In the age of professionalism, student harassment is alive and well

A medical education is as much an enculturation into the ‘mores’ of the professional role models encountered and the learning climate experienced as it is the sum of knowledge gained and competencies acquired. The charge that a transgenerational legacy of aversive teaching methods, including public belittlement or humiliation, as well as physical and sexual abuse, racial or ethnic discrimination and verbal abuse, has been laid at the doors of a medical education culture, which has traditionally been male-dominated, strictly hierarchical, and resistant to change.1 Harassment – and particularly sexual harassment, may well have its roots in such a culture. How ironic that a profession that espouses ‘caring’ and ‘empathy’ has a history of creating a poisonous learning environment that can extinguish the very passionate altruism of would-be medical professionals and then pervert the course of medical education for the next generation of students, as mistreated graduates meet unto others what was perpetrated against them. Medical education is as much a process of enculturation as the sum of knowledge and competencies gained The chorus of dismay echoes through more than 20 years’ worth of publications documenting medical student harassment – and 20 years represents virtually a whole generation.2,3 What have we learned over this timespan about the causal or preventative factors that impact on the abuse and, particularly, sexual abuse of students while they travel through the medical school curriculum and what does the recent study carried out by Rademakers et al. in 2 medical schools in the Netherlands contribute to our understanding of the issue?3 Reports of student harassment extend back a whole generation Rademakers and colleagues compared the prevalences of sexual harassment of medical students in 2 relatively similar Dutch medical schools using a semi-structured questionnaire that contained questions about student experiences of sexual harassment during clerkships. The schools differed only in that clerkships in Utrecht begin earlier than in Nijmegen and, consequently, students in Utrecht had had more clinical exposure than their peers in Nijmegen at the time the questionnaire was administered. The study was confined to the topic of sexual harassment, which was defined as ‘unwelcome, sexually oriented attention’.3 The authors found that women were much more likely to have been sexually harassed than men, consistent with the previous literature, with an overall prevalence of 20% in the 2 medical schools. The latter figure is lower than that reported from some other countries, but similar to numbers recorded from North America.1,4 Differences between the 2 schools in prevalences of sexual harassment may be attributable to the fact that women students in Utrecht had experienced more clinical rotations at the time of the study than their peers in Nijmegen. No other explanation for this was forthcoming from the study authors. A more remarkable finding was that two-thirds of the perpetrators of this harassment were patients. Comparable statistics are difficult to ascertain from the literature. Frank and colleagues performed a longitudinal survey at 3 time-points across the 4-year curriculum at 16 US medical schools (2884 medical students of the class of 2003).5 Harassment was not broken down by category, but 28% of the instances of abuse reported by women students were perpetrated by patients. I think that these 2 studies, by Rademakers et al. and Frank et al., respectively, exemplify the problems that arise when we attempt to make comparisons across and even within different countries of statistical differences in reported prevalences of student harassment. As Wood points out, the results of the many published studies of student abuse should be interpreted with caution.6 Many of the studies reported are small and cross-sectional, and were carried out by faculty members of the institution conducting the study.6 The proportion of women students in the class and other student characteristics, definitions of abuse and sexual abuse, respectively, and the inclusion or exclusion of patients or nurses from the list of potential abusers must all be controlled for. Thus the contentions of Rademakers and colleagues that a more masculine culture where men have to prove their masculinity in the USA (compared with Holland) leads to more harassment, and that Dutch women are more assertive in expressing their boundaries, remain somewhat speculative. However, although there may be heterogeneity in what is being reported, there is no doubt that a subtle or not so subtle undercurrent of student harassment is continuing in medical schools around the world. I have asserted that transgenerational customs have changed little over the past 20–30 years; so how can this culture be changed? There is heterogeneity in the definition of various forms of harassment and many reported studies are small In North America, the medical student accreditation system through the Liaison Committee on Medical Education (LCME) has established standards related to student ‘mistreatment’. This may have put the issue on the radar screen for medical school administrators, but is insufficient to change an ingrained culture. Individual medical schools must define their own norms of professional behaviour Each medical school has to define the cultural norms of professional behaviour, between peers, faculty and students, interprofessionally and in a doctor−patient context. Although such a process requires leadership, norms cannot be dictated by the senior administration. Ogden and colleagues attempted to probe the norms of doctors, nurses, residents and medical students in relation to abuse at 13 medical schools in the USA.7 Five videotaped scenarios of different types of potential abuse were created and shown to study participants, who were asked to identify whether each situation portrayed abuse, and if so, to provide a rating for it. Even the relatively small differences between the groups in their ratings in this study would be worth discussing in a group setting. A stimulus video vignette shown in an interprofessional, peer or even student−teacher group setting with a facilitator could allow an open discussion of assumptions and values to surface, and perhaps create a dialogue wherein would lie the seeds of a consensus as to what constitutes acceptable behaviour and what should be the strategies for reporting and dealing with unacceptable behaviour. Such interactive learning situations have been reported to have a positive impact on reducing abuse.8 Clearly, it makes sense to optimise the teaching skills of medical teachers (residents and faculty) and improve interprofessional relationships, but these improvements must be grounded in a shared value system at an institutional as well as an individual level. A stimulus video and a facilitator in a group setting can allow open discussion of values and assumptions Today in our medical schools we pay increasing attention to the development of professional behaviour and professional competencies in our medical students; however, this education will have little lasting benefit unless the environment in which it takes place reflects the underlying values and professional cultural norms espoused in what is being taught.

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