Monday, April 9, 2007

Learning the hard way

Lately I have noticed an increasing number of posts on medical blogs about medical students and residents being treated badly by the people who are supposed to be teaching them. At "medschoolhell" (a domain name that already suggests poor treatment) we read about the cruel whimsy that many medical students are subjected to by those who have power over them. Over at Panda Bear MD we read about how a senior and experienced resident is treated poorly, and then made to pay (by unfair evaluation) for not accepting the behaviour as appropriate.

Almost all medical students and residents will be able to describe being abused in some way during their training. In many ways the medical training system is set up in such a way that this abuse is predictable. The medical education system is complex, and subject to it's own set of peculiar social rules. Some of the factors that lend themselves to various forms of abuse include:

  • Medical education follows a strict hierarchical model.
  • Most medical teachers have received no education in teaching.
  • Many medical teachers were themselves trained in abusive environments.
  • When subject to abuse, medical trainees are often forced to disclose up the chain of command, with the first disclosure often to the abusive person them self.
  • Medical trainees can be subject to significant reprisals for reporting abusive behaviour.

Evidence based medicine is a mainstream medical concept. Clinicians attempt to practice what has been shown to be effective through well conducted research, while discarding those practices shown to be ineffective. For some reason, however, this thinking has not gained any hold in the realm of education. The idea of evidence based education, or teaching using techniques that have been proven to be effective, is simply not a part of medical culture. In fact most medical teaching is based more on culture than on evidence. As a medical trainee any lament of poor treatment is likely to be met with 'I had it harder in my day', from whoever lives one rung up the ladder.

In addition to the necessary learning of factual information, decision making skills, and physical techniques medical education undoubtedly provides a function of socialization into the doctor role. It is this reason more than any other that is used to justify the maltreatment of trainees as an initiation rite, vital to the future functioning of the trainee as a doctor, rather than simply abusive behaviour. In fact, while maltreatment probably serves a memetic function, passing the abuse forward generation through generation of doctors, there is scant evidence that any initiation rite, abusive or otherwise, plays any important role in the actual practice of doctors.

Maltreatment itself exists in at least 2 important categories; that which is part of a supposed educational process, and that which is not. The latter is easier to deal with (in that is more easily shown to be inappropriate), and includes overt rudeness, hostility, threats, degradation, sexual harassment and physical abuse. These behaviours are objectionable to society in a broad sense, and resonate as inappropriate with virtually everyone. It is hard to imagine that it would ever be appropriate for a bank manager to throw a stapler at a teller as a logical consequence for an error, yet it is not unheard of for a surgeon to throw a scalpel at a trainee who has made a mistake (both acts are probably criminal assault). Behaviours that are not socially or societally acceptable aught not to be justified as teaching or initiation. As a group of adults, doctors of any level of training should be required (and require of themselves) to treat one another within the bounds of normative behaviour.

Maltreatment in the guise of education may seem a stickier point, though once dissected is equally unpalatable. The act of pimping (for the uninitiated, the act of rapid fire questioning until the point of error or beyond), first credited to Dr. Walter Koch, is such an example. In reality pimping probably stretches back to time immemorial. Hippocrates probably pimped Polybus about which of the four humors was most responsible for abdominal pain, and indeed the pimpers will often try to pass off the technique as Socratic questioning, or learning through induction. The essence of the Socratic method of course is that it is a dialectic technique, and probably most applicable to philosophy and non-absolute arguments (though of course Socrates did use his method to extract mathematical ideology from the non-educated). Medicine, at least in the way it is usually taught, is absolute in so much as the doctor at the top is the one with the right answer. So as a Socratic dialogue, pimping seems to fall short.

The idea of teaching through negative reinforcement is also frequently used to justify questionable teaching behaviours. Negative reinforcement, as logical unpleasant consequences of an unwanted action, does exist in medicine, though the term is often used to mean public humiliation or shaming. Indeed negative reinforcement has been shown to be a successful educational strategy...mainly in rat models. Applied to adult learners however, negative reinforcement, shaming, and humiliation produce only short term behavioural changes, that usually reverse once the negative stimulus is removed (i.e. when you move on to a new rotation.)

As a medical teacher I am far from perfect. I have a short attention span at the best of times, and lack many of the 'answers' that students seem to be searching for. I am sure that I frequently frustrate students when I say 'there really is no right answer.', or go off on a tangent with a patient telling me about some fishing trip they took 5 years ago (really, that is more interesting than how many salads they are eating these days). I will say though that I make an effort to be patient with students, to tell them they are doing a good job, and to try to build up their confidence. I admit to them that I too forget the results of the COMMIT study, and still (somehow) manage to practice medicine. And above all else, when I see a student or resident being bullied (because I think in the end we probably all see that this is all just grade 6 style school yard bullying) I attempt to extract them from the situation.

I think it is high time that the EBM folks stepped up to the plate with a new initiative: EBE (Evidence Based Education). There is simply no room for bullying and antisocial behaviour in medical education, not only because it is morally wrong, but also because it is simply ineffective.


student dr. blaze said...

Dr. J, you capture the educational experience perfectly. I'm an "older" non-traditional medical student and I've been horrified by the manner in which we're treated as students. On one hand we're being told to be professional, on the other hand, if we don't know the answer to a question, the professor offers the student a job application for some horrible fast-food restaurant (implying that the student is a complete idiot).

Do you have any advice as to how students might better survive this process without becoming cynical or like-minded abusers? Is there anything we can do to encourage change in the educational system? We are, after all, the students going in to debt (now beginning to reach the $200K+ level for recent grads); we're the consumers; how can we proactively address this problem?

Kudos to you for taking the time to think about how you teach medicine. I'm grateful you're not perpetuating the cycle of abuse and I'm impressed by your clear, rational argument against it.

Panda Bear said...

Nice post. But at this stage of the game, a bad evaluation (which is what I got out of the rotation) doesn't mean a thing. I'm not going to do a fellowship and when I'm done with residency, I am done with formal education forever amen.

In fact, I am now at the point where I don't give a rat's ass what attendings and residents on my off-serivce rotations think about me. They are just obstacles. I am just a low-paid scut whore to them so if there are any hard feelings, well, that's too bad.

Dr. J. said...

Dr. Blaze: I think if you look at the issue really as an issue of bullying, it becomes a little clearer. In a group situation, a bully picking on one person is really bullying the group with the implicit message 'and you could be next'. My suspicion is that stratagies to reduce bullying behaviour in other workplaces or schools would probably also have some effect. At a very basic level this would include a zero-tolerance policy around this sort of bad behaviour, and rational avenues for reporting and investigation.
On a more personal level, I believe that one of the solutions is for people to stand up against this behaviour, simply by saying something like 'The way you are acting is inappropriate and unprofessional'. When the message comes from many it becomes harder to ignore.
Most medical teachers try hard to do a good job, but unfortunately they are often forgotten by their students as the few abusive teachers remain promenent in memory. In many ways these good teachers are also feeling bullied, and afraid to stand up for the rational and often excellent teaching they are doing.

Dr. PB: I agree that the power of inflicting repercussions is in most respect an illusion. I do think it is sad hawever that these bad experiences have kept you from doing a fellowship (if that was something you were interested in). Your case is one where the people with a clear view of the problem tend to depopulate academia ASAP, and have less chance to pass on thoughtful teaching to those docs still in training.

Dr. J.

Nancy said...

I hope this culture of abuse is gradually changing for the better. In nursing it is, although it's slow. From the close sidelines I've always been amazed at how inhumane the internship and residency of medicine is, it's part of what kept me out of trying for a career in medicine and I have no regrets.

Luckily, workplaces in general are becoming aware of and less tolerant of bullying. Education campaigns by the unions are helping (once bullies have their type of behavior publicly identified they tend to ease up), but I'm sure that's harder in medicine as you don't have that seperate structure to nip at the heels of those who are (often indirectly) responsible.

sdbaral said...

but Dr. J (what does this stand for :) ),

look at your classmates. there are those who are strong and those who are weak. and i am not referring to their knowledge base, rather their character. those that are strong feel no need to gain satisfaction by coming down hard on some rookie, or just someone lower down on the chain than them. those that are weak do (it is the medical equivalent of small man syndrome...think of mice and men.).

if you think of it in that context, then it is just some sad display of immaturity coming from a "small" weak person. and that really is the truest definition of sad. i feel bad for those people. that said, as i become more senior myself, i have less of a tolerance for it. i do try and extract constructive criticism from nearly everything that i face. sometimes there is just nothing constructive to be taken out of those comments.

so that is that. i had a crazy awkward interaction with a pretty senior doc here in tdot. i think she was trying to burn me...i actually thought she was kidding and made a joke back. and then it was awkward. painfully so. the actual story is told better in person, which i hope the opportunity to have with you at some point in the near future.

anyhoo, i agree that it is sad if people don't do something that they were interested in because of some shmoe. that is the saddest thing of all...

anyhoo, i think i was going to keep yapping, but im sure everybody stopped reading after the second line :).

sdbaral said...

oh, right! i was going to yap about my experience as a new boy at the athol murray college of notre dame. the relationship between old and new boys is the hockey/discipline school in saskatchewan equivalent of the relationships that you describe.

needless to say that after a year of being a new boy, i did not return to become an old boy. just didnt see myself bossing or beating up random kids to make myself feel strong (though in retrospect having somebody bring me breakkie and clean my room for the next three years wouldnt have been that bad!).