Why do few medical students report their experiences of mistreatment to administration?

Abstract

Introduction Over 50% of medical students worldwide report experiencing mistreatment and abuse during their clinical education, yet only a small proportion of students report these concerns to administration. It is unknown how medical students make sense of their experiences of mistreatment and come to decide whether to formally report these experiences. Improved understanding of this phenomenon will facilitate changes at the administrative and institutional levels to better support students. Methods Using Constructivist Grounded Theory, we interviewed 19 current and former medical students from one institution about their experiences with mistreatment and reporting. Data were analysed in an iterative fashion, using focused and theoretical forms of coding. Results The decision of whether to report mistreatment is only one phase in the process that students report experiencing when encountering mistreatment. This process can be understood as a journey consisting of five phases: Situating, Experiencing and Appraising, Reacting, Deciding and Moving Forward. Students move through these phases as they come to understand their position as medical learners and their ability to trust and be safe within this institution. Each experience of mistreatment causes students to react to what has happened to them, decide if they will share their experiences and reach out for support. They choose if they are going to report the mistreatment, at what cost and for what outcomes. Students continue through their training while incorporating their experiences into their understanding of the culture in which they are learning and continually resituating themselves within the institution. Discussion Student perceptions of trust or mistrust in their educational institution are highly influential when it comes to reporting mistreatment. Interventions designed to support students and decrease exposure to mistreatment may be best focused on increasing organisational trust between students and the medical school.

‘Promises turn to dust…Trust into mistrust’: Medical students' experiences of mistreatment

“…We have previously explored opportunities for medical students’ perspective transformation through immersive simulation in relation to their understanding of the importance of non‐technical skills in the clinical workplace 3 . The initial stages of transformative learning evidenced in our data set included experiencing a disorienting dilemma whereby previous assumptions are challenged ; self‐examination with emotional disturbance and a critical assessment of assumption s. These phases resonate with Bell et al’s stages of a student experiencing and appraising whether behaviour they have been subjected to constitutes mistreatment, and reacting , often with strong emotions such as self‐blame 1,2 . Furthermore, Mezirow's description of how the development of a new perspective prompts the exploration of new roles and relationships , and subsequent planning of a new course of action , resonates with Bell et al’s phases of students deciding and moving forward , whereby ‘experiences are incorporated into their identity and their understanding of the culture in which they are learning’ 1 …”

“…The student journey described by Bell et al draws some interesting parallels with the process of perspective transformation, first described by Mezirow 1,2 . Perspective transformation occurs when certain experiences prompt reflection on one's prior assumptions, leading to a significant shift in one's outlook and understanding of the world.…”

“…Bell et al have recently explored medical students’ decision‐making processes regarding the reporting of mistreatment experienced in the learning environment to administration 1 . They outline an iterative process that students undergo when experiencing and processing mistreatment: experiencing and appraising mistreatment; reacting; deciding; and moving forward 1 .…”

“…Bell et al have recently explored medical students’ decision‐making processes regarding the reporting of mistreatment experienced in the learning environment to administration 1 . They outline an iterative process that students undergo when experiencing and processing mistreatment: experiencing and appraising mistreatment; reacting; deciding; and moving forward 1 . Bell et al also describe a central state of situating , the process through which students develop an understanding of their position within an institution, as well as their capacity to trust and feel safe within it 1 …”

“…Their perspectives are transformed, perhaps permanently. The upsetting experience of mistreatment in the clinical workplace without the support or intervention of bystanders, as described by Bell et al, highlights the stark contrast between behavioural norms within medicine and those in other social contexts 1 . Intimidation and humiliation of medical students has long been viewed as ‘an accepted means of enculturating the young’ 4 in a way that is less recognised and accepted in other disciplines 5 …”