Bullying in Medicine: The Realities That Toxicity in Medical Training Exists.

As our time in medical school draws to a close, and as residency training is fast approaching, we took some time to reflect upon our experiences as trainees in the medical education system.Upon reflection, I get nostalgic thinking about the experiences that exceeded my expectations. I will never forget those certain attendings that were kind, passionate and instilled in me such confidence, when I didn’t have much at that stage in training. They also never failed to praise those innate qualities in me that made me…..me. It is to these attendings that I hold my glass to, and to who I will never forget. I will continue to honor them by passing along their same kindness and investment into others, just as they had unto me. But, this blog is not about those experiences that have made us the people we are today and inspired what we hope to contribute to the future generations of medicine. Toxicity in the medical field is improving, but unfortunately, some remnants of this tradition still exist. As much as the confidence invoking experiences vastly outweigh any of the bad ones, we will now have a discussion about some of our more disappointing experiences. We hope that with reflection, we can learn to not be deterred by this, but to become further inspired to teach, invest, and value each of our future students going forward.Ashley: So, I can start this off by discussing the brutal and unforgiving nature of medical school in general. Medical school is hard, that is no surprise. And it should be. As physicians, we will be responsible for people’s lives, and there are consequences if we are not adequately prepared for this reality. We pay$60,000/year to be thrust into a world where we are expected to be studying constantly, all while attending class from 8 to 5. This is coupled with pressure to tack on extracurriculars and tackle any random assignment that gets piled on top. There is always this underlying pressure to be adding more to your plate, even when it’s already full, because there is always someone doing more than you are.Surprisingly, it wasn’t the piles of work and the weight of the world on my shoulders that was the biggest reality check for me; it was essentially how unforgiving this world is in regards to any form of weakness or the need for a “personal day”. You take one day off, you fall behind. I read in an article somewhere that “weakness in medicine is not tolerated” and “mental health stigma still exists”. To me, this is potentially dangerous and can have catastrophic consequences.Melissa: I completely agree. There is little room for being human in medical school. In addition to the stress about falling behind, medical education also encourages you to minimize yourself and your needs. Most of us went into medicine because we wanted to help others; we accepted that frequently we would put others before ourselves. Putting others before yourself shouldn’t mean that you cease to exist though. I’m not sure many of us initially understood how easy it would be to lose ourselves. Medicine does not have time for you, the individual. You as a student doctor, then resident, and eventually, attending are what is valued in medical education. Your intelligence, your confidence, your eagerness to learn and sacrifice, your willingness to show up early and stay late, and your extroversion are valued in medical education. While there is some crossover in the traits that you, the doctor, and you, the individual, have, there is a lot more room for you, the doctor. Years are spent carving out the space for that role, and a lot of the people you spend most of your time with expect that version of you. You, the individual, has to be deliberate, and sometimes that will upset professional relationships. You the significant other, you the brother/sister, you the friend, you the outdoor enthusiast, you the poet, you the empath - a lot of it falls to the wayside without deliberate work to prevent it, and I think many trainees come out when they’re done with an identity that is exclusively “doctor”. Which never should have been an identity to begin with, because the whole person matters. Because of this struggle, it is not surprising to me that so many trainees suffer in silence with their mental health and burn out. If your identity has become predominantly "doctor", negative feedback hits even harder.Ashley: “Putting others before yourself shouldn’t mean that you cease to exist though.” This is fire! I feel that medicine now is trying really hard to place value on “physical and mental wellness”, but the realities are, the time for them is very limited. Experience has shown me that everything important to you, whether that be a significant other, family, hobbies, pets, are often shoved to the side to make room for the expectations that befall you in medical training. As you said, “the rest of us should matter”, not just our craft. Transitioning our discussion to experiences in the clinical world: The worst experience I had as a medical trainee was half way into my 3rd year, where I still had a lot to learn, but was receptive to learning everything I could about a field that is considered one of the "cores of medicine". My attending at this time was a brilliant, powerful woman, who had endured so much in her lifetime to break down barriers for women in medicine. During my rotation, she would openly talk about how amazing one of my colleagues was on a regular basis, which only made me feel inadequate in comparison. When we came to the conclusion that one of my weaknesses was orally presenting patient cases, the plan to work on them never came to fruition, as I was always interrupted prior to completing them. In the end, my evaluation was less than stellar, regardless of how hard I fought. I felt that, instead of taking opportunities to mentor me, she chose not to. A physician, who worked so hard to combat the history of discrimination towards women in medicine, had ultimately made me feel undervalued and not worth investing in. Ultimately, I was left to feel discarded, and like an utter failure. I felt that the intrinsic nature of who I was had no right to be here and as if all of my other glowing evaluations were a fluke. Melissa: I know what you mean about feeling inadequate and being compared to a peer.  Pre-COVID, I planned a sub-internship (a rotation where you act like a first-year resident in terms of caseload and expectations) in another state. I strategically planned my first Sub-I at a program that I was not interested in because I wanted to feel a little more experienced when I actually went to sites I was interested in for residency. For all they knew though, I was there because I wanted to apply for their residency program. The site was pretty toxic from the top down. While I was rotating there, the program director kept talking about a fourth-year student that had done a core rotation in the past and who they needed to interview because he was just absolutely amazing for all sorts of reasons that were regularly expressed in front of me. He did that so often, that one of the residents actually reminded him that I was on an audition rotation. Listening to all the things that the student did well might not have been so bad, but that was coupled with being made fun of by the program director during morning rounds on more than one occasion. The whole rotation was an abusive mess. There was a lot of talking about people behind their backs. When people did address each other with feedback, it was wrought with personal attacks. Nurses were regularly yelled at by residents. My senior resident yelled at me for forgetting to print the rounding list one morning, because that was lazy of me and he should not have to print his own list “as my senior” . I was grateful that at least the interns were pretty kind and would try to diffuse these situations.All of this while I was away from my partner and my dog. They were being showered with wildfire ash, and I was alone in a really abusive environment. I was incredibly depressed. I had no appetite and was barely eating. By the second week, I accepted it for what it was. I took what I could out of it and celebrated so, so hard when I finally got off that rotation. Ashley: When you told me about this, I wanted to drive down there, kidnap you, and bring you back home to Oregon, even if it was on fire! That situation was absolutely detestful in every conceivable way. Knowing you both from a personal and professional standpoint, they missed out on an incredible human being. Instead of fostering you, they chose to intimidate, which speaks volumes about their character. I truly feel that a positive work environment filled with respect and constructive feedback  makes me WANT to give my all. Personal attacks should not be included in any equation, as its sole purpose is to harm, not teach. I truly commend you for not letting them diminish your learning experience, but for taking away everything you could out of this toxic situation. I am a firm believer, that even in the worst of situations, you can always take something from it. In the same article, another snippet stood out to me: “Abusive medical culture affects everyone in the profession. Training brutalizes idealistic students who dreamt of doing good. Practicing physicians don't fare much better. In this closed-off world, perfection is the standard. The bar is set so high that any real or perceived error elicits not just guilt, but a corrosive shame.”During one of my 4th year rotations, I was conducting a patient interview while my preceptor observed. After the session concluded, my attending scolded me for asking a question that I had understood to be “standard”. I know my limitations and am always receptive to learning from my mistakes. What took me back was not the criticism, but their exaggerated response, for did I not only feel berated, but was further condescended by being provided an analogy, where I felt its sole purpose was to make me doubt my basic common sense. After feeling beyond frightened that I had “messed up any chance of impressing my attending or having a future in my desired field”, I spent about a week feeling immense shame and utter embarrassment. Upon further reflection and discussing the incident with other preceptors, I knew this response from my attending was wrong, and that there were better ways to convey a teaching moment. Instead of shaming, I wish they had taken this perfect opportunity to explain why they felt so strongly and when it was appropriate to ask said question.Melissa: I was really shocked and disgusted when you told me about this. Even if the attending’s point was valid, I can’t understand why scolding or shaming would be used as an effective tool to communicate. Especially, when it was not a life or death situation...Like, it's not even commonplace to train dogs that way. Having known you for a few years now, I cannot think of anything you could possibly do that would warrant that reaction. So often I feel like there is a failure to communicate with trainees in a constructive manner. I did a rotation in a surgical subspecialty. During that rotation, my attending physician took a lot of time off and suggested that I be in frequent contact with the PA. I did not have computer access, so I was unable to see when/where different surgeries or procedures were taking place and who was performing them. Because of that, I depended on that PA to know what was going on and who was doing what. I worked with other docs that I had met when I could, but I ended up working with her quite a bit throughout the rotation. Towards the end of the rotation, she suggested I go work with one of the other PAs. I did, and as soon as I sat down with that PA, I overheard her say to one of the medical assistants that I was “X-years old” and I did not “take any initiative”. Thankfully, the medical assistant responded that she did not see me that way.

I made it through the rest of the day and barely made it to my car before the tears started flowing. I spent the entire weekend feeling really small. “Corrosive shame” captures the feeling pretty well. The way that she expressed her thoughts about me was inappropriate, but maybe there were some things I could have done better. As a learner, I think there are always things I could do better. I don’t love conflict and I am a quiet person, but I was not going to let her comment slide. On Monday, I pulled the PA aside and told her that I overheard what she said. She didn’t deny saying what I heard her say, but when I addressed her she seemed to remember all the times that I did take initiative on the rotation and listed them to me. She apologized – kind of. I was proud that I stood up for myself, because there were a lot of years prior that I would have never done anything like that. That, and the fact that hopefully she won’t do that to another student, was enough for me. Ashley, I totally understand the concerns that you had on your rotation about messing up a chance to impress your attending. I never got an evaluation from this rotation, and I often have wondered if that was because I stood up for myself. It was still totally worth it though! :)

Ashley: There is often a failure to effectively communicate criticism constructively, and this leaves students feeling shamed, inferior and fearful. I am beyond PROUD of your ability to stand up for yourself. You knew this was wrong and you approached her in the respectable manner that you should have been approached if she had a concern. There are other instances in my medical training experience where I felt ignored, undervalued, and even told my “kind demeanor” would not serve me well in medicine. There was another instance where my attending brought up the concept of Eugenics and asked me about my stance pertaining to certain issues surrounding medical ethics, and even another rotation that I cancelled purposely to avoid being asked about my religious and political affiliations. What implications can toxicity have? From personal experience, I feel that these ramifications can include imposter syndrome, diminished self value, self doubt and isolation. I fear these can even lead to long standing anxiety, depression, and even suicide.The discussion of toxicity in medicine should be had, but the question is: Should it exist? While toxicity and perceived abuse are seemingly terrible, where do you draw this fine line between tough love and demanding excellence, with bullying? We are doctors. We will be expected to work long hours, excellence will be demanded from us, and this steep learning curve will serve us for the better, no doubt. But, what about abuse in the form of tearing your self worth down for no reason whatsoever, or making you feel inadequate in comparison to another? Is this productive? Is this going to make me a better doctor?Melissa: I’m with you.  I’ve lost track of the number of times I have felt ignored and not invested in. On many rotations, half of the battle  was just finding someone to learn from. I’m sure you can relate to this, but I’ve often wondered if part of the struggle is attributable to being an introvert. Having discussions about medical ethics is an important thing, but having those discussions with someone in a position of authority, while still a student, is distressing. There is no way to express your thoughts without the fear of consequences due to dissenting opinions. So then you just sit there and respond with  “hmm’s” while getting bombarded by their beliefs. I hate that feeling. Also, I cannot believe someone would say that your kind demeanor would not serve you well in medicine. I can’t imagine seeing a psychiatrist who doesn’t have a kind demeanor. You’re exactly the person that needs to be in medicine, in part, BECAUSE OF your kind demeanor.  I’ve also wondered if some of the abuse stems from being a woman. I have been on male-dominated rotations where I was treated more poorly than my male classmates for doing almost the same things. All of these things: being an introvert, having dissenting opinions, being a woman, are not the kind of things that are likely to make your evaluations glow. As I reflect on my experiences, I recall a number of times that I was depressed and it was in response to those negative experiences. As Ashley mentioned, many of us live in a world where we struggle with feeling inadequate or like imposters; these experiences push us further into believing that we do not belong in medicine. And if medicine is our life, because we’ve carved out so much space for it, then there is nothing left. It is isolating, and many licensing boards, attending physicians, and peers make it difficult to ask for help.The road to despair, depression, and suicide are so visible in medicine. That is the sad truth of our profession: there is no space for less than perfection. That being said, I do think that trainees should be held to high standards, but this is not the way. I’m proud to be in a new generation of physicians where these abusive practices are becoming less tolerated. Ashley & Melissa: As medical trainees, we should be held to the highest of standards, but it is not realistic to expect that we can meet this level of perfection. And moreover, shaming and diminishing us is not the way to help students achieve that level of greatness that we all strive for in our chosen craft. Every person who pursues becoming a doctor knows that they have sacrificed their time, youth, money and at times, dignity, to be here. For me, that sacrifice was worth the privilege of being able to help people in this profound way. So, should bullying in medicine exist? NO, absolutely not. Could these situations have been handled differently?  Yes, without a doubt. There is a line between rigorous training and preparing us for the realities of medicine vs outright toxicity. Constructive criticism is one of the cores to which we learn to become better. If we can steer away from the mentality that bullying students into greatness is the most effective way to go, we can then begin to look for ways to improve our effectiveness in training and apply this to the next generation of medical professionals without detrimental consequences. I think I speak for both of us when I say that these experiences, both positive and negative, have taught us who to be during the upcoming segments of training. While I wish that the negative experiences were not part of our medical school journey, I know we will use them as fuel to become more compassionate residents, attendings, and people.  My hope is that the people who train under us in the years to come will feel valued not only as doctors-in-training, but as the people that they are inside, and outside of, medicine.

Co-authors: Melissa Mahoney, OMS IV & Ashley Maestas, OMS IV