I just saw Whiplash, a 2014 drama that was highly touted, and I know at least nominated for some kind of cinematic award. Should have won. What an incredible exploration of excellence, the pursuit of it, and, frankly, abuse. Perhaps it’s more the other way around. A study of abuse in the search for excellence.
New medical students, and residents don’t get it. At least as much. They get negative feedback, but not so much abuse. I hope. I was standing in ER this am when a young fresh face politely asked a RN for help with a pelvic exam. He was told to fly a kite. Laughter ensued, not from him. Admirably, he said nothing, sat down, composed himself, and asked another nurse, who managed to give a more polite answer. I don’t know what to do about that. That’s part of the gauntlet line that medicine will always have, I think. The nursing culture has to change. I agree, medicine was abusive to nursing in the past. Largely in the past. Come on. He handled it about as well as could be expected.
One of my vivid memories of abuse was actually prior to even getting into medical school. I was working hard, or at least I thought I was. I applied for special consideration for early admission, because in high school I was an all star. My grades were reasonable, and hey, I was going to turn it around, right? Well, I walked in, all decked out in my new suit (yes, this was in 1980), shook his hand, the whole act of which was rather brusque, and sat down.
Not as vivid, or in your face as Whiplash, but about the emotional equivalent. He didn’t say anything, looked down at my papers for about three minutes, then put his head up and quite crisply told me I’d never get into medicine, and to stop wasting the faculty’s time.
He put his head back down and told me to get out.
Abuse. He didn’t throw anything at me, or yell in my ear and call me four letter words, but it was tantamount to the same thing. Abuse.
What’s the correlation with Whiplash? Well, I thought I was working hard before. You should have seen me after. Holy smoke. You should have seen the drum rolls. That interview probably got me into medicine, I kid you not.
Then there were the hours, which are a bit better now. No more 36 on, 12 off. 36 on, 12 off. It affects patient safety, or such is the drill. Younger MDs wonder how I’m up at 0500 at my age, and finished rounds before they’re out of bed. Early training dies hard. There was a point to it: even exhausted, or sick, my performance is pretty stable on chart audit and reflection.
Senior residents did it more than staff. Does it still happen? The sneer. I remember being brusquely told about my shirt being unacceptable. (I wore ties back then…) Seniors would leave the ward and leave you, alone, all night, unavailable by phone, signing orders in the morning. Not all mind you, but what do you do, when you’re so junior? Yes, in retrospect, and with the wisdom of years, a phone call to staff would have been appropriate. But as a completely new addition to the system, you think this is the way things run.
There was the demand to do an operative procedure, as the staff person was clearly incapacitated. That I had never done before.
I was witness to screaming fits. None of these staff, but senior house staff to junior. I wasn’t the brunt of any, thank God.
Got an email from the academics at my university system the other day, about a suicide of a medical resident, high performer. In Whiplash, one of the teacher’s prior victims also suicided. High performance students are more vulnerable.
Studies have shown bullying and harassment is rampant in medical training (Wood, 2006), most students having experienced it at least once. Suicides are known in almost every medical school. Rates are 40% higher for male physicians, and 130% higher for female physicians, than the general public. Belittlement and bullying leads to work dissatisfaction, binge alcohol use, and depression (Frank et al, 2006).
The feared “Socratic Method” employed on the medical ward is meant to shatter arrogance, and display knowledge / logic deficits (Aref-Adib, 2006). But this can be a weapon of abuse in the wrong hands. On the ward, we need to listen to our colleagues, and give them feedback if they need it. There is helpful, educational Socratic questioning. Then there is the other kind.
Negative feedback. It has a place. It is a motivator, clearly, and is also clearly separate and distinct from abuse. Have you seen Whiplash? The negative feedback was the norm, and the abuse was regular. I would think students would get just be cowed…What kind of effect would this have if it was just the norm?
This is a tool that has to be used very delicately. A bit of sensible, polite negative feedback on a background of congruent, accurate feedback and appropriate praise will stand out, and be greatly effective.
We have to be careful here. All teachers must be careful with negative feedback, and just STOP the abuse. Our students put more than their academic lives in our hands.
Sometimes, it’s their very lives.
Aref-Adib. (2006) Belittlement and harassment of medical students: is a source of medical education. British Medical Journal, Oct 14;333(7572):809. doi:10 1136/bmj.333.7572 309 a
Frank, E, Carrera,Js, Stratton, T, Bickel, J & Nora, LM. (2006) Experiences of belittlement and harassment and their correlates among medical students in the United States: longitudinal survey. British Medical Journal, Sep 30;333(7570):682-4
Wood, D. (2006) Bullying and harassment in medical schools: Still rife and must be tackled. British Medical Journal, Sep 30;333(7570):664-665 doi 10 1136/bmj.38954 568143.BE