This study provides insight into medical students’ experiences of mistreatment, and the impact it has on their wellbeing and clinical learning. Although many participants did not report serious instances of misconduct, they nevertheless identified some of the driving forces perpetuating mistreatment in medical school, as well as other challenges faced by medical students. The findings highlight problematic aspects of medical teaching and culture, and potential avenues for change and future research.
Participants often felt that intergenerational change was not occurring and that anti-bullying strategies have been ineffective because of the cyclical nature of mistreatment. This helps explain why mistreatment is entrenched in medical culture, and where intervention may be necessary. Wood (19) argued that the psychological qualities that allow some students to cope with abuse or ignore unwanted events perpetuate the problem. These students qualify, move into positions of authority within the medical workforce, and encourage the same behaviours and practice of non-reporting, not viewing these issues as problematic within their own training. For example, Australia’s Productivity Commission Report found 74% of medical students have been victims of and 86% have witnessed intellectual humiliation (20), in line with participants’ experiences and reinforcing their self-described need to be resilient. Scott, Caldwell (22) propose that intellectual humiliation forces students to align their values with those of their superiors, adjusting their professional ethical code in order to survive, and maintaining the dominant culture of medicine wherein victims become perpetrators. For this reason, more structural change may be needed, such as formal training of supervisors, to protect current medical students and break this cycle.
Several elements of medical culture were discussed by participants as problematic and potential contributors to mistreatment. Self-sacrifice and resilience were identified by most participants as central to being a doctor. This plays into traditional medical paradigms; because of the vulnerability of patients and non-proprietary nature of the medical profession, doctors are bound by moral obligations to be altruistic, even when this compromises their own wellbeing (32). Cohen (33), then President of the Association of American Medical Colleges, described ‘commitment to self-sacrifice’ as an essential attribute for acceptance into medical school. Major (34) attributed the emphasis on self-sacrifice to structural pressures in the healthcare system that require medical students to ‘act as professional and ethical chameleons’. Consequently, in an overburdened hospital, concealing minor errors and unconditionally agreeing with senior doctors are encouraged. Participants in this study, similarly, identified overworking and underreporting as products of self-sacrifice, propagating mistreatment.
Participants described the medical hierarchy as a pervasive feature of medical education and source of toxic workplace culture and underreporting. Similarly, a 2004 British qualitative study yielded the ‘hidden curriculum’ of medicine (35). This was defined as an informal standard of learning that instills acceptance of hierarchy, compromise of ethical integrity and emotional neutralisation. These agendas may manifest as abuse and intellectual humiliation, leading to the perpetuation of the medical hierarchy at the cost of professionalism.
This study provides clear evidence to support the need for change in medical school and hospital environments. This may involve reforming the medical admission process, greater accessibility of reporting systems and emphasis on self-care, and formal workplace restructuring to prevent overworking, such as more interns allocated to a team.
Understanding how medical students approach reporting mistreatment was a key aim of this study. Many participants cited being labelled as ‘sensitive’ or a ‘troublemaker’ as barriers to reporting. The resilience participants identified as being necessary to cope with confronting emotional or physical situations may translate to professional reticence and underreporting, though this requires further research. Participants also lacked confidence in the anonymity of reporting systems and certainty of repercussions for troublesome personalities. These results reinforce Australian studies by the AMA (17) and Scott, Caldwell (22), who found less than one third of victims reported abuse in medical school. They cited fear of reprisal, lack of confidence in the reporting process, fear of impact on career, and cultural minimisation of the problem as reasons medical trainees do not report mistreatment. These findings align with a Canadian study that found, of students who had reported incidents, only 35.9% were satisfied with the outcome (36).
An array of solutions were suggested by participants to address unprofessional behaviour. For example, one participant mentioned the Vanderbilt Coworker Observation Reporting System (CORS) which aims to address disrespectful and unsafe physician behaviour with scaled consequences, escalating from an ‘informal’ cup of coffee intervention to ‘disciplinary’ intervention (37). Piloting a similar framework in Australian medical schools and hospitals could potentially encourage utilisation of reporting systems, guarantee confidentiality, and assure outcomes, all of which were identified by participants as desirable to counter underreporting.
All female participants felt gender played a problematic role in their clinical teaching or future decision-making. They felt medicine was male-centric, in both the quality of teaching women received and curriculum itself. Many female participants stated they had received fewer opportunities, were ignored by male supervisors, or felt uncomfortable because doctors were always referred to as ‘him’ or ‘he’ by physicians. Beyond Blue’s 2013 Australian survey, which included 1,811 respondents, showed that 20% of medical students had contemplated suicide in the last twelve months, but 25% for female medical students (38). However, this is the extent of academic literature regarding Australian female medical students’ experiences and perceptions of mistreatment. Because this was a key issue raised in this study, there is scope for further research into gendered experiences in clinical teaching.
Participants described a toxic workplace culture, including ‘servant’ behaviour and gendered mistreatment, which made participants and their peers feel uncomfortable, unsafe, and unhappy. The practice of ‘pimping’ students – an American term meaning excessive, inappropriate questioning of students and trainees that produces shame and humiliation– was also a stressor for participants. (39) Academic literature has well established that medical students who report mistreatment are more likely to experience lower career satisfaction including questioning their chosen profession, increased likelihood of drop out, substance abuse, anxiety, reduced self-esteem, higher levels of stress, depression and suicidality (15, 19, 36, 40, 41). The literature also suggests that medical students’ experiences may differ by chosen specialty.(15)
Some participants also believed patient outcomes are compromised by overworking and mistreatment, factors like sleep and adequate family time being essential to better mental health and, consequently, quality of patient care. Disruptive workplace behaviour has been shown to have negative impacts on team collaboration and communication efficiency, diminishing staff performance and morale, and contributing to trainees feeling forced to cope with clinical issues beyond their training (17, 23, 42). Similarly, a US staff survey showed that 71% of respondents (doctors and nurses) believed unprofessional behaviour contributed to medical errors, with 27% stating it had contributed to a patient’s premature death (43). This is supported by a 2015 randomised blinded trial showing that medical teams treated ‘rudely by an expert observer’ performed significantly worse in a paediatric emergency simulation (44). Furthermore, higher staff absenteeism due to stress and workplace dissatisfaction impacts continuity of patient care and increases the workload of other staff (43). This study contributes to this body of literature necessitating structural change to address toxic medical culture in order to maximise quality of patient care and student wellbeing.
This study had some limitations. Firstly, the inclusion criteria purposefully sampled people who had experienced or witnessed mistreatment, which may have influenced the study’s results as participants were more likely to have strong views about mistreatment in clinical settings. Secondly, participants were only eligible if they attended a Sydney-based medical school. However, six of the participants had rural clinical experience, and discrepancies between rural and metropolitan teaching were often raised. There is scope for future research comparing rural and metropolitan teaching and working environments. Finally, as a small qualitative study the results may not be generalisable to a wider population.
Despite these limitations, this study provides a strong qualitative foundation for understanding the challenges faced by medical students, and how these obstacles, such as those preventing incident reporting, can be overcome. More clarity surrounding reporting systems, reinforcing their confidentiality and guaranteeing outcomes are some ways in which medical students may feel safer and more supported in their training. Additionally, providing participants with more structured clinical teaching, including enforcing formal learning objectives and supervisor training, may alleviate the anxiety and inappropriate teaching currently problematic in unorganised clinical teaching.
Furthermore, this study identifies concerns of medical students for which there may be scope for future research. These include inclusion of diversity in teaching, the medical admission process, and ethics and values in the medical curriculum.