Beaten down before they've even started: The sad mistreatment of residents and students

Burned out already when you’ve barely started medical practice? If you answered yes, you’re probably a resident or student who experienced mistreatment in your learning years. “So many students and residents feel so beaten down and so drained after their training—they’re kind of just hanging on because they had to survive this gruelling experience,” Dr. Amanda Bell, clinical professor in the department of family medicine at McMaster University in Hamilton, Ont., told the Medical Post. “They enter the profession already burned out.” Mistreated learners are, unfortunately, not a minority among their peers. A 2020 survey by Resident Doctors of Canada found about 65% of residents had been bullied in the last 12 months, most frequently by nurses. More than 90% of residents who had been mistreated said they were subjected to inappropriate verbal comments. About a year earlier, a presenter at a family medicine forum hosted by the College of Family Physicians of Canada asked doctors in the room to provide examples of the mistreatment they experienced during training. The responses included verbal abuse, being belittled in front of nurses, racism, getting screamed at by a surgeon and being told “I was responsible for the death of a patient.” “What’s really important to understand is that mistreatment can be intentional or unintentional, but it’s still mistreatment,” said Dr. Christina Grant, professor of pediatrics and faculty lead for the office of learning environment and mistreatment at McMaster. Read: Who's choosing family medicine in 2023? During a recent presentation at a Society of Rural Physicians of Canada conference, Drs. Grant and Bell defined what constitutes mistreatment towards trainees—disrespectful or unprofessional behaviour that has a negative effect in a learning environment—and outlined the five key categories of mistreatment: general, physical, race or cultural background-based, sexual orientation- and gender-based, and ableist or based on a learner’s disability. “General mistreatment—such as being humiliated during rounds or in a conversation—is the most commonly occurring category,” said Dr. Grant. “A close second is sexual mistreatment, which could take the form of really inappropriate sexual comments.” Understanding these concepts can help learners and educators identify if and when mistreatment occurs, and take steps to address the problem, she added. An example of behaviour that might be described by a learner as mistreatment but viewed by an educator as just a teaching moment is when a decision made by student or resident is challenged aggressively or even mocked in front of others. “There’s a really big grey area of behavior that might be unproductive or unsupportive but might not necessarily be classified as mistreatment,” said Dr. Bell. “So I think being able to have open discussions about this is really important.” While students and residents may experience similar types of mistreatment, the implications for each group may be somewhat different. Read: 'Adapting to starting practice': Doctors of BC webinar tackles key finance skills for residents and new physicians “I think students are particularly vulnerable because they're thinking about matching to residency spots and not wanting to risk their matching opportunities,” said Dr. Bell. By comparison, residents are paid employees—with contractual rights and obligations—whose presence is “really important for the delivery of healthcare.” Nonetheless, residents are also in a vulnerable position because they’re at the stage where they need to find jobs and make career connections. “Residents are thinking about getting jobs and future colleagues and what it’s going to look like if they bring something up with somebody who may be on a hiring panel or in a department where they want to work in the future,” said Dr. Bell. “It’s especially challenging for those in smaller disciplines where word travels quickly and a resident may be worried about how a complaint could affect their reputation.” While reporting of learner mistreatment is starting to improve, it’s doing so “very slowly.” Consequently, beyond surveys it’s hard to get a more fulsome picture of the problem and its prevalence, said Dr. Grant. She urged residents and students to take the time and trouble to report mistreatment they’ve experienced or witnessed. “The first thing a student or resident should do if they experience mistreatment is they need to take care of themselves—they need to reach out for support,” said Dr. Grant. “In all the universities across Canada, there are pretty robust resident affairs and students affairs offices where learners can reach out to have a confidential conversation and to get support, because that’s Number One.” Read: Stay away: Most family doctors will not recommend a career in family medicine Even when learners aren’t sure they want to report mistreatment, it’s a good idea to document their experience in as much detail as possible, ideally right after the incident. A good way for learners to log and time-stamp an incident is to send themselves an email and to organize these messages in a digital folder, suggested Dr. Grant. “Then find out from your resident affairs or student affairs office if they have a mistreatment office,” she added. “You’ll also want to ask questions about the mistreatment office’s confidentiality policies, what the options are in your particular situation and what their process is for handling mistreatment complaints.” For their part, educational institutions and hospitals need to be clear about their policies and processes and be diligent with follow-through. Recognizing the serious psychological impact of mistreatment is critical, said Dr. Grant. “At McMaster we’re taking a trauma-informed approach because we recognize that a lot of these experiences are traumatic and really upsetting,” she said. “We want to follow the lead of the person who experienced this trauma, give them information and control to the degree that they want and let them know we’re not going to do anything they don’t want us to.” Dr. Bell said it’s important for schools and hospitals to ensure learners know concrete action is being taken to address and resolve their complaint. From a broader perspective, it’s important for all learners—even those who have never been mistreated—to know that complaints against educators and supervisors are taken seriously and that offenders are held accountable. One way to do this was put forward in March 2019 in a Canadian Federation of Medical Students position statement, which outlined six recommendations for medical schools that included publishing de-identified statistics on the outcomes and efficacy of mistreatment policies, including how cases are resolved. Read: How can you recruit healthcare workers to your region if they can't afford to live there? “The consequences of mistreatment are enormous, which is why it’s something that needs to be addressed from different directions, at all levels,” said Dr. Bell. “For the individual learner there are psychological and sometimes physical consequences, and definitely their choice of discipline may also be affected by their experience. But we also see a negative impact on patient care and on the healthcare system—it's all very sad." The educators and supervisors who intentionally or unintentionally mistreat learners may also feel the adverse effects of their actions, perhaps in the form of job dissatisfaction and poor relationships with their trainees and colleagues. “So it really is not just an individual issue but one that affects the whole system—it just doesn’t work as well when learners are being mistreated this way and they enter the system as broken human beings,” said Dr. Bell. “I’m glad we’re talking about this.” Read: Healthcare workers doubt B.C.’s new whistleblower protections

Beaten down before they've even started: The sad mistreatment of residents and students

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