Toward a Humanistic Learning Environment: Addressing Resident Mistreatment

Abstract

While we find the results of the study by Mullan et al1 in the March 2013 issue of the Journal of Graduate Medical Education alarming, the findings sadly do not come as a surprise. The authors administered an anonymous questionnaire to more than 500 interns at Partners Healthcare, Boston, MA, during 2010 and 2011. Of the nearly 400 participants, 93% had experienced “disruptive behavior” during internship, including condescending behavior, berating, exclusion from decision-making, inappropriate jokes, abusive language, and gender bias. Even more concerning is the fact that 54% of the interns reported experiencing these behaviors once a month or more.1 A culture of disrespect in medical training is certainly not a recent development: Rosenberg and Silver commented on the pervasiveness of verbal abuse and humiliation in medical training nearly 30 years ago.2 Fifteen years later, Kassebaum and Cutler described a similar climate of learner abuse in US medical schools, and they advocated for medical educators to “tidy up the environment for learning.”3 Though there is a paucity of data regarding perceived learner mistreatment in the US graduate medical education programs over the past decade, there continue to be reports of learner mistreatment in the undergraduate medical education community. In the 2012 Association of American Medical Colleges Graduation Questionnaire, medical students reported that interns and residents are nearly as likely as faculty to be the source of student mistreatment.4 This is concerning as it perpetuates a phenomenon in child abuse when those “abused” become the “abusers.” In fact, Silver related abused medical students to abused children in his 1982 commentary in the Journal of the American Medical Association.5 The board of directors of the Accreditation Council for Graduate Medical Education (ACGME) recently charged the Council of Review Committee Residents (CRCR) with defining the scope and magnitude of the problem of resident mistreatment in the clinical learning environment. The CRCR is currently working to further clarify what types of learner mistreatment behaviors are occurring in the graduate medical education learning environment, the prevalence of these behaviors, and the consequences of learner mistreatment. Moving forward, it should be our objective to ensure a humanistic clinical learning environment for current and future trainees. We anticipate that the Next Accreditation System of the ACGME will provide a model structure to encourage this lasting cultural change. We need to better understand the root causes of hostility, harassment, and the culture that creates “disruptive behaviors,” such as between interns and critical clinical team members such as nurses who were highlighted by Mullan et al.1 Solutions should be sought that maximize the ideals of professionalism in service to our patients and to us, as the future of medicine.