#KeyLIMEPodcast 353: When it Comes to Student Mistreatment, Does Specialty Matter? [Trigger Warning]

Jason shares an article on a sensitive topic: medical student mistreatment. Via a series a papers, the PAMS (Perceived Abuse of Medical Students) Investigators consortium operationalizes a definition of medical student mistreatment, and explores attitudes to standardized mistreatment scenarios. Have things gotten any better in terms of reported incidents, and after years of intervention? 

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KeyLIME Session 353

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O’Brien et. al., Perception of Medical Student Mistreatment: Does Specialty Matter? Acad Med. 2022. 97(2):247-253-540.


Jason R. Frank (@drjfrank)


This might be a dangerous episode. Today we are reviewing a paper about medical student mistreatment. This can be a debated phenomenon to define, despite much good will in our community. Odds are, many who listening to this episode, regardless of profession, can name times when they felt distinctly uncomfortable in training. 

The literature on medical student mistreat goes back decades. Are we getting better, in terms of reported prevalence, after years of intervention? Apparently no. About 50% of graduating students endorse mistreatment during medical training. About 30% of female faculty in academic medicine report experiencing sexual harassment, and 66% report experiencing gender bias. Prevalences appear to be stable over many years. Why is that?

We are conducting this review of a relevant paper in an era where our health professions community is more aware than ever before that we need do more to fight racism, end systematic oppression, welcome greater diverse colleagues and create safer learning environments. At this point we know there are deep-rooted, pervasive, and structural problems. We need to take informed action. Is there evidence to guide the next generation of strategies?


Enter O’Brien et al and the PAMS (Perceived Abuse of Medical Students) Investigators consortium. Though a series of papers, this group has gathered the world’s literature (mostly American), operationalized a definition of medical student mistreatment, and explored attitudes to standardized mistreatment scenarios. In this current paper, Perception of Medical Student Mistreatment: Does Specialty Matter?, the authors set out to:

…to better understand how attending and resident physicians in different specialties view mistreatment and its severity…[p.247]

The paper appears in the February 2022 issue of Academic Medicine. (Online June 29, 2021)

Key Points on the Methods

The authors operationalized the following as a definition of medical student mistreatment:

…policies, speech, actions, or behaviours that treat a student in a threatening, intimidating, or otherwise inappropriate manner sufficient enough to adversely affect the student’s learning environment [p248]

The authors developed 5 professionally produced trigger videos using actors at Texas A&M University that illustrated mistreatment scenarios, including:

  • Sexual harassment
  • Aggressive questioning
  • Negative feedback / belittlement
  • Ethnic insensitivity, and
  • Assignment of inappropriate tasks.

From October 2016 to August 2018, investigators recruited a convenience sample targeting staff and resident physicians from 6 specialties they felt best represented early medical student clinical experiences—Internal Medicine, Family Medicine, OBGyn, Pediatrics, Psychiatry, and General Surgery—at 10 academic medical centres.

Participants could watch the videos in person or online. They were then asked to complete a survey after each video asking their reaction as to whether mistreatment of student was illustrated. Participants also were asked demographic questions and questions about their own experiences as a student with mistreatment.

Analysis involved conducting 5 separate logistic regression models using the largest population as the comparator. This largest demographic group were Internal Medicine residents.

The authors conducted many, many comparisons, setting up the possibility that differences are by chance. They used a difference of p<0.05 as statistically and educationally significant.

Key Outcomes

The authors approached 705 physicians and 650 participated (92%). The majority of participants were residents and female, with the most weighting to IM & OBGyne.

Compared to the IM group, the authors found there were significant differences between specialties for the scenarios involving aggressive questioning, negative feedback, and inappropriate tasks. Surgery, ObGyne, and “other” physicians (mostly EM who happened to be in the audience) were less likely to rate these scenarios as mistreatment. Family physicians were more likely to score the “negative feedback” scenario as mistreatment.

There were no differences by gender or ethnicity. Participants with prior mistreatment experiences had higher odds of perceiving mistreatment in the ethnic insensitivity scenario.

Key Conclusions

The authors conclude…that there are differences in how certain specialties (especially Surgery and ObGyne) perceive these mistreatment scenarios. They go on to hypothesize the potential causes and implications:

  1. This sample is not representative or generalizable to the larger community;
  2. Each specialty may have its own discrete culture that influences the perceptions and mental models of these behaviours;
  3. A certain kind of person is attracted to these disciplines;
  4. Those who did not experience student maltreatment gravitate to these disciplines;
  5. These disciplines experienced maltreatment and perpetuated it;

The implication for health professions education is that current awareness-raising interventions may be ineffective if different subgroups have their own mental models of acceptable behaviour.

Spare Keys – other take home points for clinician educators

  1. These authors explicitly defined their construct they were exploring, a key ingredient in an effective study and often lacking in #meded.
  2. Beware studies with many comparisons. The more comparisons, the more likely to have some difference by chance. This makes results hard to determine.
  3. Gold standards to compare to need to be chosen carefully to be defensible and interpretable.
  4. This study is another reminder that “Tell and Sell” is often an ineffective change management approach.

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