Scenario: A third-year medical student (she/her) is on her Internal Medicine rotation. During morning rounds, her resident asks, “What are the criteria for Spontaneous Bacterial Peritonitis?” The medical student thinks for a moment, but she can’t remember. The resident rolls his eyes and says, “How could you not know this?” The resident then asks every team member to come over to the medical student’s desk and watch her look up the criteria on UpToDate. Five team members are now standing over the medical student as she tries to look up the answer. The resident says: “We’re all going to stand here until you figure it out.” The medical student can barely concentrate on looking up the answer because she feels humiliated.

Impact: The medical student is humiliated as her team of residents, other medical students, and attending physician physically stand over her. For the rest of the rotation, she is motivated by fear of humiliation to learn diagnostic criteria. She becomes anxious whenever a question is asked of her that a similar scenario will happen again. She no longer looks forward to working with her team. 

Outcome: The medical student, who had been interested in Internal Medicine, seriously questions if Internal Medicine is the right field for her and if these are the people she could see as her future colleagues.

Takeaways:

• It is perfectly acceptable for residents or attendings to ask medical students questions for teaching. However, when these questions are tied to a humiliating action (having the whole team hover over the student’s desk and watch her look up the answer), they no longer serve the purpose of teaching and can have a lasting negative impact on a student.
• Before asking a medical student a question, think about your intention in asking that question. Is your intention to teach, or is it to trick/embarrass the student? 
• It is okay to point out gaps in medical students’ knowledge or ask them to look something up, but it is vital to do so respectfully. 
• Here are some alternatives:
  • “I’d like you to prepare a one-minute talk on SBP for afternoon rounds.” 
  • “I’d like you to look up the diagnostic criteria for SBP. In the meantime, how might a case of SBP present?

Author: Katya Lavine MD'23

Scenario: A fourth-year medical student, who identifies as a cis-gender woman (she/her), is on a subspecialty elective. Along with a fellow and attending physician, both cis-gender men, she enters the room of a patient who is a cis-gender man. After the attending physician introduces her to the patient, the patient takes her hand and says, “I love nurses. It’s hard for me not to kiss every nurse I meet.” Her attending physician then laughs at the patient’s comment, turns to the medical student, who is silent, and says, “Well… aren’t you going to say something?”

Impact: This is an example of both public humiliation and sexual harassment. The medical student is misidentified as a nurse and sexually harassed by a patient, and the attending physician and fellow had the opportunity to step in and redirect the conversation. Instead, the attending physician laughed at the patient’s comment and asks the medical student to respond, thus humiliating her in front of the team. The student is mostly silent for the rest of the day, and she can tell that her attending and fellow are annoyed at her sudden silence and non-engagement.  

Outcome: The student does not file a Learning Environment Report because she is not sure that this behavior is serious enough to warrant consequences. She is also fearful that she will be identified as the person who wrote the report. She is applying for residency this year and wants to get Honors in the rotation, so she decides not to say anything. 

Takeaways:

• If you witness a patient mistreating a trainee, several courses of action exist. Agreeing with the patient is not one of them. At the moment, you can redirect the conversation, and later you can acknowledge the mistreatment with the trainee privately and ask how you can best support them. 
• Once a student is publicly humiliated, it is extremely difficult for them to refocus. In this student’s case, she was unable to engage meaningfully with the team or other patients for the rest of the day as she recovered from the humiliation and harassment. 
• You can always remind trainees that Learning Environment Reports can be submitted confidentially, and students have the option to indicate that they’d like the administration to wait a certain amount of time before bringing up the issue – for example, they can wait until after the student has received a grade for that rotation, or after the student has graduated. Retaliation is also strictly prohibited.

Author: Katya Lavine MD'23

Scenario: A second-year medical student (he/him) who identifies as Black is in his afternoon small-group Doctoring session. The session’s topic is racism in medicine, and students in the group were assigned an article to read before class. During the discussion of the article, the student shares his thoughts with the group on a few occasions. Towards the end of the discussion, the course leader, who is white, says to the student, “You’ve been awfully quiet – you must have thoughts on this topic that you’d like to share.” 

Impact: This student is called out inappropriately due to his race to comment on an article on racism and feels humiliated in front of his group. Regardless of whether or not he had shared previously, he should not have been singled out or asked to make a comment. It is presumed by the small group leader that as a Black student, he has the responsibility to comment on the article and educate the group about his experience – a problematic and racist assumption. The student is now anxious about attending future Doctoring sessions.

Outcome: The other Doctoring students speak with the singled out student and ask how they can support him. With his permission, the students bring this incident to the course leaders’ attention, and the Doctoring course leader speaks with the faculty member. 

Takeaways: 

• It should never be expected that a BIPOC student share during a discussion of racism. It is not the job of BIPOC individuals to educate students and/or faculty members about their experiences.
• As a general rule of thumb, do not single out or call on any student during a small-group discussion unless they ask to share.

Author: Katya Lavine MD'23

Scenario: Two third-year students are completing the first week of their Surgical Clerkship and are joining their team for morning rounds in a conference room. They’re instructed to sit in two chairs at the front of the room. The rest of the team sits together at a round table. When the attending enters the room, she sits with the team and asks the two students about pleural effusions. The students had not anticipated this topic, and they both stumble through the questions. The attending laughs at each answer the two students give and proceeds to ask them even harder questions.

Impact: Both students feel embarrassed and put on the spot. One of the students fights back tears during the question session. Afterward, both students discuss how miserable it was to be laughed at and that none of the team members had prepared them for morning report. 

Outcome: The students dread the weekly morning report, and one begins to disengage from the team entirely. During the final day of the Clerkship, one of the students reports her concern that this attending may have unfair expectations of learners and has made students feel very uncomfortable. The leader of the feedback session replies that this sort of learning is a part of the culture of surgical teams and is not meant to be taken personally.

Takeaways:

• Humiliating learners in not an appropriate teaching method.  There are proper ways to assess learners' understanding that do not involve mocking or group shaming.

  • “What can you tell me about pleural effusions?” 

  • “I had a patient last week who developed a post-operative pleural effusion. I’d like to spend two minutes talking about Light’s criteria. Has anyone heard of Light’s criteria?” 

• Humiliation and/or public embarrassment disempowers students and discourages future participation in the learning environment. A bad experience on a particular clerkship may lead to a student avoiding learning more about a specialty altogether.