Talking about trainee treatment

Historically, there wasn't much doctors in training could do when they felt they were mistreated by their educators.

That, of course, has changed as many in medicine have pushed for the training environment to become more universally respectful and professional. But at least one academic center decided to make this shift more explicit in 2019, by implementing an online reporting system to identify unprofessional behaviors and mistreatment directed at trainees.

Administrators analyzed 196 of those reports in a study published by JAMA Network Open on Dec. 2, 2022. Most (88.3%) described unprofessional interactions; more than half were reported by residents and fellows, and a third came from medical students. The majority of negative reports described behaviors by faculty, and 20 faculty members accounted for 52 of the 104 reports describing unprofessional behaviors.

To get more perspective on this issue and project, ACP Hospitalist recently spoke with lead study author I. Michael Leitman, MD, professor of surgery and medical education and dean for graduate medical education at the Icahn School of Medicine at Mount Sinai in New York City.

Q: What motivated this project?

A: Stakeholders at our school, for undergraduate, for graduate medical education, and for our graduate school, all agreed several years ago that the impact of mistreatment and unprofessional behavior on our trainees was resulting in burnout and other negative emotional outcomes. This is not unique to Mount Sinai. I've been on the faculty of other medical schools in my career, and I've observed this everywhere. But we felt that it was time for us to try to take some measures to help mitigate this.

Q: What was your solution?

A: To create a system that allowed for easy reporting, to develop it in such a way that people would get familiar and comfortable with it, and to give them a number of avenues, anonymous or confidential or with delayed intervention so that they would know it would be after their grades were received. We put it throughout the health system—put it on desktops in the hospital, put it on the computers in the library, linked to the websites that our students and our residents and our fellows use. It was everywhere.

Q: What happens to the reports?

A: If [the reporters] were not anonymous but confidential, we thanked them for the report. We might ask them a few questions. We created a triage system so that the reports came directly to my email inbox as the dean for graduate medical education, as well as [to] the dean for undergraduate medical education and the dean of our graduate school. … Depending on what the report was, we figured out how best to triage them. We had people from our HR [human resources] department, legal department, our chief medical officer—various stakeholders—join us, and we had regular meetings.

Q: What was typically the response to a report?

A: It might be as simple as calling up the subject and having somebody sit down with them and give a reflective statement: “You are perceived as X” or “A trainee felt that they were treated in such a way and you might want to be careful about things you say or things you do in the future.” Sometimes they were really egregious and, through our human resources department and our leadership, we had to make real changes. Individuals with egregious reports or individuals with repeated reports had other interventions, everything from a conversation all the way up to removal from the learning environment. We've referred a few for wellness check-ins and we have identified individuals that unfortunately have been suffering at that time from some wellness issues.

The other thing that's important that we do is, quarterly, we give the reports in summary to our stakeholders. So, our community knows these reports that we have received—from something as modest as humiliation on rounds to physical abuse—are all taken seriously. We've let people know, in general, the range of options in handling these behaviors, and that lets our community know that we're very focused on this.

Q: You mentioned humiliation on rounds, which to some extent was once a standard component of medical training. To what extent does mistreatment as defined by your system represent a culture shift in medicine?

A: I grew up in that era where the Socratic method kept you on your toes and we all thought that this would help you learn because you were scared about not knowing the answer. But through the years, understanding adult learning behaviors, we don't really believe that pimping on rounds is engendering a good learning environment. It's all about our learners being in an environment where they feel comfortable and they want to learn, as opposed to being scared. We have the philosophy that that is not acceptable behavior in 2022. We took the reportable behaviors from a standard list that the [Association of American Medical Colleges] produced about 10 years ago and made part of the graduate questionnaire for medical students. Humiliation or embarrassment on rounds is probably the least serious and probably the most frequent report that we get, but we get reports of gender or racial mistreatment—things that are said or [discriminatory] opportunities for advancement or grades. We've kind of seen it all.

Q: What reports, if any, have you been surprised by?

A: We have learned that sometimes people have weaponized the [reporting] system, which we didn't expect, somebody that has a personal conflict with another person. We've also had a couple of reports—we don't know how they came in—from the outside, pretending to be somebody from our health system, sending negative reports about individual people. We had to do some pretty serious investigations to understand that. We were also not expecting repeat offenses. But there were a handful of people that had more than two.

Q: What do you do about repeat offenders?

A: Some of the people that popped up, especially repeat offenders, we had known about even before we developed this system. There are individuals that create a difficult conversation with leadership. They might be high RVU-generating physicians that we feel in the educational world are certainly not suitable for educational roles but in our system, we have to have learners near them because of the way that they operate their practices. That conflict hasn't gone away. It's allowed us to have a more serious conversation with our leaders, because we've all embraced these efforts. Ultimately, our leadership has made those tough decisions to remove those individuals from the learning environment, but it can take some time. … We're still getting some repeat offenders, unfortunately, as we try to remediate individuals, perhaps unsuccessfully.

Q: How have faculty generally responded to learning they've been reported?

A: Not a lot of denial that the episode occurred. A lot of defensiveness. They typically ask questions that might help them identify the person who reported the issue, and we don't do that. In fact, we don't answer any questions. We just say, “Hey, rightly or wrongly, this learner felt this behavior was such that they needed to report it.” So they know that these types of behaviors are not tolerated. We tell them, “This is not going anywhere in your credentialing file. It's not going to your chair. This is a safe conversation. We're not sending this to anybody unless the behavior continues and is repeated. It's really just to help you perhaps calibrate and improve the way that you interact with trainees.” The majority of them are handled in that way and never happen again. While it's a little bit uncomfortable, when they realize that the report and the feedback is safe, they generally do engage with it.

Q: Are there any interesting trends you've uncovered in the reporting?

A: We were able to see which departments tend to send us these reports, and it's not what you might think. We very rarely get these reports from psychiatry, pediatrics, pathology. We very rarely get them from general surgery or many of the surgical specialties like neurosurgery. They come from OB, they come from internal medicine, they come from emergency medicine. It might not be the list of departments that you associate with pimping or with mistreatment or unprofessional behavior.

Q: How do you interpret that?

A: The reporting culture might not be as established in some of the hierarchical departments like surgery or neurosurgery. I think it happens there too. They may not be as comfortable reporting as the department of OB or the department of medicine. I do believe that some of the departments' reports are related to the stress over the last three years, the pandemic and the impact of all the changes in health care. We did see a lot more reports early on in the pandemic, especially from the departments that were most impacted by the massive surge of patients.

Q: Do you think other institutions should implement similar systems?

A: We think that it will be helpful. We've had institutions ask us about this, and we've been willing to share everything about the system with them. From my 38 years of experience in a variety of academic medical settings, mistreatment exists everywhere.

Q: What challenges should those following your model expect?

A: Bandwidth. I still get these reports. It's kind of like a hot potato now that I have it. What do I do with it? How much time do I have to intervene properly? We really believe that immediate feedback is the way to go. I wish we had more people to help us triage the reports, but it's still kind of a mom-and-pop shop. It's the deans that get the initial reports, and then we have more people now helping us administratively. … With time, we received a lot of reports. When we wrote the article, it was around 200 reports. Now we're actually up to about 325 reports. They have started to drop off a little bit, which we think might be a good sign.