The Association of American Medical Colleges (AAMC) surveys graduating medical students each year (¹) and consistently reports student mistreatment rates of about 15%. The AAMC questions fall into four categories: general mistreatment, sexual mistreatment, racial/ethnic mistreatment, and mistreatment based on sexual orientation. Only 30% of these students report mistreatment to authorities during medical school, citing several reasons, such as, "it did not seem important enough" (50%), "I did not know what to do" (25%), and "fear of reprisal" (50%). Students also report feeling guilty and confused, preferring to "handle it themselves" (²—⁴). More in-depth studies have found higher rates; for example, in a study of 2,884 medical students from 16 medical schools (⁵), 42% of seniors reported harassment and 84% reported belittlement during medical school. In a sample of senior medical students from 14 U.S. medical schools (⁶), 92% of female students and 83% of male students experienced, observed, or heard about at least one incident of gender discrimination and sexual harassment during medical school. Medical student mistreatment is ubiquitous and is reported in the United Kingdom (⁷) and in Finland (⁸).

Gender and ethnicity have been reported to be both significant (⁹) and nonsignificant (⁵) in experiencing mistreatment. Students who have decided on a specific field of study are noted to be subjected more to mistreatment during other clerkships (¹⁰). Medical students report changing specialty based on experiences of "abuse and humiliation" during training (¹¹). Gender discrimination and sexual harassment influence female students more than male students in their specialty choices (45.3% versus 16.4%) and residency rankings (25.3% versus 10.9%) (¹²). Female medical students notice more abusive and discriminatory behavior than male medical students (¹³). In a sample of women who were interviewed during residency from 116 different medical schools, 96% could identify one instance of sexual harassment of the hostile environment type (¹⁴). However, these women stated that they had to learn not to be "oversensitive in a tough environment" and that they needed to "adjust to the male hierarchy." In other words, women’s fears of being perceived as "too sensitive" kept them from viewing sexist behaviors as problematic.

The known consequences of mistreatment are increased binge drinking (¹⁵), suicidal ideation and depressed mood (¹⁵), and alcoholism and clinical depression (¹⁶, ¹⁷). In a study of 2,884 medical students from 16 U.S. medical schools, having been harassed or belittled was significantly associated with ever having made a suicide attempt, having suicidal ideation in the past year, increased alcohol consumption, and increased frequency of binge drinking (⁵). Students also reported a lack of confidence in clinical skills and ability to provide compassionate care (¹⁷—¹⁹). However, no studies have assessed the role of workplace mistreatment in the development of posttraumatic stress symptoms in medical students. This study aims to extend our understanding of the effects of workplace mistreatment in medical students by exploring the responses of third- and fourth-year medical students to a teaching vignette and asking them to describe any mistreatment they experienced during medical school. If students experienced mistreatment, they completed a questionnaire on symptoms of posttraumatic stress disorder (PTSD) related to their mistreatment.

During the 2004—2005 academic year, third- and fourth-year medical students met during two clinical clerkships in an informal lunch setting with an independent faculty member to discuss their clerkship experiences. The primary goals of the meeting were to raise awareness of the importance of a healthy learning environment and to educate students about what constitutes mistreatment and sexual harassment. A secondary goal was to try to identify and solve problems in real time, thus improving the learning environment. It was explained to the students that the faculty members leading the meeting had no role in evaluating them and that their comments and questions were confidential and could appear in aggregate form in a report to the dean’s office at the end of the year. They were offered the opportunity for further private consultation and given e-mail addresses and telephone numbers of independent faculty members who could work with them confidentially on any issue related to mistreatment or harassment and who were appointed to facilitate discussion of mistreatment and harassment. Several examples of previous reports by students and resulting solutions were given, without any student or faculty identifiers.

The decision to assess the students’ attitudes more formally occurred as several themes emerged from the discussions. Gender, ethnicity, and having chosen a future specialty appeared to be pertinent in the voicing of complaints. We also wondered if those students who had experienced mistreatment responded more forcefully to the discussion of the vignette. No attempt was made to screen the students for premorbid pathology because recent scholars have considered mistreatment as significantly more likely to contribute to poor mental health, rather than vice versa (⁵).

This survey had no funding, there were no incentive payments to students, and it was exempt from institutional review board approval. Confidentiality was maintained because no student identifiers were used.

After the introduction, the students were asked to take 10 minutes to complete the questionnaire, which was divided into two parts. Part 1 asked students to identify their age, gender, ethnicity, education track, and intended field of study and then to read a vignette and answer questions based on it. The vignette was chosen from the AAMC’s booklet "Appropriate Treatment in Medicine" (²⁰), specifically because it was ambiguous and provoked more discussion among the students than the other AAMC vignettes (see Appendix 1). Students were asked about the possible actions of the person in the vignette (e.g., "What would you suggest Mary do?"). They were also asked about their general impressions of medical school (e.g., "The level of professionalism in medicine has met my expectations"). The students rated their responses on a 5-point Likert scale (1=strongly agree; 5=strongly disagree). Part 2 assessed experiences of mistreatment only for those students who could think of an instance of humiliation that they had witnessed or experienced as a medical student. The students were asked to describe the situation and then rate each question separately. The Impact of Event Scale-Revised (IES-R) was used because it is a short self-report instrument with adequate reliability and validity (²¹). The scale has 22 items, with three subscales measuring avoidance, intrusions, and hyperarousal, and is scored on a 5-point Likert scale (1=not at all; 5=often).

Data were analyzed by grouping students according to their intended field of practice. Students who circled several possibilities in different specialties or left this question blank were grouped as undecided. Responses were also analyzed by age, gender, and ethnicity.

Seventy-one of 91 medical students completed the questionnaire, for a response rate of 78% (Table 1). The sample consisted of 29 men and 42 women, with a mean age of 26.3 years old (SD=2.47). Ethnicity was described as Caucasian (n=28), Asian (n=13), African-American (n=7), Latino (n=6), and other (n=3). Forty-five students were in their third year and 23 were in their fourth (three did not indicate year). Some were at the beginning of their clinical training whereas others were approaching the end. The students indicated that their intended fields of practice were medicine and medical subspecialties (n=35), surgery and surgical subspecialties (n=13), and undecided (n=23).

Fifty-two of the 71 students who returned the questionnaire completed Part 2, meaning that 73.2% of students had witnessed or been subjected to mistreatment. Of the 71 respondents, 51 completed the IES-R, with a mean score of 32.79 (SD=15.81). There were no differences in scores on the IES-R across intended field groupings, age, or gender. Two of the vignette questions were endorsed differentially by individuals who scored higher on the IES-R, after controlling for age, gender, and for differences across intended field groups. For the question "When deciding to write up a complaint, Mary should consider: she’s doing the right thing," a higher score was related to increased agreement (β=0.01, SE=0.004, p<0.04). For "In general, do you think residents are sympathetic to medical students’ concerns?" a higher score was related to less agreement (β=−0.01, SE=0.004, p<0.03).

Personal experiences with mistreatment ranged from "being harshly criticized" (12 on the IES-R) to "I have been called [weak] and told I operate like a girl. Been jabbed with scissors. Told I would likely make a patient septic by putting in a contaminated Foley" (29 on the IES-R). A student who reported racial and ethnic discrimination quoted the attending as saying, "When did you come across the border?"

There was little difference in medical students’ responses to the vignette according to age, gender, or intended field of study. Ninety percent of students (n=64) thought that Mary should do something, including discussing with her peers, the resident, or administration. In writing up a complaint, medical students mostly believed that she was doing the right thing, although a significant percentage thought that it would affect her chances of getting a good recommendation, take up too much time, or result in possible backlash. It is reassuring that most students supported Mary and encouraged her to seek out support. Only 40% of students (n=28) thought that medicine had met their expectations in the level of professionalism. Administration was considered most sympathetic to medical students’ concerns, followed by residents, then attendings. Only 28% of students (n=20, more men than women) thought that nurses were sympathetic to their concerns.

The majority of students had witnessed or been subjected to mistreatment. Their average score on the IES-R was in the symptomatic range for posttraumatic stress symptoms. This study did not identify how recently these episodes occurred, and it may be that this response would diminish over time. This study did not assess students for any premorbid psychopathology, which could have predisposed students to respond in a more sensitive manner, although recent scholars have refuted this association (⁵). The students who scored in the high range on the IES-R were more likely to believe that Mary should complain about mistreatment and to view residents as unsympathetic. This finding most likely reflects mistreatment from residents, who are the most prevalent sources of medical student mistreatment (¹).

There are several limitations to this survey. First, not all third- and fourth-year students attended the seminar. Second, some students who experienced mistreatment may not have chosen to complete Part 2. Third, the groups who participated contained several students who were at the beginning of their clinical training and thus may not yet have experienced mistreatment. Fourth, some of the negative experiences reported in Part 2 were not uniformly agreed upon as mistreatment, such as being harshly criticized or watching a peer being harshly criticized. Fourth, the study used an informal survey rather than a structured interview.

What can be learned from this survey? First, medical students, given the opportunity, will discuss their experiences in the learning environment, thus affording the institution an opportunity for improvement. From this preliminary survey of medical student attitudes, symptoms of PTSD commonly occur from experiences of mistreatment. More formal study of the possible development of PTSD symptoms from experiences of mistreatment in medical school needs to be conducted.

At the time of submission, the authors disclosed no competing interests.