The Surgical Educational Environment

Clerkship Directors WorkshopApril, 2014

Part 1:

Socrates & Halsted

Toby C Tally MDGRU/UGA Medical Partnership, Athens, GA

Goals & Objectives

• Attempt to define types of mistreatment.• Examine teaching methods traditionally used

in surgical training.• Discuss issues at the intersection of teaching

methods and mistreatment.

Socialization

SECI model (Nonaka & Takeuchi 1996)

Tacit

Years 1 & 2: Teaching professionalism• Small Group Learning, 6 hours/week• Explicit expectations• Controlled, safe environment• Faculty role models (many non-MDs)• Formative and summative assessments

The Clinical Years• New environment, new game • Don’t know the rules• Rules keep changing• Told what NOT to do.• Experiences differ from their

classmates’• No longer all about them

AAMC GQ Definition of Mistreatment• Mistreatment, either intentional or unintentional, occurs

when behavior shows disrespect for the dignity of others and unreasonably interferes with the learning process. Examples of mistreatment include sexual harassment; discrimination or harassment based on race, religion, ethnicity, gender, or sexual orientation; humiliation, psychological or physical punishment and the use of grading and other forms of assessment in a punitive manner.

The ‘Never’ Column AAMC GQ

• >95% checked NEVER for most – the bad ones.• Handful in range of 85-93%• 76.7% NEVER Publicly humiliated • 52.8% NEVER Publicly embarrassed

The ‘Never’ Column AAMC GQ 2013 Summary

•76.7% NEVER Publicly humiliated •52.8% NEVER Publicly embarrassed

BADBAD

Not so bad

Not so bad

Legitimacy Assessment Model of Rationalization

Socialization.• we teach this way because it works

– to train surgeons who can think on their feet, – make critical decisions quickly with incomplete information.

• we teach med students this way – to show them what surgery is about and – see if they want to do it, and if they can.

• “There is research to suggest that some stress and anxiety can be beneficial in learning. There appears to be a certain level of tension and disequilibrium needed to stretch and challenge students to learn.” [VM]

Pimping is…

• A useful training tool?• A formative assessment tool?• An initiation ritual?• Socratic teaching method + peer pressure?

PimpingBenign Pimping

• Teaches

• “Encourages you to become eloquent in being able to verbalize what you have read in a manner you can share with your colleagues”

• Identifies gaps in knowledge

• Tests how you handle pressure

Malignant Pimping

• any question that was “clearly inappropriate for students’ level of training,” that was meant to “trip students up” or “humiliate” them, or that was asked “to make students feel stupid”

Military Training• Hazing in basic training was believed to provide

– socialization

– cohesion-building

– weeding out those unfit or unwilling to serve

• NO HAZING, but “physical and mental hardships associated with operations or operational training do not constitute hazing”

• “Eradications of hazing has not diminished the socialization, camaraderie or commitment of new recruits.”

Raising children• Why do we torture 9-year olds with thousands

of multiplication problems?• Why do we let our children beat up on each

other?

• So they can succeed in the real world

so it is with medical students

• This is the real world:• Tell them what to expect• Challenge them• Make them practice • Encourage, don’t coddle Jessica Hagy, thisisindexed.com

• And they will learn how to handle themselves with “good” pimping and tough love.

References1) Virtual Mentor: The Problem of Mistreatment in Medical Education. AMA Journal of Ethics, March 2014,

Volume 16, Number 3: 153-234

2) Experiences of belittlement and harassment and their correlates among medical students in the United States: longitudinal survey. Frank E, Carrera JS, Stratton T, Bickel J, Nora LM, BMJ. 2006 Sep 30;333(7570):682. Epub 2006 Sep 6. PubMed PMID: 16956894; PubMed Central PMCID: PMC1584373.

3) ‘You learn better under the gun’: intimidation and harassment in surgical education. Laura J Musselman, Helen M MacRae, Richard K Reznick1 & Lorelei A Lingard. Blackwell Publishing Ltd 2005. MEDICAL EDUCATION 2005; 39: 926–934.

4) Wanted: role models - medical students’ perceptions of professionalism. Anna Byszewski, Walter Hendelman, Caroline McGuinty, Geneviève Moineau, BMC Med Educ. 2012; 12: 115. Published online 2012 November 15. doi: 10.1186/1472-6920-12-115

5) The relationship between verbal abuse of medical students and their confidence in their clinical abilities. M K Schuchert, Acad Med - August 1998 (Vol. 73, Issue 8, Pages 907-9

6) Perceived stress during undergraduate medical training: a qualitative study. Christina Radcliffe & Helen Lester, Medical Education 2003;37:32–38

7) Delese Wear , Margarita Kokinova , Cynthia Keck-McNulty & Julie Aultman (2005): RESEARCH BASIC TO MEDICAL EDUCATION: Pimping: Perspectives of 4th Year Medical Students, Teaching and Learning in Medicine: An International Journal, 17:2, 184-191