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A look at Stanford’s “zero tolerance” policy toward student mistreatment

Humiliation, belittlement, and harassment of medical students have long existed within medicine. According to those in the field, it’s a problem perpetuated by the profession's hierarchical structure — attending physicians above residents above interns. And medical students, who sit at the bottom of the totem pole, often face social pressure to always "appear strong” and not report mistreatment.

Far from a hidden problem, the mainstream media is full of reported incidences of this type of institutional mistreatment. As Nathaniel Morris, MD, a Stanford resident in psychiatry and graduate of Harvard Medical School, recently wrote in the Washington Post:

This hierarchy engenders a culture of bullying toward medical trainees. More than eighty percent of medical students report mistreatment from supervisors. I’ve seen classmates shouted at, cursed at and mocked in clinical settings. A surgeon referred to me as 'Helen Keller' because I couldn’t suture fast enough.

Earlier this year, in a paper (subscription required) in the journal Academic Psychiatry, a group of Stanford educators wrote about this problem and their efforts to reverse it here. The goal, say the authors, is to break the "cycle" of mistreatment, a problem that "lies in the culture of medical training:"

Once the learners become the teachers, the cycle of mistreatment often repeats with residents and physicians treating students as they were treated.

The paper describes how in 2009, the dean of the medical school at Stanford, concerned that the rate of mistreatment reporting by graduating students had increased above the national average, redoubled efforts to enforce the schools "zero tolerance" policy toward mistreatment. New efforts included getting monthly feedback from students about problems, increasing awareness through educational materials, and using tools such as videos, as training for students and educators.

"When we started this mistreatment initiative in 2010 it was a program ahead of what other medical schools were doing,"Rebecca Smith-Coggins, MD, first author of the paper and associate dean for medical student life advising, told me. “We wanted other schools to have an example of a program to help develop their own.”

The ongoing efforts at change are making a difference, Smith-Coggins; Charles Prober, MD, senior associate dean of medical student education; and their co-authors explain. From 2012-2014, a consistently smaller percentage of students reported mistreatment. Though that trend stalled in 2015, the authors remain hopeful this reflects progression toward a more respectful culture on campus.

"In medical education it has been traditionally accepted to use techniques that publicly humiliate students in an effort to teach them,” Smith-Coggins said. "It’s been our goal to help our educators find respectful ways to teach, and to help our students understand the culture of medicine, and to make sure issues are addressed without fear of reprisal for the student."

Additional efforts entail techniques that allow for anonymous reporting, a structured policy for addressing claims of mistreatment with educators that include disciplinary action if necessary, and a series of educational videos depicting behavior that may be interpreted as mistreatment developed by the surgery, Ob/GYN and emergency medicine departments.

“We are focusing on this so intently in medical school so our future residents and attending physicians will change,” Smith-Coggins said. “Culture change is such a difficult beast. But that’s the hope.”

Previously: Mental health in medical school: a resident calls for reforms, An RX for physician burnout, Keeping an even keel: Stanford surgery residents learn to balance work and life
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