealistic expectations from clinical teachers.
‘Trying not to look stupid because the standards are so high. And so you don’t want to say something that will make them think, “This guy doesn’t know what he’s talking about, he doesn’t really study, he’s just a waste of space”.’ (Arosh)
Eight participants also articulated the emotional pressure on medical trainees, in that they witness and have to cope with confronting situations and negative outcomes.
‘It has unique challenges, like raw human emotions, and just seeing trauma scenarios or even if you’re on the surgical ward and seeing drains or wounds, stuff like that can be a bit confronting.’ (Peter)
Participants did not express these two pressures as problematic or demanding change.
Financial pressure was the third issue, discussed in depth by two participants, one of whom was from a rural location. Jarra and Abby said the expectation in medical school, due to the unpredictable timetable, is that you’re not employed, which they found unreasonable. They also believed the uncertainty medical students suffered with forcible relocation, sometimes annually, made university unnecessarily stressful and financially inaccessible, especially given the inadequate ‘rural scholarships’ allocated by their universities.
‘I hate the uncertainty of it. I want to have at least one stable thing in my life, even being able to stay in the same area and knowing that I can keep the job that I have instead of having to look for a job.’ (Jarra)
‘You often have medical faculties telling students that they shouldn’t have a part-time job and that that’s incompatible with studying.’ (Abby)
The fourth challenge for medical students was regarding gender. Gender seemed to affect the quality of teaching participants received, with female participants sometimes being made to feel uncomfortable, having fewer teaching opportunities, or being ignored, exclusively by male supervisors.
‘He always referred to doctors as ‘him’ or ‘he’, so always in the male version… and often would do the same thing with nurses and other allied health, always referring to them as ‘she’. And so, immediately, myself and others in the class, felt like we didn’t belong in that classroom.’ (Alice)
Gender discrimination ranged from a ‘quantity of low level things’ (Colette) to the most serious example of sexual harassment reported in this study, Abby’s friend having had a surgeon touch her thigh, ‘making it quite clear that to report it would be a blight on her future career’ (Abby).
Gender played a role in every female participants’ future decision-making. Female participants felt they would have to fight harder to succeed in certain specialties, and that certain training programs were inaccessible because of sexist culture or training requirements, such as having to repeat whole terms if maternity leave is taken. Six of the seven women used surgery as an example.
‘Even the most benign aspects of sexism in the workplace, like being constantly reminded that I need to factor my future family into career choices, far beyond that of which my male peers receive or face, is pretty demotivating… When I think of things like specialties I’m leaning towards, I do actively wonder if things like not being interested in surgery isn’t a decision I came to by myself because of my interest, or because it has been consistently reinforced to me that that’s not an area where I would be welcomed or valued, and where I’d have to fight even harder to make it just because I’m a woman. I think those kinds of pressures weigh very heavily on the minds of women.’ (Abby)
Two female participants from two different medical schools also noted gender played a role in the content of the curriculum, believing there to be excessive focus on normal male physiology and male study populations.
‘All the women were a little bit frustrated with the time we spent on how normal male physiology works, but not a lot on how female physiology works… We didn’t have a “This is how normal menstruation works” lecture, whereas, as a girl, I know how that works. As a guy, you’re going to be in trouble.’ (Lauren)
One queer-identifying participant noted similar lack of diversity, criticising the emphasis on heteronormative conceptions of health.
‘Teaching is very hetero in its guidance. There’s very little discussion on how to deal with queer or gender queer people … I think it would be rare for us to be given a fake patient who is gay, facing a particular challenge relevant to health and being gay, or is incidentally gay presenting with something completely irrelevant.’ (Theo)
To a lesser extent, racial discrimination was believed to be a stressor for some students, although not by the ethnic participants in this sample. The one international participant, Arosh, had not experienced any racism, while New Zealand-born Indian Sanjna, although she’d experienced racism, believed it was a societal problem no more prevalent in medicine than anywhere else. In fact, she reported ‘skinny, white, blonde’ female students were more likely to suffer sexual harassment because of conventional beauty standards. Five other participants said patients and older doctors commonly made racist comments, and that language barriers created a divide between international and local students and doctors.
‘He would make, sort of, demographic jokes… and some of them weren’t appropriate.’ (Theo)
- Mistreatment from Patients
Eight participants reported witnessing or experiencing sexist or racist comments from patients, such as female medical students being assumed to be nurses, sexualising comments, or international students being criticised for their accents. However, two students said they did not know how to address these issues, which are usually brushed off, because not every moment can be a ‘disciplining, teaching moment’ (Abby) when you’re trying to manage the patient.
‘Obviously I don’t enjoy patients being like, “I’ll have the pretty blonde one”, but can you really educate every single person who comes through the hospital?’ (Lily)
All participants provided some positive commentary on clinical teaching, with some participants emphasising that, for the most part, they had received good quality teaching. Common positive characteristics of medical teaching included an emphasis on communication and patient-centred care, as well as tolerance and empathy for patients, respecting sociocultural factors contributing to their conditions.
‘I think, probably, communication skills. That’s been a big thing. And not making assumptions about people.’ (Colette)
However, several issues were raised regarding the quality of teaching. Firstly, six participants remarked on the indifference of teaching doctors, stating that many view teaching as a burden, reflected in their impatience and lack of effort. Being approachable and engaged in teaching was considered highly desirable, with ‘interest in students and other staff’ being the most commonly identified quality in participants’ role models, discussed by eight participants. Interestingly, Alice and Colette, both of whom had experienced rural teaching, believed lack of interest from teachers was less common in rural hospitals.
‘I’ve had teams where it has been pretty clear that no one on the team [in a metropolitan hospital] was particularly interested in teaching or even having students… It made it very difficult for us to learn and for that to be a productive placement.’ (Abby)
Abby and Sanjna accredited this to the lack of upskilling in senior doctors, who are expected to teach without any formal teaching training.
‘Any level of responsibility at all and you’re expected to teach, and that’s the automatic default. There’s really no system finding people as being poor teachers or dangerous teachers.’ (Abby)
This idea was often linked to the lack of standardisation in clinical teaching. Six participants, without prompt, expressed a lack of direction as one of the most stressful elements of learning, as there’s often a disconnect between examinable content and what senior doctors teach, and clarity is lacking regarding expected hours and level of knowledge.
‘I think probably… a little bit more direction, in terms of clinical teaching. More clarity about expectations. Because it sometimes feels like you’re really unsure how many hours you’re supposed to be there, how much you’re supposed to know at different stages and what you should be doing with your time. And that’s been the number one stressful thing for me this year.’ (Colette)
‘There’s no standardisation in your clinical time. Registrars aren’t told what they’re meant to be doing with you. You’re often seen as a hindrance to the operation of the team. So you can either have really good clinical experiences, or you can be there doing nothing and it’s annoying and you’re expected to bear the burden of being the least efficient.’ (Sanjna)
While most participants did not report intellectual humiliation as a major problem in teaching, eight participants nevertheless described experiences of ‘grilling’, where senior doctors yelled at, cursed or belittled them for not performing tasks adequately or knowing answers to questions, usually in front of their peers. The participants stated these experiences made them uncomfortable and hindered their learning, often because they felt they could not approach these teachers with questions. They also believed this ‘baptism by fire’ (Abby) could damage individuals’ mental health.
‘A particular lecturer in Aged Care called a student out because he couldn’t answer a question, saying he was a ‘waste of space in the medical program’ because he could be taking up the place of a student who deserves and knows his stuff to be there. In front of the whole class.’ (Arosh)
When asked what values are instilled in clinical teaching, many participants identified academic values, such as dedication, communication and sacrifice. Three participants felt strongly that ethics, such as honesty and integrity, if taught at all, are taught superficially and in a tokenistic manner. One participant argued that any positive values emerging in medical students cannot be credited to any formal teaching, and the admission process is not rigorous enough to ensure all medical students have such values.
‘I feel like sometimes there are values that they’re trying to enforce which are very important like honesty and integrity in medicine, but the way that they go about trying to teach you that is perhaps not the best… not really any formal or implied measuring of that or focus on that.’ (Lauren)
‘There’s certainly an increasing amount of lip service to things like diversity in leadership and being more aware of the medical workforce that we are and should be. But the extent to which that is really absorbed past medical school is, I think, hard to say… I think that the culture in medicine is stronger than the teaching in medicine and even the most aware and considerate medical student on graduating can be crushed into the general way of things pretty quickly.’ (Abby)