Thursday, May 9, 2013

Medical student mistreatment

Medical student abuse is a major problem in medical education. The Association of American Medical Colleges' (AAMC) yearly Graduate Questionnaire from 2011 found that 16.8% of medical students report being personally mistreated during medical school. This number has been pretty much the same for the past five years (16.6 to 17.0%). The most common form of mistreatment is public belittling or humiliation which happens occasionally to 46.8% of medical students and frequently to 4.2%. The scary part is that there are only 18.3% to whom it never happens. 8.1% of students were physically harmed or physically punished. The examples given included being hit, slapped, or kicked. Wow! Other forms of mistreatment are less common but notnon-existent. Of those who reported mistreatment, almost one percent were asked for sexual favors in exchange for grades or awards, eight percent were subjected to unwanted sexual advances, and 20% were subjected to offensive sexist remarks. Fourteen percent were subjected to racially or ethnically offensive remarks. The mistreatment of medical students comes from a wide variety of sources-clinical faculty, residents and interns, nurses, and even patients. This is scary! These students are highly educated, highly motivated, and paying a lot of money for the opportunity to become doctors. A article published in AcademicMedicine, details the efforts of one medical school to eliminate medical student mistreatment. The article, by Fried and colleagues (1), describes a 13-year study in which their school (the David Geffen School of Medicine at UCLA) sought to change the culture of medical education. The school convened a group of faculty, administrators, and mental health professionals to develop school-wide interventions that could address the problem of student mistreatment. These interventions included policies, reporting mechanisms, as well as resources for discourse among students, faculty, nurses and residents. In addition, they surveyed all of their medical students at the end of the third year. Now, this is after they finished their clinical clerkships. They asked questions that were similar to the AAMC's GQ-how often have you experienced mistreatment which included physical, verbal, sexual, and ethnic categories. They also asked how often there was power mistreatment defined as feeling intimidated, dehumanized, or had a threat made against you. As an aside at this point. If you are wondering why these definitions are so specific, you only have to understand how often students are made to feel this way. It is so much the norm, that the researchers have to explicitly state what they consider abnormal or students will not even identify it as abnormal. The authors included data from 1,946 medical students between 1996 and 2008. In this study, the authors found that an average of 57% of students had some form of mistreatment and there was no improvement in this number after the school instituted mandatory mistreatment education or sexual harassment prevention training. Women were significantly more likely to experience sexual harassment than men over the period from 1996-2008. Students often did not report mistreatment. They were least likely to report to report incidents of ethnic mistreatment (only 7% were reported). The authors' final comment was "despite the proactive approach taken by our institution to eradicate student mistreatment over this period, we found that the majority of our students continued to report some form of mistreatment at least once during their third-year clerkships." They also admitted that "we find it disconcerting that students continued to report incidents of all categories of mistreatment at these rates." References (1) Fried JM, Vermillion M, Parker NH, Uijtdehaage, S. Eradicating Medical Student Mistreatment: A Longitudinal Study of One Institution’s Efforts. Academic Medicine 2012; 87(9): 1191–1198.

Self-regulated learning and performance in medical school

We are always worrying about medical student performance. Measures of performance, including grades and standardized test scores, are monitored and discussed regularly. After sitting on an academic performance committee for several years, I have noticed that some students that struggle are a surprise to the faculty. Oh sure, there are some students who have lower pre-matriculant variables (undergraduate science GPA, MCAT, performance in upper level science courses) prior to starting medical school. In those students we might expect a lower performance in medical school. But there are regularly, students who did well during undergraduate studies, they have MCAT scores that are fine, and they are coming before the academic committee because of poor performance-usually failing a course or multiple courses. Why does this happen? Educational researchers in the Netherlands (ErasmusUniversity Medical Centre) and the Centre for Research and Innovation in Medical Education) have tried to tackle this question. (1) Their research question was: what is the relationship between motivation, learning strategies, participation, and performance in medical school. They are interested in the concept of self-regulated learning (SRL) which can be thought of as a learner that uses meta-cognition, motivation, and behavioral proactivity to improve their own learning. Several things that can be seen in self-regulated learners (and I would say in high-performing medical students): they monitor their progress towards their own goals; they are interested in learning for the sake of learning; and they develop and utilize effective learning behaviors. This study was done in a medical school in Rotterdam, the Netherlands which has a six-year medical curriculum. First year students in 2008 and 2009 were included in the study. There were 303 students in 2008 (32% male) and 369 students in 2009 (37% male). Students were given a questionnaire that was about their study techniques and were given immediate feedback and recommendations for ways to improve. An 81 item survey with six motivation subscales and nine strategies subscales was given to measure their Self-regulated Learning. The survey used a Likert scale (1=not at all true of me to 7=very true of me). The questions were things like “understanding the subject matter of this course is very important to me” and “I ask myself questions to make sure I understand the material I have been studying for this course” and “I make sure I keep up with the weekly readings and assignments for this course.” Students also rated their attendance in lecture, clinical skills training, and assignments The authors found that Participation (lecture attendance, completing study assignments, and skill training attendance) was positively associated with Year 1 Performance and improvements in the mean GPA. Deep learning strategies were negatively associated with Year 1 performance. So students who utilized deep learning strategies more frequently as their study method, had more difficulty in the preclinical (Year 1) curriculum. So why does participation affect performance? Is it just because people that go to lecture are able to learn things and get explanations that are not in the available written information? Or is it because of the repetition of the material? They have heard it more times- a concept known as distributed practice (study effort is distributed over several study sessions). Or is it differential repetition? Material is presented in lecture, on-line modules, tutorials, small groups, skills training, and independent study which gives more opportunity to absorb and integrate the information into a structured knowledge base. Is it just because people that go to lecture are more in tune with the material covered and how it will be tested? Since they go to lecture, they know what is going to be on the test based on the cues and clues from the faculty. This is an area that needs more research. We want students to utilize deep learning strategies because information that is learned this way are more likely to retain that information. We don’t want students that do better on the test just because they show up, unless showing up leads to deeper learning and retention of information.

Physician burnout | Is there anything that we can do?

A recent post by Pauline Chen, MD on the New York Times Wellblogspeaks about the nation-wide epidemic of physician burnout. She quotes a recent study published in the Archives of Internal Medicine by Shanafelt, et al (2) that measured the symptoms of burnout using a validated survey instrument (Maslach Burnout Inventory) (3). There were huge differences based on the specialty of the physicians. The highest rates of burnout were found in doctors at the front line of access to medical care: emergency medicine (OR 3.18), general internal medicine (OR 1.64), and family medicine (OR 1.41). These differences remained even after adjusting for age, sex, call schedule, relationship status, primary practice setting, hours worked per week, and years since graduation from medical school. When compared to a probability-based sample of working adults in the US, physicians had a higher risk for emotional exhaustion (32.1% v. 23.5%), depersonalization (19.4% v. 15.0%), and overall burnout (37.9% v. 27.8%). Overall, 45.8% of physicians had at least one symptom of burnout. Wow! That is scary! These are practicing physicians who are working themselves to a state of emotional and physical exhaustion. When physicians feel like this they are more likely to make mistakes and medical errors. So, bringing this back to medical education, is there evidence about burnout in learners? Well, a recent article in AcademicMedicine by Dyrbye, et al (4) addressed this question. The authors found that positive mental health had a protective effect on burnout. In this study, 4,400 medical students from seven medical schools (Mayo College of Medicine; Uniformed Services University of the HealthSciences; University of Alabama School of Medicine; University of California,San Diego; University of Chicago Pritzker School of Medicine; University ofMinnesota Medical School; University of Washington School of Medicine) were surveyed. The students’ mental health was measured using a validated instrument that measures emotional, psychological, and social well-being. The symptoms of burnout were measured using the same Maslach Burnout Inventory that was used in the practicing physician survey. What the authors found was not surprising: medical students also had high levels of burnout. 42.1% of the students had high scores in emotional exhaustion, 52.5% had a positive depression screen, and 17.4% reported suicidal ideation. When they asked about mental health, interestingly, most students were doing well. 53.1% were flourishing and 42.5% were moderately healthy, while only 4.3% were languishing. Students that were described as languishing reported a low frequency (“never” or “once or twice” in the past month) on more than one of the emotional well-being items and a low frequency on at least six of the signs of positive functioning. 48.2% of students who were languishing reported suicidal thoughts in the past 12 months compared to 25.1% who were moderately mentally healthy (p< 0.001). The scary part was that those who were flourishing still had a 9% rate of suicidal ideation. Students who were languishing were more likely to cheat, more likely to display other dishonest behaviors, less likely to endorse altruistic beliefs, and less likely to care for medically underserved patients. This is scary stuff! It suggests that a lower, more negative mental attitude in a medical student is correlated with not only their personal feelings about themselves (ie: suicidal ideation) but also how they act within the professional environment (dishonesty and cheating). It may be that if we could identify those students who are languishing, we could intervene to help them improve their mental health. Interventions could impact their professional behavior and quite possibly their performance in the academic realm of medical school. The question is: what are those interventions? More research will be needed to figure out what can be done and what works best. References (1) Chen PW. The Widespread Problem of Doctor Burnout. New YorkTimes. August 23, 2012 (2) Shanafelt TD, Boone S, Tan L, et al. Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population. Arch Intern Med. Published online August 20, 2012. (3) Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, Calif: Consulting Psychologists Press; 1996. (4) Dyrbye LN, Harper W, Moutier C, et al. A Multi-institutional Study Exploring the Impact of Positive Mental Health on Medical Students’ Professionalism in an Era of High Burnout. Academic Medicine 2012;87(8):1024-1031.

Career outcomes of graduates

I know that I have been gone for a while. Sorry about that... I saw a really interesting article in Advances in Health Sciences Education (1) this month. The authors decided to study the career outcomes of graduates of six Midwestern medical schools who had initially failed USMLE Step 1. In this retrospective study, the authors sought to determine the academic and professional career outcomes of medical school graduates who failed Step 1 on the first attempt. They took a cohort of students who graduated from the Ohio State University College of Medicine, Michigan State University College of Human Medicine , Washington University School of Medicine, SouthernIllinois University School of Medicine, University ofIowa Roy J. and Lucille A. Carver College of Medicine, and the University of Michigan School of Medicine. In this cohort of 2,003 graduates from 1997-2002 were 50 (2.5%) students who initially failed Step 1 and these students were compared to the 1,953 students who passed Step 1 on the first attempt. There were several interesting findings in this study. The authors used information from the MSQ (Medical Student Questionnaire), the GQ (Graduate Questionnaire), the AMA Physician Masterfile, ABMS Board certification, and the AAMC Faculty Roster System. Data was gathered from all six schools and merged into a single database. Some of this data has issues, for example the MSQ and the GQ both rely on student self-report. The AMA Masterfile may mis-categorize some doctors and the cohort only includes students who made it to graduation and for whom they had complete data available (about 43% of the total graduates). But with that being said, this is a pretty good study with a large cohort of graduates. So, what did they find? As you would guess, passing USMLE Step 1 on the first attempt has major repercussions for medical students. Most students (94%) pass the test, but not all. Students who fail Step 1 are less likely to pass Step 2 and less likely to ultimately graduate from medical school. (2) But this group of students had all graduated so are they still impacted? There is not a lot of evidence that medical school test performance is correlated to residency clinical performance, but Program Directors still put too much emphasis on Step 1. In fact, a national survey of Program Directors (3) found that 84% would seldom or never interview a student who had failed Step 1 even if they eventually passed Step 1. In this study, those who failed were more likely to be women, minorities, and older. In fact, there were significant differences between these groups. When compared to men who graduated, women were 3.2 times more likely to have failed Step 1 on the first attempt (p < 0.001). African Americans were 13.4 times more likely to fail when compared to whites (p < 0.0001), and Latinos were 7.4 times more likely (p < 0.0001) to fail when compared to whites. They are more likely to end up in primary care residencies, to be older, and to come from families of lower income. This data obviously has huge implications. Every medical school has a few failures on Step 1 and should be concerned about the implications. Are we willing to tolerate this difference in the relative risk of failing a nationally standardized high stakes examination? There may be pre-matriculate variables that explain some of the differences, but there also may be ways to identify and intervene in high-risk students’ academic career in ways that can decrease their risk of failure. Take a look at the programs that are in place at the University of Texas Medical Branch in Galveston and Southern Illinois University. They have been successful in helping students that were identified as at-risk students. Unfortunately, but many schools would rather try to decrease the number of at-risk students that they admit. The method that is often used is to try to admit students with higher MCAT scores and higher undergraduate GPAs. The problem with this strategy is that in doing this the school will also increase the number of rich, white, male students who come from urban backgrounds. This leads to a student body that is less diverse. That is something that our schools should not tolerate. References (1) McDougle L, et al. Academic and professional career outcomes of medical school graduates who failed USMLE Step 1 on the first attempt. Adv in Health Sci Edu. 7 April 2012 (Online First). (2) Biskobing DM, et al. Study of selected outcomes of medical students who fail USMLE Step 1. Medical Education Online 2006;11(11):1–7. (3) National Resident Matching Program, Data Release and Research Committee. Results of the 2008 NRMP Program Director Survey. Washington, DC: National Resident Matching Program. 2008

Wednesday, January 11, 2012

Impact of medical school tuition

In my blog, How much should medical school cost?, I wrote about an innovative proposal by Peter Bach and Robert Kocher to make medical school free. Dr. Bach is the director of the Center for Health Policy and Outcomes at Sloan-Kettering Cancer Center. Dr. Kocher is a special assistant to President Obama on health care and economic policy. Their proposal has gotten a lot of press. It seems that many people have an opinion about the cost of medical education. Dr Joshua Freeman wrote in his blog, Medicine and Social Justice Would free medical schools increase primary care?.  Dr Kenny Lin, in his blog the Common Sense Family Doctor wrote Strengthening the primary care pipeline.  Dr Pauline Chen wrote in the New Times Health blog about The Hidden Cost of Medical Student Debt

I was thinking about another aspect of the cost of medical school.  It is something that I have not heard people talking about. Most of the negative aspects that have been talked about are related to the negatives to the student and the impact on their future career choices. There is also some (important) talk about the societal negative of less students choosing primary care and family medicine.

But what about students who never graduate from medical school?  Medical schools try very hard to keep students in school because of the big investment in that individual student. If you get into medical school in the US, your chances of graduating are extremely high. Something like 96 percent.1  But what happens if you don't graduate? At most schools, the student would be on the hook for the cost of their education.  Wow!  Saddling a medical school graduate with $150,000 in debt is bad, but we say--they are going to be doctors, they can afford it. But if a student leaves school or is dismissed from medical school for academic reasons, they are still going to have that debt of $150,000.

It is a big deal. When the faculty are talking about the academic performance of a medical student, they should not have to worry about the financial ramifications of their decision. But, honestly, how can they not consider the implications. They are essentially condemning someone to financial ruin by saddling them with a debt that rivals that of a new home. And state schools are relatively cheap. If they are at a private medical school or one of the osteopathic schools, their debt may be as much as $300,000. 

The faculty on a dismissal committee are given an unenviable task. They are acutely aware of their responsibility to the public and society. They do not want to graduate a student who is not qualified to be a physician. By the time a student gets to this point they have been on the dean's office radar for a long time. These students have generally failed several courses or national standardized examinations, they have been through a lot of remediation, and there has been an enormous effort to salvage their medical career. The faculty have invested a lot of time and effort into the student. The faculty really care about the students. The school has invested a lot of money in them. A position in the medical school class can never be regained, so if a student is dismissed that spot is gone forever. The faculty feel that they have failed when a student is dismissed. The financial ramifications just make it worse.

So, I would like medical schools to consider a no-fault system.  If a student is dismissed from medical school, their tuition and fees are refunded to them. Let's take the financial part completely out of the discussion.  This will be better for the students and for the faculty. An potential effect of this policy, would be to encourage schools to take a chance on more at-risk students.  Some of these students might be from disadvantaged backgrounds, some might be underrepresented minorities, and some might be from rural areas. These students are less likely to apply to medical school and even when they apply, less likely to graduate.1 Disadvantaged students may choose to not even try medical school because of the financial consequences of failure. A no-fault system would eliminate those consequences.

What do you think?

1) Garrison G, Mikesell C, Matthew D. Medical School Graduation and Attrition Rates []. Analysis in Brief AAMC.  2007. Vol 7 Number 2.