July 2020

posted in: 2020 Journal Clubs | 0

Student mistreatment

Assessment of the Prevalence of Medical Student Mistreatment by Sex, Race/Ethnicity, and Sexual Orientation.

Hill KA, Samuels EA, Gross CP, et al. JAMA Intern Med. 2020;180(5):653–665.  Reviewed by Jacob Schulman & Elizabeth Van Opstal, MD   https://dx.doi.org/10.1001/jamainternmed.2020.0030



What was the study question?  Does the self-reported prevalence of medical student mistreatment vary based on student sex, race/ethnicity, and sexual orientation?

How was the study done?  Retrospective cohort study utilizing data from the 2016 and 2017 versions of the Association of American Medical Colleges Graduation Questionnaire from 140 US allopathic schools. The study analyzed differences in the prevalence and frequency of student mistreatment and discrimination based on student sex (male, female), sexual orientation (heterosexual, LGB), and race/ethnicity (White, Asian, URM, Multiracial).

What were the results?  Overall, 35.4% of students reported at least one episode of mistreatment.  Females compared to males faced a higher incidence of mistreatment (40.9%vs 25.2% P<.001) including a higher reported rate of sexual harassment (6.8% vs 1.3% P<.001).  Females reported a higher rate of gender-based discrimination (28.2% vs 9.4%, P<.001).   Asian (31.9%), URM (38.0%), and Multiracial (32.9%) students all had a higher reported incidence of mistreatment compared to white students (24.0%; P<.001).  There were also higher rates of discrimination (15.7%, 23.3%, 11.8%) when compared to white students (3.8% P< .001).   LGB students reported a higher rate of discrimination based on sexual orientation compared to heterosexual students (23.1% vs 1.0%, P<.001). 43.5% of LGB students reported at least one episode of mistreatment compared with 23.6% of heterosexual students.

What are the implications?  Mistreatment and discrimination have lasting effects as students face long-standing mental health issues and lower job satisfaction. Modeling of faculty behaviors perpetuates these harms in future generations of physicians. Inequities faced by these groups of students have been studied and documented for decades, yet still persists. As the U.S. reckons with its troubled history of racial injustice, medical schools must follow suit in leading to end racism and discrimination in medical schools.

Editor’s note: This study, not surprisingly, documents a high prevalence of discrimination and mistreatment of medical students, especially the groups that experience those phenomena more often. It will be interesting to monitor the effectiveness and results of different medical schools’ efforts to address this stubbornly persistent problem. As is well known, mistreatment and discrimination is rampant in society at large. It would be great for medical education to set an example and lead the way to improve this situation. (RR)

And you may ask yourself “Well—how did I get here?”
Association between characteristics of imposter phenomenon in medical students and Step 1 performance.

Shreffler J, Weingartner L, Huecker M, Shaw MA, Ziegler C, Simms T, et al. Teaching and Learning in Medicine (2020);  https://doi.org/10.1080/10401334.2020.1784741

Reviewed by: Chris Novak

What was the study question? Do imposter phenomenon characteristics correlate with medical student performance on the USMLE Step 1?

How was the study done? Imposter phenomenon (IP) describes the experience where successful people attribute achievements to error, luck or networking rather than their own ability. All students at the University of Louisville (M1-M4) were invited to participate. Participants completed the Clance Imposter Phenomenon Scale (CIPS), a validated instrument which scores participants as having few, moderate, frequent or intense IP experiences. CIPS scores were compared to USMLE Step 1 scores using a Welch’s ANOVA.

What were the results? 233 medical students were included in the final analysis involving students from M2 to M4 who had completed the USMLE Step 1. IP was highly prevalent, with participants reporting few (10.3%), moderate (47.6%), frequent (31.8%) and intense (10.3%) characteristics of IP. There was no significant difference in mean Step 1 scores among any of the four categories of IP. Some CIPS items were associated with worse performance including “I sometimes think I obtained my present position or gained my present success because I happened to be in the right place at the right time and knew the right people.” Other CIPS items were associated with superior performance including “I feel bad and discouraged if I’m not ‘the best’ or at least ‘very special’ in situations that involve achievement.”

What are the implications? This study shows that there is no strong correlation between IP and performance on the USMLE Step 1. This suggests that IP neither impairs nor supports performance on standardized testing. Some CIPS items describing traits such as perfectionism may have positive impacts, while others may have negative impacts on performance. Perhaps, the biggest implication of this study is that almost 90% of participants experienced at least moderate levels of IP. These results highlight the importance of medical educators addressing and normalizing IP to address student wellness. Further research should explore the relationship between IP and performance in the clinical environment or on OSCE examinations.

Editor’s Comments: Although the authors hypothesized that students with the highest IP scores would have the lowest Step 1 scores, they found high and low scoring students in each IP category with high rates of IP overall. If we note that the Step 1 is taken at the end of the second academic year, for some students there would have been up to a 2-year interval between when Step 1 was written and when the IP self-assessment was taken. It would be interesting to look at IP in relation to year of study to establish if there are differences between those who have had experience in the clinical setting (e.g. M3s and 4s) versus those who have not yet started clerkship as this may help educators identify different factors contributing to IP (KFo).

Black voices matter

Developing a Medical School Curriculum on Racism: Multidisciplinary, Multiracial Conversations Informed by Public Health Critical Race Praxis (PHCRP).

Hardeman R, Burgess D, Murphy K, et al. Ethnicity and Disease. 2018;28(1): 271 – 278. https://doi.org/10.18865/ed.28.S1.271

Reviewed by Rebecca Siegel, Melanie Rudnick MD

What was the study question? How can PHCRP (Public Health Critical Race Praxis) methodology be utilized to develop and implement an anti-racism curriculum for medical students?

How was the study done? A multidisciplinary and multiracial group of professionals at one institution were convened in two phases to develop and pilot a curriculum on racism for first year medical students using the already established PHCRP model. Briefly, the PHCRP model, has four foci: (1) contemporary patterns of racial relations, (2) knowledge production, (3) conceptualization and measurement, and (4) action; which creates a semi-structured approach to promote racial equity in public health research.

In phase I, the core group, which was made up primarily of women of color, (following the PHCRP methodology of “centering at the margins)” convened monthly to discuss foci 1 and 2 above.   Phase II, which included the core and expanded groups, was then employed to further refine focus 2 as well as focus 3.   The expanded group consisted of four White male physicians/researchers, one White female researcher.

Detailed notes of these conversations as well as a post-intervention reflective meeting were taken. Qualitative data analysis of the notes was performed using an inductive approach and employing PHCRP tenets Coding was performed by the lead author, with confirmation and feedback from a subset of participants.

What were the results? In phase I, core group members described these curriculum development meetings as “powerful,” and members described feelings of psychological safety (theme of mutual respect and support) in this group. The other major theme that emerged in phase one was that of “centered,” emphasizing the success of the PI’s goal of “centering at the margins.”

In phase II the dynamics and norms changed significantly. Voices of some of the core group members were quieted compared to those in the expanded group. Members of the core group also experienced a shift in norms and felt a loss of trust.  Members of the expanded group described themselves fitting into stereotyped roles, such as a “white pragmatist.”  Some core group members questioned the motivations of members of the expanded group. Despite these challenges, both groups described the experience as a success, as the curriculum was successfully piloted and its success was due to the critical role of women from marginalized communities.

What are the implications of these findings? This study shows the significance of leadership and curriculum development by people at the margins, and the need for White people to make space for this, including but not limited to the development of anti-racism medical school curricula that are less white-centric.

The PHCRP is an established framework that can be utilized in discussions around anti-racism in healthcare, which extends to medical school education and curriculum development. This study shows how such a structure can be utilized in this way, and some of the limitations that occur when this framework is utilized. It will be interesting to see the results of the actual implementation of the curriculum that was created from this process.

We, the reviewers, who are not people of color, acknowledge that in order to more fully understand the implications of this study, we should employ a similar methodology to that which was used in the study above, and have this review first looked at by “centering at the margins.” We realize that our lens of deciding this was important enough to discuss by two White women may also play into the power that was described during phase two of the study, and cede further discussion to those who can create the psychological safety and “trust” that was more fully experienced during phase one of the study.     Editor’s Note: This article, published in 2018, is more timely today than ever.  It is both inspiring to hear how marginalized voices can be brought to the fore and frustrating to hear how quickly they are quieted, even by those with good intentions.  (JG)