Time for gun control?

One of us regularly uses an exercise on motivation as part of faculty development workshops (‘What motivated and what inhibited your learning as a student?’), and the issue of ‘teaching by humiliation’ always crops up, invariably generating a passionate and often bitter discussion. Just about everyone has an unpleasant memory and a story to tell, with both undergraduate and postgraduate levels and all specialties represented. However, there is often someone in the group who describes a positive experience; they are often surgeons. The discomfort and embarrassment, and the negative emotions, it seems, are outweighed by the positive effect on their drive to learn – Yes, old ‘Buffy’ is a bit of a bully, and it's not a pleasant experience, but, boy, do you make sure you're well prepared and learn your stuff thoroughly! A thought-provoking paper from Toronto in this month's journal explores this area in the context of surgical residency.1 Using focus groups and interviews with video triggers the authors set out to elucidate these phenomena with faculty and residents, looking at both definitions and perceptions of the impact of intimidation and humiliation. Interviewees acknowledged they were still prevalent in surgical training, although they were reluctant to actually use those exact terms. However, they rationalised their existence in several ways: whether they could attribute some purpose to the perpetrator, and/or whether the effects were perceived as either beneficial or necessary, i.e. whether the intimidation was seen as a functional educational intervention. The authors conclude ‘The cultural value currently accorded these behaviours needs to be taken into account in educational interventions designed to shift attitudes and actions in this domain.’ Inevitably they call for further research into the context and culture of the environments in which such behaviour is present, and into the relationship between intimidation and humiliation and trends such as decreasing interest in, and attrition out of surgical residency programmes. The problems are clearly not confined to postgraduate surgical practice. Elnicki and colleagues surveyed medical students completing an internal medicine clerkship in West Virginia2 and found that 11% reported some kind of abuse during their clerkship. Worryingly, but perhaps not surprisingly, less than one-third had reported the episodes to someone for fear of retaliation and in the belief that reporting is pointless. Potential consequences included a poor learning environment, and feelings of depression, anger and humiliation. At a more general level, Lempp and Searle interviewed students from all year groups in a London medical school, and although there were many reports of positive role models and approachable teachers, they also talked about the prevalent competitive atmosphere in their school in which teaching by humiliation occurred, especially during the clinical years.3 As it happens, we have an impression, based upon feedback and conversations with students in our own and other medical schools in the UK, that the prevalence of this malign approach to teaching is declining, at least at undergraduate level. Nonetheless, there are still enough reports of ‘teaching by humiliation’ for us to remain concerned. On a broader front, workplace bullying (of which teaching by humiliation is a subset) is still apparently alive and well in training settings. In a study of psychiatric trainees nearly half had experienced one or more bullying behaviours in the preceding year,4 although another recent survey of junior doctors suggested a lower (falling?) rate.5 There is ample evidence that learning is more effective in an environment free of fear and anxiety.6 The consequences of negative experiences can be profound, especially for more vulnerable individuals – in the words of none other than Albert Einstein, ‘Humiliation and mental oppression by ignorant and selfish teachers wreak havoc in the youthful mind that can never be undone and often exert a baleful influence in later life’.7 Sadly, such practices may also promote a culture of bullying, and set in motion a self-perpetuating cycle of abuse, in which victims become perpetrators4, 8 whether or not such behaviours are genuine, if misguided attempts by trainers to improve trainees' performance.5 There are also problems about reporting systems for those who feel bullied. Although ‘whistle-blowing’ is increasingly encouraged, at both undergraduate and postgraduate levels, with anti-bullying policies apparently well established, victims may either not know about these mechanisms, or may not feel confident in them. There is an argument for institutions to be more pro-active in both preventing and detecting such behaviour, and providing support for the victims.4 Musselman et al.′s paper highlights that there is more to do specifically in respect of attempting to deliver good quality surgical training in a conducive and supportive learning environment. This is not to say that the phenomenon of bullying has been ignored. Much has in fact been done to improve the situation, recognising that an educational rather than punitive approach is most likely to succeed,5 but moving from a system of apprenticeship and patronage takes time. For example, in the UK, the Royal Colleges of Surgeons have worked carefully with educationalists and made serious efforts to alter the structure and delivery of surgical training with an emphasis on ensuring that sound educational principles underpin the numerous ‘training the trainers’ courses, encouraging teachers and trainers to move away from the ‘see one, do one, teach one’ approach, and actively discouraging teaching by humiliation. Not only methods of teaching, but also methods of assessment have come under scrutiny. Examiners are now strictly monitored for technique, consistency and fairness and receive detailed feedback on their performance. Questions are from a bank of approved syllabus-related topics so no longer can the ‘grumpy old men’ of the Examinations Board ask questions on their pet subjects. The importance of training and teaching has also increased in recent years with regular assessment of surgical trainees by the Regional Training Committee now forming part of progression through the training programmes. In the future, Modernising Medical Careers will hopefully ensure that assessments in the round are carried out, not just by the consultants, who appear to be the main perpetrators of abuse, but also by members of the nursing staff and the peer group.9 The introduction of the new consultant contract has allowed teaching and training to be more easily identified through the job planning process. Staff development for consultants who have trainees and teach is available through many Trusts, deaneries and medical schools. Despite these serious attempts to improve the profile and quality of teaching, constraints still exist in relation to funding of courses which in a practical craft specialty such as surgery can be very expensive. Limited budgets with Postgraduate Deans means that there is not enough for everyone, and rightly non-surgical specialties question whether surgical trainees should get a bigger share than non-surgical. There certainly is evidence of improvement over the past 20 years but undoubtedly surgeons could do better.

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