I trained to be a doctor in the bad old days — not the worst old days, but the bad old days. Humiliation was part of the deal, sometimes deliberately inflicted by certain grandstanding, sadistic attending physicians, sometimes more casually, because everyone could see that you didn’t know something you should have known.
Now we are aware of the consequences of harassment and unconscious bias, and we are trying to give medical students room to learn and grow — but many medical students and residents continue to experience harassment and discrimination and bullying. At the same time, some faculty members worry that they cannot discuss difficult subjects, or give negative feedback of any kind, for fear of upsetting students. In other words, though the training environment now looks much gentler to those of us who trained in the bad old days, we still don’t seem to be consistently getting it right.
In August, a commentary in JAMA Pediatrics addressed the intrinsic complication that medical training inevitably makes people uncomfortable: “Walking on Eggshells With Trainees in the Clinical Learning Environment — Avoiding the Eggshells Is Not the Answer.” You can’t avoid the eggshells, they argue, because medicine is going to bring you up against difficult situations and tricky conversations, and also because part of the responsibility of those who train doctors is to tell them when they’re messing up.
The lead author, Dr. Melanie A. Gold, a professor of pediatrics and population and family health at Columbia, said that she and her co-authors had repeatedly heard medical school faculty members express concerns about trainees feeling penalized when they heard feedback that was not positive.
“Trainees will experience discomfort, but we don’t grow unless we work through our discomfort,” said Susan L. Rosenthal, a co-author who is a professor of medical psychology at Columbia. “Discomfort is a part of learning new skills, of learning new ways of interacting with people. We have better ways to help trainees with the discomfort of learning new technical skills than with the skills of interacting with a wide range of people under stress who have a range of different ideas,” she said.
“The practice of medicine involves really uncomfortable issues,” said Dr. Arno K. Kumagai, the vice chairman for education in the department of medicine at the University of Toronto. “We deal with blood; we deal with death; we deal with suffering.”
Dr. Janet R. Serwint, professor emerita of pediatrics at Johns Hopkins, agreed. “When I look back at my career and my life and how important some of that feedback was, and it was hard for the giver to give to me, I’m sure, but they did it in a respectful way.” She felt an obligation as an educator to give feedback in her turn, she said.
“I worry that the balance is swinging in such a way that it’s all about, oh, you are wonderful,” she said. When she served as the vice chairwoman of education and the residency program director, faculty members often told her about problem residents, she said, but rarely had they actually spoken to the trainees. “It’s the discomfort, or the worry of retaliation and evaluation.”
The core of successfully giving feedback, Dr. Serwint said, is making it clear that you care about the person you are evaluating. Faculty members also need to be able to talk about their own frustrations and the times they themselves came up short. “I learned so much more from my failures than my successes,” she said.
“I think that if physicians and trainees are going to make the most out of the learning environment, it has to be a learning environment in which feedback can go in both directions so the trainee can share respectfully with the attending how they’re experiencing the situation,” Dr. Rosenthal said.
One fraught area is personal style.
“I had to share with a resident, ‘that outfit is not suitable for work,’” Dr. Serwint said. “We didn’t have a dress code, but several people had mentioned it — she left in a huff, saying we were so conservative.” A few years later, that same former resident came to her office to tell her that she had had to deliver the same message to one of her own trainees, “and she understood how hard it was.”
And patients may also make comments that doctors in training (or out of training) find hurtful or offensive. “At some level, the physician needs to have the bigger shoulders,” Dr. Rosenthal said. “The patients are stressed.”
But medical practice brings you up against complicated and difficult issues, from sexual practices to poverty, from child abuse to death, and we have to teach — and evaluate — in all of those domains.
“I’m interested in looking at medical education as a moral education,” Dr. Kumagai said. “We talk about medical ethics, but we often don’t talk about the development of a moral orientation to the world.” We have to look at medical education as encompassing more than a training in skills, he said, but also as how students come to understand “what it means to practice medicine with excellence, compassion and justice.”
In a previous position where she was doing adolescent medicine, Dr. Gold said, she had experiences with medical students who said they had religious objections to advising pregnant patients about the possibility of terminating pregnancies.
“We weren’t forcing them,” Dr. Gold said. “We told them that if they were unable to do the kind of options counseling we felt was the standard of care, we wanted them to stay in the room and hear, and they didn’t want to.”
When another student complained that he couldn’t understand why health care for transgender patients was part of the curriculum, Dr. Gold said, the course director told him “it was a normal part of training to feel uncomfortable with situations you aren’t familiar with — there’s a diversity of patients we need to take care of.”
“We haven’t received a lot of training as faculty in how to handle these challenging and difficult conversations,” Dr. Gold said.
The recent article suggests ways to “create an environment that fosters the ability for trainees and faculty to walk across eggshells without fear.” That includes training about unconscious bias, which may affect evaluations by both faculty members and students (in one study, students were harder on female faculty members). It’s also important to talk clearly with students and trainees about how feedback will be given, and to make sure that they get a chance to discuss their experiences — especially with regard to those difficult uncomfortable subjects.
And finally, the authors conclude with advice to note whether you’re hungry or tired or upset yourself, when giving feedback. And so often, in the medical setting, everyone is stressed, Dr. Rosenthal said. “You’re living in a world where well-meaning, kind, caring people are not at their best.”