To the Editor:Academic Psychiatry’s July-August issue highlighted bullying (1–4) and referenced a 2005 editorial (5) concerning the safety of medical students and residents. That editorial cited our 1996 article, “Awareness and Fear of Violence Among Medical and Social Work Students” (6), which was written after our experiences while working in an adolescent inpatient psychiatric unit, an emergency department, and a county jail.
Graduate school education in the Midwest and clinical supervision helped us understand the genesis of violence and learn de-escalation skills. Psychiatric settings recurrently trained us in aggression management. Our chief of psychiatry was an excellent teacher, clinician, and manager of people. He made it abundantly clear that the safety of patients, staff, residents, and medical students was important. He reminded us that most of the children and adolescents on our unit were there because they could not choose their parents and many had experienced physical, sexual, and emotional abuse from their chemically dependent and psychiatrically impaired parents. He said that when we taught residents or medical students, we were in a parental role and the residents were in a more subordinate role. We were advised not to become abusive and neglectful “parents” of the medical education process to avoid recreating dynamics similar to an abusive family system.
In the early 1990s, I took a faculty position in Nevada, one of the most medically and psychiatrically underserved states. I was amazed by the lack of security in hospitals and the lack of psychiatrists and community resources. While teaching medical students and residents on clinical rotations, I became aware of the paucity of training in most types of violence prevalent in the city: gang violence, child abuse, elder abuse, intimate partner violence, and pet abuse. During this time, more and more acts of violence directed toward health care providers were reported. Many may remember the shooting deaths of emergency physicians at the University of Southern California (7), the shooting death of an otolaryngologist in a clinic at the University of Michigan (8), and the deaths of several social workers (9, 10). Sadly, there have been many more since then.
A colleague and I surveyed medical students and social work students for their awareness and fear of violence on clinical rotations and in field work settings (6). This proved to be challenging. Our attempt to acquire a few hundred dollars in seed money was rejected by a medical organization but was funded through social work networks. In the denial of funding letter, the medical organization reported that it was an interesting idea and violence to health care professionals was a concern, but it could not offer funding.
The editors of Academic Psychiatry (5) commented that our study imprecisely defined aggressive acts/threats. We had sent out anonymous surveys to 100 third- and fourth-year medical students and 100 graduate social work students. The surveys contained 10 questions with multiple response options in a yes/no and fill-in-the blank format. Forty-six medical students and 78 graduate social work students returned the surveys. Several survey forms had detailed accounts of personal experiences on the back. Two medical students called me and asked to speak confidentially about their experiences while on rotations. It seemed to be cathartic for them to detail their experiences.
One female medical student talked about a surgery resident who groped her while she was holding retractors during a surgical procedure. Another told of a surgery attending having a temper outburst during surgery and throwing a scalpel at her. Many reported theft of personal property from hospital lockers. What is especially concerning is that the students who wrote detailed accounts were victimized more from within their medical “family” than from patients.
The family metaphor is important (11). Medical students go to great expense academically, financially, and personally to become members of the medical family. They may isolate themselves from their own families and take on the rigid thinking and unrealistic expectations of this new family, even denying their own physical and emotional needs. The abusive behavior experienced by those surveyed was witnessed by others; however, as in abusive family systems, the abuse was denied or minimized. Disclosing the victimization might be seen as disloyalty and could threaten membership in the medical family, which most medical students might not be willing to risk.
Students cannot learn when they are fearful. Faculty behavior speaks volumes. There is no excuse for disrespectful treatment of patients, staff, students, residents, or colleagues. Acts of aggression and bullying must have consequences. Academic medicine is no place for the replication of the dynamics of an abusive family system!
At the time of submission, the author declared no competing interests.