Culture | The Pillbox

A series of briefs by the Texas Medical Students

By: Elleana Majdinasab and Rishi Gonuguntla

Medicine has its unspoken mores, does it not? Certain specialties are notorious for their personalities, and the idea of foregoing food and sleep are deemed signs of strength and resilience. Upperclassmen advise against getting in Dr. X’s way, lest you become subject to a tailored diatribe, and you hear whispers of Dr. Y’s career-crushing evaluations. Your roommates do not bat an eye over your tears every evening, because chances are they are no stranger to such days themselves. It doesn’t require a detective to identify that the above are the direct result of mistreatment in medical school.

Per the AAMC, mistreatment occurs when there is a show of disrespect for another person that unreasonably affects the learning process. Public humiliation and belittlement by doctors are the most common forms of mistreatment in medical school.¹ The practice of aggressive “pimping,” or the act of doctors disparaging students for not knowing information, potentially in front of patients or fellow classmates, is a phenomenon too many medical students needlessly experience.² Other examples of mistreatment include the shaming of students for asking questions and being subjected to offensive names and remarks.¹ According to one 2014 study, over three-fourths of third year medical students reported being mistreated by residents, with over 10% of those responses citing recurrent mistreatment.²

Given the omnipresence of these events, one may consider whether there exists a common denominator among guilty attending physicians. Indeed, mistreatment of medical students can occur secondary to a multitude of reasons. Physician burnout is still rampant as ever, and ironically, often occurs partly due to the same toxic culture attendings themselves experienced as budding residents.³ The doctors in question blissfully perpetuate the cycle, humiliating and pimping, justifying their behavior with the mentality of, “I went through it back then and turned out just fine.” Thus, the vicious cycle continues. What doesn’t kill you makes you stronger, right?

As medical students, we are quietly told by the older and wiser to improve our resilience – to grow tougher skin. We are advised to expect, or even welcome, microaggressions and impatience from our superiors while we work toward our lifelong dreams.⁴ We take deep breaths and smile through the jabs because we are fully aware of the consequences of speaking out against the deeply ingrained practice of mistreatment.⁴ Mistreatment in medical school matters because doctors eating their young further propagates the toxic reputation of the career’s culture while contributing to the development of many future doctors’ unhappiness.³ It is the accumulation of years of pressure, competition, and negative experiences that leads to feelings of burnout in students and physicians alike.⁵ Even worse, medical students act on these feelings, and they are three times more likely to commit suicide than their similar-aged peers in other educational settings in the general population.⁶ The hazing of medical students is in no way constructive or beneficial to anybody involved. Stress and toxicity in the learning environment prevents students from being themselves and asking questions, thus damaging their confidence during the formative years of their training.⁷

Even more alarming is that mistreatment is more commonly directed towards minority students, including female, underrepresented in medicine, Asian, multiracial, and LGBTQ+ students, than it is toward their white, cis-gendered, heterosexual, male counterparts.⁸ In the same vein that we encourage and recruit people from minority communities to join medicine, we must be aware of the potential mistreatment they will experience and take clear, targeted steps to protect them. If we, as a community, fail at this task, then we are complicit in perpetuating the systemic inequities and inequalities that are currently prevalent in medicine.

The reality is that the culture of medicine doesn’t have to be this way. It is certain that mistreatment has been inadvertently ingrained within the culture of medical training, so attempting to address this problem feels daunting. There is a current lack of literature regarding what interventions successfully reduce mistreatment, but introspective analysis yields some steps we may take in an attempt to slowly chip away at the current social infrastructure.⁹

First and foremost, students must realize and acknowledge the negativity they have been subjected to is not ‘all in their head,’ but instead a universal and rather unfounded experience. The next step is to seek support from classmates, friendly administration, and trusted professors and physicians who can provide guidance and vouch for students’ justice. Addressing mistreatment is at its core a collaborative effort, as we cannot expect only the bravest, most outspoken students to carry this initiative to fruition. Each and every person in medicine can enjoy a role and responsibility in this endeavor. School administrations can create interventions aimed at educating faculty and students about recognizing mistreatment and the harmful effects that public humiliation can have on student learning.¹⁰ It is only when students recognize abuse and have a strong support system that they may finally gain the confidence required to be vocal against toxic behavior and speak out for both themselves and classmates. Schools can further assist efforts by ensuring students are aware of their rights in this context, and offering guaranteed protection if mistreatment does rear its head.¹¹ Current physicians may also positively contribute by gently and constructively pointing out questionable behavior among their colleagues to create a more effective learning environment. Finally, our generation of medical students is tenacious, progressive, and outspoken. We can weaken, and even break the cycle, by remembering our roots, exercising our rights, and manifesting the golden rule: to always treat others the way you want to be treated.

2020 GQ All Schools pdf. (n.d.).
Cook, F., Arora, V. M., Rasinski, K. A., Curlin, F. A., & Yoon, J. D. (2014). The Prevalence of Medical Student Mistreatment and Its Association with Burnout. Academic Medicine : Journal of the Association of American Medical Colleges, 89(5), 749–754. https://doi.org/10.1097/ACM.0000000000000204
Major, (2014). To Bully and Be Bullied: Harassment and Mistreatment in Medical Education. AMA Journal of Ethics, 16(3), 155–160. https://doi.org/10.1001/virtualmentor.2014.16.3.fred1-1403
Assessment of the Prevalence of Medical Student Mistreatment by Sex, Race/Ethnicity, and Sexual Orientation | Medical Education and Training | JAMA Internal Medicine | JAMA Network. (n.d.). Retrieved March 16, 2021, from https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2761274?guestAccessKe y=5b371de5-4978-4643-b125-f26972348616&utm_source=For_The_Media&utm_medium =referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=022420
Dyrbye, N., Thomas, M. R., Massie, F. S., Power, D. V., Eacker, A., Harper, W., Durning, S., Moutier, C., Szydlo, D. W., Novotny, P. J., Sloan, J. A., & Shanafelt, T. D. (2008). Burnout and suicidal ideation among U.S. medical students. Annals of Internal Medicine, 149(5), 334–341. https://doi.org/10.7326/0003-4819-149-5-200809020-00008
Markman, D., Soeprono, T. M., Combs, H. L., & Cosgrove, E. M. (2019). Medical student mistreatment: Understanding ‘public humiliation.’ Medical Education Online, 24(1), 1615367. https://doi.org/10.1080/10872981.2019.1615367
Full article: Exploring medical students’ barriers to reporting mistreatment during clerkships: A qualitative study. (n.d.). Retrieved March 16, 2021, from https://www.tandfonline.com/doi/full/10.1080/10872981.2018.1478170
Hasty, N., Br, M. E., ford, Lau, M. J. N., MD, & MHPE. (n.d.). It’s Time to Address Student Mistreatment. American College of Surgeons. Retrieved March 16, 2021, from https://www.facs.org/Education/Division-of-Education/Publications/RISE/articles/student- mistreatment
Markman, D., Soeprono, T. M., Combs, H. L., & Cosgrove, E. M. (2019). Medical student mistreatment: Understanding ‘public humiliation.’ Medical Education Online, 24(1), 1615367. https://doi.org/10.1080/10872981.2019.1615367
Stone, J. P., Charette, J. H., McPhalen, D. F., & Temple-Oberle, C. (2015). Under the Knife: Medical Student Perceptions of Intimidation and Journal of Surgical Education, 72(4), 749–753. https://doi.org/10.1016/j.jsurg.2015.02.003
Mazer, M., Bereknyei Merrell, S., Hasty, B. N., Stave, C., & Lau, J. N. (2018). Assessment of Programs Aimed to Decrease or Prevent Mistreatment of Medical Trainees. JAMA Network Open, 1(3), e180870–e180870. https://doi.org/10.1001/jamanetworkopen.2018.0870

Culture binds together the building blocks of our identity. It defines the paths we choose to walk, the people we seek to befriend, and the meaning we place upon our lives.

It is present at every job interview, every birthday, every heartbreak and every wedding. It is the voice in our ear that cautions us when we go against our values, the shoulder that nudges us with soft hands towards tradition. Whether we choose to acknowledge it or not, the fact remains that something so vital to our being also forms the roots of nourishment and support during the most trying times of our lives: ill health.

Think of the word “culture”, and many definitions come to mind. For some, it is a cage; bars that stow rigid beliefs and deep lines of division in the sands. For others, it is a sweet reminder of their childhood, their distant family. A link to their ancestors perhaps, or a nod to the countless sacrifices that so many generations past have made.

Clearly, culture is not a gleaming jewel in itself. There are walls that culture can build – stereotypes, divisions, segregation and war to name but a few. And we must be aware, in this ever-increasingly globalized world, that cultures are not typically singular. Families immigrate and pick up traditions and values as they plant their new lives upon fertile soil. Our beliefs about ourselves and those around us continue to change and transform as we step outside of our boroughs and breathe in new air. It is this mixing of values and beliefs that can help form ties with traditions long lost, offering diversity and different ways of looking at life. For example, Bhui (2011) found that there was a high risk of suicide in South Asian women, but this risk was attenuated when these women were born in the UK. What is it about growing up in the UK that has an impact upon such a profound decision? Or indeed, what is it about growing up in South Asia that directs people down the path of self-destruction? If culture can have an impact on such a deep level, perhaps it is something worth examining.

Are we looking after a sick body or a sick society?

Culture teaches us how to speak, how to act, how to think and how to breathe. The range of emotion we express to our friends, our family and to the public at large is limited by the boundaries of by our cultural habitats. Some cultures place emphasis on dignity and self-reservation – of being stoic in times of difficulty. Others may open arms wide, taking in grief and self-loathing, pity and joy, stirring these feelings into a melting pot of human life, rich in colour. The more we learn about our culture, the more we learn about ourselves – the way we think, what we think, why we think the things we think. Not only is this important for us as individuals, allowing us to grow and change, but it is also important for us as clinicians, when we are charged with the task of rebuilding and restoring these things when they inevitably fall apart.

We, as healthcare professionals may continue to learn from our textbooks about drugs and their effects, but in a world transformed by increased living, both quantitatively and qualitatively, perhaps it is no longer drugs that matter to our patients, but how we choose to approach our decaying bodies.

It is culture that shapes the way we face our woes and despairs. During the moments of agony, of aches and pains, it is culture that provides the lens through which we view ourselves. Do we remain stoical, chuckling heartily at the jokes juggled around by the nursing staff, or do we sit down with our head in our hands, so consumed by our grief that our need to wear a mask is but a luxury of a world far away. In the end, it is up to the doctor, the nurse, the healthcare professional to explore and understand how it is the patient views themselves, their body and the world around them. We can do this gently, by probing into the innermost recesses of our patients’ lives – encouraging a conversation, engaging in questions that touch at the heart of the person:

What do you do to stay healthy?

What does illness mean to you?

Who are your social supports?

How do you view doctors and medications?

We must remember that medicine is not a dogma upon which we pontificate. People may have differing beliefs about their illness, and in the end, these may be the only things left to tie their hopes to. For example, some people in India may use karma to explain illness, underlying their deeply religious and spiritual background (Fernando 2012). In the Western nations, where society has gradually built its walls between thyself and thy neighbours, people may return to their GP again and again with vague complaints, when the underlying problem may be psychosocial. This idea is illustrated beautifully in the following blog post: https://abetternhs.wordpress.com/2013/05/04/loneliness/

Although bodies have signs and symptoms, only people become sick.

Nichter 2010 described five expressions of idioms of distress:

Medicine-taking behaviour: requests for prescriptions, self-medication
Biomedical disease nomenclature: associating distress with disease
Diagnostic tests: expressing distress to others by taking tests
Healthcare-seeking: searching for a practitioner and a diagnosis
Changes in consumption patterns: e.g. increased smoking – distress communicated nonverbally

As we can see, people seek help for a variety of reasons. It may not be as simple as a quest for a prescription, for a scan or a blood test. By focusing only upon these rigid scientific measurements, you lose what it means to be a patient – to suffer. This is a loss not only for the patient, but for the clinician and for the healthcare system. When the physician becomes a robot, with an ever-increasing checklist to tick through, or list of procedures to complete, the vital relationship between doctor and patient is lost. This is the relationship upon which lies the patient’s hopes, fears, trust, and beliefs. When this relationship begins to wither, with it goes compliance and faith in the healthcare system – the willingness to step in front of a clinician and say ‘I need help.’

Of course, taking into account such a colossal term as ‘culture’ and applying it to each and every patient, one after another, day in day out, is not an easy task. Try as we may, the largest part of our curriculum is based on the medications we administer, the scans we perform, the blood tests we order. Our training in the scientific and technical fields gives us our title and our role. It takes a lot of courage, determination and compassion to go beyond these components of the therapeutic relationship, and explore our patients as whole persons with equal parts body, mind, and spirit. To help expand upon this, Blumhagen (1962) cited in Parry (1984) compiled some sample questions:

What do you think has caused your problem?

Why do you think it started when it did?

How severe do you think your illness is?

What do you fear most about your illness?

What are the chief problems your illness has caused for you?

What are the most important results you hope to get from treatment?

The Culture of Healthcare

I have spoken much about the cultures in which our patients present themselves. However, we too are human beings, which means we too are subject to cultural conditioning. We are part of the culture of healthcare, which has biases all its own. In a world that has become and continues to become transformed by multiculturalism, it can be easy for doctors to feel alienated from patients. After all, we cannot hold the same beliefs as every single one of our patients. It is not similarity of beliefs that is required, but an understanding and an appreciation. What patients want isn’t a parrot to recite back their own ideals, but a person who is able to accept the world in which they reside, respecting the decisions they make with an appreciation of the diversity of human life. And perhaps, through this understanding, a truly patient-centered approach can be adopted, in which it is the patient’s belief that takes precedent, and not those written down in a textbook by a retired professor. To reach this level, there is but one obstacle: ourselves. We need to become aware of our own biases –what makes us tick, what prejudices we hold, what makes us squirm, what opens our heart and makes it beat. Once we begin to learn more about ourselves, we can then take the step to learn more about our patients and the lives they lead.

If we do not take these steps to gain a greater understanding of our own being, then the outcome can only be confusion, unease and distress. One example of this is the release of the National Mental Health Program in 2002 by the Indian government, which placed emphasis on psychotropic medication. Jain and Jadhav (2009) argued that this focus on medication silenced the voices of the community. They noticed that social workers in rural villages took histories of patients, decontextualizing the symptoms into a list from which the doctors could make a diagnosis. The symptoms of the patients were seen through a biomedical lens, and clinical dialogues were structured around compliance. The medication eventually served as a boundary, with psychologists and social workers seen as assistant doctors– the power lying in the hands of the prescribers. The clinicians were alienated from the daily lives of their patients, ignoring the idioms used by their patients to describe their suffering.

What do we do?

Although physicians may memorize lists of cultural attributes, we must not forget the individuality of each patient. Families can adopt new values that may not always be tied to their heritage. Alas, culture is an ever-sticky concept – yet if it were anything else it would not be human.

So what can we do? We can acknowledge the person sitting in front of us in their entirety. We can become aware of any judgments that may cross our mind, and fix our eye on the person with open curiosity. We can learn from our patients, and allow them to teach us how we can best help them. They are the experts in the room.

References

Bhui, K. 2002. Explanatory models for mental distress: implications for clinical practice and research. The British Journal of Psychiatry. 181:6-7

Bhui, K. 2011. Cultural psychiatry and epidemiology: Researching the means, methods and meanings. Transcultural Psychiatry. 48:90-103

Campbell, C., Burgess, R. 2012. The role of communities in advancing the goals of the Movement for Global Mental Health. Transcultural Psychiatry. 49: 379-395

Chau, R.C.M., Yu, S.W.K., Tran, C.T.L. 2010. The diversity based approach to culturally sensitive practices. International Social Work. 54:21-33

Fernando, G.A. 2012. The roads less traveled: Mapping some pathways on the global mental health research roadmap. Transcultural Psychiatry. 49:396-417

Ganzer, C., Ornstein, E.D. 2002. A sea of trouble: A relational approach to the culturally sensitive treatment of a severly disturbed client. Clinical Social Work Journal. 30:127-144

Jain, S., Jadhav, S. 2009. Pills that swallow policy: clinical ethnography of a community mental health program in Northern India. Transcultural Psychiatry.46:60-85

Kleinman, A., Benson, P. 2006. Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix It. PLOS Medicine. 3:e294

Lee, E. A working model of cross-cultural clinical practice (CCCP). Clinical Social Work Journal. 40:23-36

Nichter, M. 2010. Idioms of Distress Revisited. Culture, Medicine and Psychiatry.34:401-416

Parry, K. 1984. Concepts from Medical Anthropology for Clinicians. Physical Therapy. 64:929-933

Swartz, L. 2012. An unruly coming of age: The benefits of discomfort for global mental health. Transcultural Psychiatry. 49:531-538

Featured image:
The palace of culture – Warsaw, Poland – Travel photography by Giuseppe Milo