When Jennifer Kram* shadowed a neurosurgery team at her West Coast medical school earlier this year, she was repeatedly shaken by what she witnessed.
Kram recalls educators commenting snidely about a patient and an attending jokingly gesture rudely to a resident in front of a patient. Repeatedly, Kram was asked about her ability to stomach the group’s humor, “as though I were being tested,” she says. And team members often shared tales of students who complained about faculty mistreatment only to be derided, which felt like a veiled warning not to report them.
“I felt really sad, and I grieved the loss of a potential specialty,” says Kram. “But I knew that kind of environment was too unhealthy for me.”
In 2023, at least 38% of U.S. medical students reported having suffered mistreatment — being humiliated publicly or subjected to sexist remarks, for example — and medical residents report similar rates of mistreatment. Though sometimes the bad behavior stems from a fellow trainee, nurse, or other staff member, the vast majority of complaints are leveled against clinical and classroom educators.
But why would faculty mistreat those they are meant to support?
Some educators see tough teaching methods as a way to prepare trainees for the life-and-death world of medicine. Some are caught in a cycle in which they mimic the mistreatment they endured as learners. Others believe harshness pushes learners to sharpen necessary skills, says Geoff Young, PhD, AAMC senior director for transforming the health care workforce.
“The reality is that if we want people to learn, we really need environments with psychological safety,” says Young. “So educators need to be aware of how their behavior impacts that environment.”
Young, a former associate dean for student affairs, reports some improvement in addressing learner mistreatment. “In the mid-’90s, the community was just beginning to talk about this issue,” he says. “Now, it’s top of mind for many schools and teaching hospitals.”
“The reality is that if we want people to learn, we really need environments with psychological safety. So educators need to be aware of how their behavior impacts that environment.”
Geoff Young, PhD
Data also suggest some advances. For example, from 2013 to 2023, the percentage of students who knew how to report mistreatment at their schools rose from 72% to 91%.
On-the-ground educators note changes as well. “Behaviors that would be ignored when I was coming through — attendings yelling at us or throwing instruments — are now considered unacceptable,” says Anita Honkanen, MD, associate dean for wellness and student life advising at Stanford University School of Medicine in Palo Alto.
Yet some medical educators still have far to go, she adds. “A lot of places are now addressing mistreatment, but this is really about shifting a culture in medicine that’s been in place for a very long time.”
The reporting process
Most students who say they’ve experienced mistreatment — nearly 75% — choose not to report it. Among the reasons they cite are a sense that nothing will be done and a fear of reprisals.
Residents may be even more reluctant to report than students. “Residents train with their educators for years versus just weeks for students, and attendings’ recommendations are extremely important,” says Honkanen.
So a major goal for educators is helping trainees understand what constitutes mistreatment — and how to get help when it occurs. That’s important in part because learner mistreatment has serious consequences. For example, residents who experience mistreatment are almost four times more likely to feel anxious or depressed and almost eight times more likely to feel burned out.
Although each institution has its own definition of mistreatment, the AAMC describes it as any “behavior [that] shows disrespect for the dignity of others and unreasonably interferes with the learning process.”
When the University of Colorado School of Medicine (CU SOM) launched a new anti-mistreatment effort in 2023, educators asked students to share personal examples. Those ranged from feeling physically backed up by an educator while receiving negative feedback to increasingly angry questioning when students failed to provide accurate answers.
At Penn State College of Medicine in Hershey, Pennsylvania, a robust website provides a list of mistreatment examples, such as intentionally excluding someone from learning opportunities or assigning duties as punishment rather than education. It also highlights behaviors that, though uncomfortable, don’t qualify as mistreatment, such as an instructor calling a student’s summary of a patient case incomplete in front of fellow trainees.
To encourage reporting of mistreatment, institutions work to create easy-to-use online forms. “We added our form to every hospital computer, put links to it in many places, and made sure the form asks only a few questions” to make it less daunting, says Michael Leitman, MD, dean for graduate medical education at the Icahn School of Medicine at Mount Sinai in New York City.
Honkanen and others also advise offering learners multiple ways to report mistreatment. At Stanford, in addition to reporting mistreatment online, students can contact a member of the Respectful Environment and Mistreatment Committee, which includes learners and staff knowledgeable about issues facing such groups as LGBTQ+ students. They can also use an end-of-clerkship evaluation form that asks whether they felt the instructor treated students with respect.
“A lot of students fear they will lose a potential mentor or that reporting will hurt their career in some other way. That’s the biggest thing for us.”
Jennifer Kram*
Providing anonymity and taking learners’ concerns seriously are also crucial, says Leitman. At Mount Sinai, the reporting form allows users to weigh in on next steps, such as requesting action only if the faculty member had been reported before.
Debra Byler, MD, director of the Office for a Respectful Learning Environment at Penn State College of Medicine, takes several steps to honor learners’ requests. “To protect their identity, I ask them how long they want me to wait before acting on a report,” she says. “And I tell them what I would like to share with others to make sure they are comfortable with that level of detail.”
Learners appreciate such caution. “A lot of students fear they will lose a potential mentor or that reporting will hurt their career in some other way. That’s the biggest thing for us,” says Kram.
Acting when abuse occurs
When a trainee reports mistreatment, institutions that are working hard in this area act quickly and clearly.
At Mount Sinai, for example, three deans instantly receive an email when a form is submitted, and they read and triage all reports within 24 hours. (Students who want to report mistreatment by one of the deans can do so another way, such as contacting the school’s ombudsman.)
For reports alleging discrimination based on a protected category, such as race or gender, leaders forward the matter to their institution’s Title IX or Title VII officials as required by law and assist as appropriate with any required follow-up investigations. Other reports get handled based on an assessment of the behavior and the circumstances surrounding it.
“We address every single report with the faculty member involved,” says Erick Hung, MD, associate dean for students at University of California San Francisco (UCSF) School of Medicine. “We go in with a growth mindset, looking to understand what happened and to help educate the person as appropriate.”
“We also try to identify any system-level issue that’s feeding the problem, like if the unit is overly busy,” Hung adds. “We only sanction if the behavior was egregious or if there’s a persistent pattern of problematic behavior with no improvement.”
Stanford uses mistreatment coaches to reach out to educators who’ve been reported. “We recruit [faculty members] known to be empathic and then we train them,” says Honkanen. “They sit down for a cup of coffee and make sure to hear the faculty member’s side of the story.” Often, coaches help faculty understand such issues as the need to be sensitive when using humor.
“We had to remove some people from teaching responsibilities…. This sends a positive message to learners that we are really serious.”
Michael Leitman, MD
Icahn School of Medicine at Mount Sinai
Sometimes, faculty need personal support, says Leitman, because problematic behavior can be an early sign of a psychiatric or physical illness. At Mount Sinai, for example, about 8% of reported faculty were offered a wellness evaluation.
Of course, trainees involved also need support, from a sympathetic ear to mental health resources. CU SOM student Diane Richard* recalls how vital she found her dean’s support after an educator told her that her disability made it unlikely she’d get through residency. “[The faculty member] made me doubt my abilities, and I worried that I had to be perfect to prove myself to him. But being taken seriously by the dean was tremendously helpful. It gave me hope.”
Because institutions recognize that faculty sometimes are unfairly accused, they also work to prevent abuse of the system. For example, Mount Sinai’s policy states that any report submitted simply to harm someone will be investigated and the person appropriately sanctioned.
But when faculty misbehavior does occur it needs to be addressed, sometimes emphatically so, says Leitman.
“We had to remove some people from teaching responsibilities, and we did that even though it was going to negatively impact the organization financially,” says Leitman. “This sends a positive message to learners that we are really serious, and it sends a message to faculty that we’re not going to tolerate this kind of behavior any longer.”
A broader vision to end mistreatment
To significantly reduce disturbing behavior, institutions must take multiple tacks, say educators at the forefront of mistreatment efforts.
Often, that means teaching students to recognize and respond to mistreatment.
At Stanford, all medical students receive an hour-long presentation with simulated scenarios to help them better understand what constitutes mistreatment. Additional sessions cover such skills as how to ask an instructor to provide feedback that feels more constructive and less critical.
It also means ensuring faculty understand their responsibilities. At CU SOM, for example, employee contracts indicate that instructors need to treat trainees respectfully. The school also provides attendings and clerkship educators with a guide on preventing mistreatment that covers topics like balancing rigorous questioning with respectful treatment.
Another key focus is collecting — and closely monitoring — mistreatment data. At UCSF, a sophisticated dashboard that refreshes daily allows searches by some 25 types of behavior, time period, and even particular courses. “We can use the system to detect patterns, and then we can explore what’s going on, like why a particular department is having an uptick,” says Hung.
Leitman appreciates lessons learned from Mount Sinai’s data. For example, the numbers there showed that less than 1% of faculty members were responsible for more than half of mistreatment reports. The data, says Leitman, answered other questions as well: “Do trainees more often experience mistreatment based on gender? They do. Do students from backgrounds underrepresented in medicine? They do.”
Nationwide, AAMC data — which include mistreatment by faculty, staff, and fellow trainees — seem fairly unchanged in the past decade, dropping from 39.9% in 2014 to 38.1% in 2023.
But numbers don’t tell the whole story, notes Byler. For one, rising rates could indicate greater learner awareness of what constitutes mistreatment, rather than an increase in bad behavior. And although a drop in mistreatment reports is often positive, it could instead reflect a growing sense that reporting is futile. So Byler regularly connects with leaders who are positioned to know more about the environment, including a team of student representatives, student affairs deans, and staff from the Office of Diversity, Equity, and Inclusion.
Byler makes another key point about efforts to combat mistreatment: the need to create a broader, system-wide culture of mutual respect.
To help achieve that goal, Penn State has been asking learners to report exceptional teachers. “This was a game changer,” Byler says. “It showed educators that we are not here just to criticize, but to applaud them and to create a positive environment for everyone.”
Young echoes the need to change the educational environment. “Every educator who has any interaction with a learner needs to understand the privilege that comes with that power,” he says. “And we all need to own our role in the broader culture.”
Such a major cultural shift will take time and work, says Honkanen, but she remains optimistic. “When this cohort of learners moves into being faculty, I’m hopeful they’ll hold on to these ideas about respecting learners and that they will embrace them in their own teaching,” she says.
*Names have been changed and some details omitted to protect privacy.
