No crying in medical school?

The 1992 motion picture “A League of Their Own” features a very memorable scene that has been coming to mind in light of recent discussions. In it, Tom Hanks brilliantly portrays a crusty former major league baseball star who, in the early 1940s, has been conscripted to manage a team of young women participating in a league set up to replace League Of Their Own“real” baseball, which has been suspended while most men are participating in the war effort. In this particular scene, he berates a young woman who has made a fielding error causing his team to lose the game. His dialogue, carried out on the field and in front of both his team and the spectators, starts out gently and subdued, but quickly escalates. The urges her to “use her head – that lump about 3 feet above your ass”, and makes it clear for all to hear that she is solely responsible for losing the game. She breaks into tears, at which point he becomes rather bewildered. He can’t process her reaction. “There’s no crying in baseball” he shouts and repeats several times. He goes on to point out that he himself was commonly treated in the same way by his managers who would refer to him as a “talking pile of pig shit” – and that’s when his parents were in the stands. Hank’s comic flair and over-the-top performance makes humourous what would otherwise be a rather cruel exchange.

On reflection, there are some interesting observations that one might derive from all this.

  • He’s right. She made a mistake. She clearly blew the play. His credibility and authority in the matter are unquestioned.
  • His intention appears to be correction of the behaviour. He doesn’t appear to bear any personal animosity toward the player – he simply wants her to play better and, by extension, for the team to win.
  • Despite his intentions, it’s quite clear that the attack is very personal, and also very public.
  • It seems unlikely that this interaction will result in the intended outcome, since nothing about it provides her any useful direction.
  • Perhaps most interesting of all is his reaction to her emotional breakdown. To him, his response is appropriate to the situation and to the “culture”. It’s her response that is out of place – “There’s no crying in baseball”. These two people, who are brought together in this situation, are from different worlds, with different values, and therefore very different perspectives on the incident.

So what brings all this to mind? At the end of medical school, all Canadian graduates are asked to complete a survey that reviews a broad range of issues related to their education. As part of that survey, they are asked to report on whether they had, at any point during their medical school experience, been subjected to “mistreatment”, defined as any of a list of 16 behaviours varying from “public embarrassment” to having been the subject of discrimination on the basis of race, ethnicity or sexual orientation. In the 2014 survey, a rather shocking 45.1% reported at least one such incident. Within that number, 20.5% reported at least one incident during which they felt they had been “publicly humiliated in a clinical setting”.

Such a finding would be a concern in any setting, but particularly so in the context of medical education where we profess to uphold and practice the highest standards of personal behavior, sensitivity and empathy. Given that we should maintain a “zero tolerance” standard for such behaviours, the fact that our school reports lower incidents than the Canadian average provides little solace.

As a result, a decision was made to actively address this issue at our school and, that in order to do so, we needed to understand the context more completely. A Learning Environment Advisory Panel (LEAP) was formed last fall, chaired by Dr. Ruth Wilson, and populated by students from all medical years, faculty members, administrative staff and, importantly, representatives of all three of our major teaching hospitals. That group undertook an extensive literature review, and also surveyed our third and fourth year classes to not only ask that they report on these incidents, but to provide narrative accounts so that the panel might better understand their nature. The report of that panel has been received and accepted by our MD Program Executive Committee and we are in the process of undertaking their first recommendation, to raise awareness within our learning community of these concerns (this article being one of the first steps). The following are highlights of that report, illustrated with some representative student narratives:

There’s much more good than bad…

“Students and residents on the Panel emphasized that by and large medical students experience a positive learning environment, encountering faculty who provide a comfortable and encouraging place to learn. One resident summarized this by saying, “Queen’s is known as a “nice” place to learn”.

LEAP Report

“I don’t remember ever having felt humiliated. There have certainly been times when I’ve felt embarrassed, but these were mostly times when I did not know the answer to a question or felt that I did not do something as well as I should have been able to. While not pleasant experiences, I feel that they were useful in that they encouraged me to address areas of my learning that were deficient. Importantly, my discomfort in these situations stemmed from not meeting personal standards, and were not the result of harsh criticism or belittlement by a preceptor.”

Our students report predominantly very positive experiences within the clinical learning environment. Contrary to what many might think, they don’t object to being “quizzed” or “pimped”. They admit to feeling embarrassed when lacking a component of knowledge or skill, but largely accept that as part of the learning experience. Having said that, there are a small number of encounters that are truly egregious and clearly unacceptable.

“One day on a surgical rotation, I was assigned to assist in the OR with one of the staff surgeons. Since I had only received my assignment at 7:30 and the case was slated to start at 7:45, I didn’t get the chance to review the patient’s full chart before coming to the OR. When I arrived, the surgeon started quizzing me on the patient’s medical history, and I explained that I hadn’t reviewed the whole history. Before I could continue, the surgeon said to me “if you ever pull a stunt like this again, I will kick you out of my OR and you will never scrub into the OR again.””

“A physician raised his/her voice at me for not knowing something that he/she thought should be common knowledge and belittled me”

“One time only I felt humiliated at the nursing station in front of everyone during a rotation by a staff for not doing physical exam the way the way the staff expected, when I merely misunderstood expectations.”

There’s a big difference between “embarrassment” and “humiliation”.

The factors that turn a potential teaching/learning opportunity into a humiliating experience appear to be the following:

  1. When the focus of conversation shifts from the issue at hand to the individual.
  2. When the interaction occurs in a public setting.
  3. When the encounter provides no useful instruction or opportunity to correct the behaviour.
  4. When there’s no pre-existing relationship or “understanding” between the learner and the person providing the commentary.

The latter point is particularly relevant in today’s clinical learning environment, where learners may be engaged in rotations or placements with particular teachers for very short periods of time that don’t allow a useful (or trusting) teacher-student relationship to develop.

“Longitudinal relationships with preceptors are particularly valuable. The relationship of student and teacher is built over weeks to months rather than hours to days. If I don’t perform well one clinic I know that I will have another shot at it the next. I become less worried about my performance minute-to-minute and more embedded in the experiential learning that is clerkship.”

“The best teachers I have had ask me lots of questions that I don’t know the answer to. I answer incorrectly and we both get over it. If they asked me the same question the next day I would know the answer because I went home and read about it. But these same best teachers are ones who have demonstrated to me in other ways that they care about me as a learner. They are ones that don’t just ask me lots of questions I don’t know the answers to but include me in discussions of patient care, teach me at the bedside and know just how far to push me.”

Students feel under considerable stress to “perform”.

The competition for postgraduate training positions appears to intensify each year and, rightly or wrongly, students are focused on making a good impression. They may interpret each question posed as a mini-examination, with potentially dire consequences for rotation evaluations and references. What may seem to the instructor to be a simple encounter and minor issue, may therefore become considerably magnified to the student.

It’s truly an environmental issue – not just senior physicians and not just operating rooms.

no-crying-graph

Both the CGQ and our own survey show quite clearly that the negative encounters occur in all clinical settings, and with a variety of individuals, including newly recruited faculty, residents, nursing staff and even, rarely, other students.

There’s under-reporting of serious concerns.

Although one must acknowledge that the number of serious instances of mistreatment is very small, it’s very disappointing that these appear to go unreported, coming to attention only in end of medical school surveys. This is, in part, due to fear of reprisal relating to the competitive environment noted above, and exists despite available and widely publicized mechanisms for anonymous reporting.

And finally…“there’s no crying in baseball”

There appears to exist a cultural acceptance that such behavior “goes with the territory”. Like the Tom Hanks character described earlier, established physicians and nurses may feel they’ve “paid their dues” and are now somehow at liberty to pass along the same instructional methods they encountered along the way. They may honestly feel these methods are most effective in making their points and ensuring lessons are learned. Whatever the rationale, it’s quite clear that humiliation fails to provide useful instruction, is inconsistent with the attributes of effective health care providers, and poisons our learning environment. As the Advisory Panel rightfully points out, raising awareness is the necessary and most effective first step. They go on to make a number of other recommendations, including:

  1. Collaboration between university and hospital leadership in addressing this issue.
  2. Faculty and resident development as to optimal mechanisms for provision of feedback
  3. Development of debriefing strategies appropriate to various clinical settings
  4. Improved reporting mechanisms
  5. Continued surveillance

Our MD Program Executive Committee has committed to work toward these goals in the upcoming months, and to establish mechanisms to continue to monitor progress.league-of-their-own-2

Those who’ve seen “A League of their Own” will know that, by the end of the movie, Tom Hank’s character attempts, with much effort, to revise his interaction with the still error-prone right fielder. It’s not clear what brought about the reform. He may have been frustrated that his first attempt was so ineffective. He may simply have been moved by the realization that her perception was so much different than he’d anticipated. In any case, he was able to set aside his own life experience and adjust his teaching methods to the needs of his learner. But that was just a movie…

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