Medical education has darker side, study finds
A new Canadian study has offered a rare glimpse inside the culture of medicine, where psychiatrists are dismissed as “flakes,” doctors carry out childish pranks on the students they teach, and idealism withers away in the face of the profession’s stark realities.
The research by physicians at the University of Ottawa paints a picture of the socalled hidden curriculum: the unwritten attitudes and practices that medical students and residents absorb on the path to becoming fullfledged doctors.
Some of that experience can be enriching, such as observing a compassionate doctor’s bedside manner, the researchers say. Much, though, is contrary to the medical faculties’ official principles of equality, collegiality and patient-centred care.
The authors held focus groups with students, residents and staff doctors, and heard similar observations from all the groups about medical education behind the curtain.
Many reported that inappropriate behaviour by the doctors doing the teaching goes unreported and unpunished, a strict hierarchy is observed and certain specialties are routinely portrayed as inferior.
“It’s where the flakes go,” a practising doctor said of the prevailing attitude toward psychiatry.
The findings echo those from a growing body of research, mostly American, but also a small 2012 Canadian study that quoted students as saying the doctors teaching them sometimes voiced disparaging views about the obese, immigrants and female physicians.
Such inf luences are troublesome, not least because they seem linked to a steady blunting of emotion and decrease in empathy for patients among new physicians, says Dr. Asif Doja, lead author of the Ottawa study, just published in the journal Medical Education.
Patients “don’t just want someone who has book smarts,” the neurologist said in an interview. “People want other things from their physicians too … things like empathy, like communication skills, like putting the patient first.”
In fact, the hidden curriculum has been drawing increasing attention from medical schools in Canada and elsewhere, with the Canadian Association of Faculties of Medicine urging its members to address the issue.
Many medical schools now teach courses on professionalism, and have tried to combat the badmouthing of family doctors to encourage more students to become generalists.
But while some “modest inroads” have been made, dramatic change has yet to occur, maintains Dr. Sally Mahood, a family physician and University of Saskatchewan professor.
“I don’t think medical schools have yet got the message that we need to reward and show our admiration for professionalism,” she said.
In a frank 2011 commentary, she charged that “academic hierarchy” and convenience — not patients — were at the centre of medical education, despite the official stance.
“Off-hand ridicule of patients’ weight, poverty or ethnicity can juxtapose with talk of cultural sensitivity,” she said in the 2011 article in Canadian Family Physician.
The Ottawa study, also involving the Children’s Hospital of Eastern Ontario, consisted of five focus groups where students, trainees and doctors were asked to discuss the hidden curriculum.
Most commented on the portrayal of some specialties as superior to others, family medicine and psychiatry being the most disparaged. That kind of attitude has been blamed in part for lack of interest in those fields by graduating medical students, helping fuel a shortage of both.
A medical student noted that sub-specialists — physicians who have obtained additional training after their five-year residency — tend to think they are better and “just trash” other specialists.
Focus-group participants also reported that unprofessional behaviour by doctors was tolerated, and that they felt powerless to do anything about it.
A 2012 Queen’s University study surveyed students at three medical schools, and heard of some striking behaviour by the physicians teaching them.
More than one student said doctors referred to obesity as a moral failing. Another described a doctor introducing her to a patient by saying “this Russian girl will be doing your exam,” and explained how to ethnically profile patients.
And women “were described as unfit surgeons, both because they were assumed to lack manual skills and because they would never put surgery before parenting.”
Dr. Susan Phillips, the Queen’s professor who headed that study, stressed that most doctors mean to do well by their patients and can often be an inspiration to students.
But she is particularly concerned by one theme running through all the hidden-curriculum research: that the idealism students bring into medical school has largely been chipped away by the time they start practising.