The AAFP condemns mistreatment of learners in any form and promotes an inclusive and equitable learning environment for everyone. Mistreatment can be intentional or unintentional, and it occurs when behavior shows disrespect for the dignity of others and unreasonably interferes with the learning process.1 Despite substantial efforts to inform and address the mistreatment of learners by peers, patients, educators, and institutional leaders, it is still prevalent in medical education, especially for learners who represent groups underrepresented in medicine (UIM).
To comprehensively address this problem, it is vital to recognize, address, and prevent mistreatment of learners at all stages of their educational experience and from all potential sources and not overlook that educators and leaders in medical education also experience mistreatment.
The AAFP believes that medical schools, family medicine residencies, and other educational institutions should consider three priority areas affecting learner mistreatment – culture, representation, and curriculum.
The culture of mistreatment spans all spaces learners occupy, includes the hierarchy of medical education, and can only change by viewing all aspects of education through an anti-oppressive, anti-harm lens.
Representation of diverse groups at all levels and in all medical education spaces can enhance learning, decrease learner isolation and imposter syndrome, minimize mistreatment, and ultimately lead to better patient outcomes.
Curricula without racially biased content can diminish implicit and explicit bias and UIM learner mistreatment by peers, educators, and leaders. Likewise, equitable learner assessment and evaluation can eliminate potential structural, interpersonal, and implicit bias throughout medical education.
The AAFP supports each institution using a change management framework that identifies opportunities to rectify existing ideological, institutional, interpersonal, and internalized learner oppression to significantly reduce learner mistreatment and create an inclusive learning environment. Failing to address a singular level of oppression perpetuates learner mistreatment and fails to achieve the overhaul our medical education system needs in this realm. Long-term positive change can be accomplished through regularly assessing and monitoring learner, educator, and leader perceptions of inclusivity.
Since 1996, the AAFP’s policy on discrimination in resident and student education has condemned discrimination "in any form, including but not limited to, that on the basis of actual or perceived race, religion, color, natural origin, ethnic affiliation, sex, sexual orientation, gender expression, gender identity, age, mental health, physical health, disability, pregnancy, body habits, socioeconomic status, or geographic location of training."2
Despite 25 years of discussion, increased awareness, and a strong desire to address the issue, discrimination within medical education persists today at surprisingly high levels, has not declined over time, and occurs in more forms than previously recognized.3,4 A meta-analysis found that 59% of medical trainees experienced at least one form of harassment or discrimination during their training, with verbal harassment being the most common.5 Learners and educators are more likely to be discriminated against if they identify as female and/or as LGBTQ+.5,6 Medical consultants are the most common source of harassment and discrimination (34%), followed by patients or their families (22%).5
Recent data from the Association of American Medical Colleges (AAMC) Graduation Questionnaire highlights student reporting of the following mistreatment occurring during their undergraduate medical education experience7:
These figures are an increase compared to prior years.7 Students and residents must be provided the tools to respond to and act upon mistreatment experienced or witnessed by their peers, educators, leaders, and patients.
For medical education to progress into a more inclusive, supportive, and effective discipline, all educators and leaders must learn ways to correct the mistreatment of learners at all levels. A comprehensive, system-wide approach is required to create meaningful change. This includes strategies directed towards the formal curriculum in medical institutions and its hidden curriculum (i.e., the aspects of medical learners’ experience outside the traditional classroom/didactic learning environments).8 A more equitable and just learning environment for everyone can occur only by addressing mistreatment at all levels of the formal and hidden curriculum, including classroom education, clinical education, administrative training, environmental aspects, and human elements.9
Definitions of Mistreatment
According to the American Medical Association (AMA), “mistreatment, either intentional or unintentional, occurs when behavior shows disrespect for the dignity of others and unreasonably interferes with the learning process. Examples of mistreatment include sexual harassment; discrimination or harassment based on race, religion, ethnicity, gender, or sexual orientation; humiliation; psychological or physical punishment; and grading and other forms of assessment in a punitive manner."1
Mistreatment refers to a learner experiencing abuse, which has varying definitions depending on the learner, context, situation, and other factors.4 Each definition is valid and contextual to the learner's situation at that time.
Defining Learner, Educator, and Leader in Medical Education
Learner refers to the person being taught in the curricular experience (i.e., medical student, resident, fellow, new physician needing support or proctoring). An educator is the individual teaching (i.e., peer, resident, faculty, preceptor, experienced colleague) and is responsible for ensuring the learner's environment is physically and psychologically safe and free from mistreatment. A leader is in a position of influence or power and provides direction for learners, educators, and the entire medical team. Leaders take on the responsibility of helping others achieve a shared purpose, which is true in various ways in health care.10
Position Paper Framework
This position paper provides recommendations to recognize, address, and prevent mistreatment of learners at all stages of experience in medical education. This is not to say that educators and leaders do not experience mistreatment and injustice. However, typically mistreatment is directly and indirectly linked to the learner and will be the focus of this paper.
Learners in groups UIM are more commonly exposed to mistreatment.11 Better patient care is provided to patients when there is greater concordance with personal and cultural attributes, which requires increasing diversity.8 Mistreatment negatively impacts the creation of a diverse workforce. Thus, it is imperative to address mistreatment in medical education and bolster efforts to improve diversity in health care.12
This position paper follows an evidence-based framework focused on three priority areas affecting mistreatment in medical education – culture, representation, and curriculum.13 It provides background information on the issues and challenges within each focus area, recommendations to implement at institutions, and an exploration of what is possible if these focus areas are addressed.
Before proceeding, two elements of medical education should be addressed. First, good intent is assumed for learners, educators, and leaders throughout the paper. This applies to descriptions of how medical education currently operates and recommendations for change within the current learning environment. Second, one fundamental limitation of the paper is an overall lack of published research on this topic,11 particularly when trying to identify various institutional approaches, successful initiatives, best practices, and learning lessons. Thus, conclusions are limited.
Culture in Medical Education
Trainees at all levels worldwide succumb to learning within a culture of prevalent and persistent mistreatment.14 Documenting incidences of mistreatment in medical education since the 1980s reflects the increasing need for a global, cultural focus.14 A unique challenge faced by medical education is how to address a culture of mistreatment that spans all of the spaces learners occupy and includes innumerable interactions with peers, patients, educators, and leaders.
Culture of Power, Privilege, and Mistreatment in the Learning Environment
While the medical learning environment consists of a multitude of spaces, most policy and development work focuses on three spaces that meet training requirements – standard classrooms (auditoriums, labs, didactic spaces), clinical settings (where patient care occurs), and virtual spaces (platforms where learners come together for teaching sessions from a variety of teachers).
Learning occurs within various other environments also, including, but not limited to, organized medicine, mentor interactions, peer interactions, interprofessional teams, and clinical committees. Each setting comes with its unique forms of mistreatment, ranging from ‘pimping’ to ignoring learners. Pimping refers to a general teaching style in which questions are asked of the learner more harshly than in the Socratic teaching technique. These learning spaces evolved from the ingrained culture of mistreatment in medicine and developed their unique approaches to imposing harm on learners.15
Interprofessional and intergenerational interactions are often unrecognized cultural aspects that contribute to mistreatment. In these interactions, the hidden curriculum of medical education is apparent, exhibiting the power differential between educators and learners and the control educators' have over evaluations and grades.16 Teaching culture meant to challenge learners' knowledge can be perceived as confrontational when that is often not the intent, and it runs the risk of being interpreted as verbal abuse and humiliation.9
There is an inherent hierarchy of medical education that ultimately perpetuates a cycle of mistreatment. Those mistreated in their medical training often grow to become supervising physicians who mistreat learners. We see how learners are trained to view specific specialties or professions within medicine as superior or inferior, thus framing the working and learning environment hierarchically, further dividing and ingraining power and privilege to specific medical team members. Learning how to mistreat as one was mistreated effectively may become the culture in which one is indoctrinated into medicine and carries on the power differential and mistreatment culture.4
A change in medical education culture is needed to help combat this transgenerational legacy of mistreatment.4,17 However, one barrier to culture change is that educators may not have dealt with their own trauma from mistreatment during their medical training. Subsequently, they struggle to promote a healthier learning environment.
Culture of Silence
The hierarchy in medical education can lead to a culture of silence. One study found high rates of male (86%) and female (96%) respondents witnessing the mistreatment of learners by patients, colleagues, teachers, or other providers. Yet, less than 5% of respondents formally reported these encounters.18 Those who witness or are victims of mistreatment often do not know how to report, lack time to report, follow learned powerlessness considered part of medicine, or fear reporting will lead to lack of change or retribution.16
Bystanders and victims who do not report instances of mistreatment can perpetuate the culture of mistreatment. From learners to leaders, the foundation of medical education must be viewed through an anti-oppressive, anti-harm lens supporting victims and witnesses reporting mistreatment. Otherwise, persistent ideological and institutional oppression will continue to lead to imposter syndrome, the poor performance of learners, educators, and leaders, and ultimately, student burnout19 and worse patient outcomes and poorer health of communities.
Increased diversity is associated with improved patient outcomes, communication, medication adherence, and patient satisfaction when patients are cared for by racially concordant physicians.20,21 Similarly, the representation of diverse groups in medical education enhances learning.22
Diversity in Medical Education
In medicine, diversity may refer to the inclusion of "race, ethnicity, gender, disability, social class, socioeconomic status, sexual orientation, gender identity, primary spoken language, and geographic region."21 However, a significant gap exists between the diversity of medical learners/educators and the population they serve.8
The Liaison Committee on Medical Education (LCME) and the Commission on Osteopathic College Accreditation (COCA) have medical school requirements to promote diversity and prohibit discrimination.23 However, progress in diversification has been slow. A lack of diverse learners, educators, and leaders can negatively impact learner well-being and lead to stereotype threat, where a learner has impaired performance due to fear of fulfilling negative stereotypes.21
A 2018 report from the AAMC found the majority of full-time U.S. medical school faculty identified as male, and the race and ethnicity data for faculty were 64% white, 19% Asian, 4% Black or African American, and 6% Hispanic, Latino, or of Spanish Origin.24
The percentage of 2018-2019 matriculants to medical school by racial/ethnic group was white (50%); Asian (22%); multiple race/ethnicity (10%); Black or African American (7%); Hispanic, Latino, or Spanish Origin (6%); American Indian or Alaska Native (0.2%); and Native Hawaiian or Other Pacific Islander (0.1%).24 There is insufficient data on medical educators with disabilities. However, the percentage of medical learners with disabilities is increasing.25 Despite the AAMC's inquiry about gender identity and sexual orientation as part of their matriculating school questionnaire, current sexual orientation and gender identity representation among learners and educators is unclear.
Learners from historically underrepresented groups are more likely to experience mistreatment.13 UIM students are more likely to report experiencing race-related microaggressions, feelings of burnout, and compromised learning during medical school.26 They are also more likely to report that their race adversely affected their medical education experience, citing feelings of prejudice and isolation from family and faculty.27 Increasing diversity in all areas and at all levels of medical education can help alleviate UIM learners' feelings of isolation, enhance the learning experience, and decrease learner mistreatment.28
Overall, it is essential to increase the diversity of medical learners and educators, not just for their benefit but also for patients. The health workforce must reflect the personal characteristics of those they serve. Physician-patient relationships and patient health outcomes are improved when patients and physicians have similar personal and cultural characteristics.20 Therefore, one way to alleviate health care disparities is by prioritizing increasing the diversity of the health care workforce.29
Racially Biased Curriculum
There are various curricular components to consider when addressing learner mistreatment.
One is racially biased content, which can perpetuate implicit and explicit bias and subsequent UIM learner mistreatment by peers, educators, and leaders.8
Another curricular component uses treatment algorithms and medical calculators for ‘race correction,’ which takes race into account when calculating a medical result.30 Stereotypes
about age, presumed gender, and presumed racial identity can inadvertently play a harmful role in clinical and other training experiences.8
Automatic associations and mnemonics, which can help learners remember differential diagnoses and medical treatments, may inadvertently create learning associations based on the prevalence rates of disease by race, that should not be applied to individual patients.8
Relying on stereotypes and race-based curricular content in these ways may lead to premature, incorrect, and missed diagnoses. They also train learners to see people as assumed demographic characteristics. These assumptions can lead to implicit bias and perpetuate imposter syndrome for learners of color.31
Changes in medical education curricula are eliminating these assumptions and incorporating cultural humility and diversity, equity, and inclusion (DEI) into curricula. Unfortunately, progress has been slow, evidenced by the low numbers of historically underrepresented populations enrolling in health professional schools and joining the health workforce.12 To fully address the issue, educators and leaders need to re-evaluate and unlearn how they conceptualize race and apply their lessons to the care they provide and to educate learners.29
An evaluation system is equitable when "all students have fair and impartial opportunities to learn, be evaluated, coached, graded, advanced, graduated, and selected for subsequent opportunities based on their demonstration of achievements that predict future success in the field of medicine, and that neither learning experiences nor assessments are negatively influenced by structural or interpersonal bias related to personal or social characteristics of learners or assessors."32
To achieve evaluation equity, assessments should include tools and strategies that are used for their intended purpose, measure the intended construct, yield similar results under various conditions, and are utilized similarly across settings or institutions to make decisions. The assessment tool or strategy should be practical to implement, and the assessment methods should motivate learners and drive them to focus on specific activities. The learners and educators should find the assessment tools and procedures workable and credible.32
Despite a lack of intent to discriminate, the approach to assessing learner performance in medical education can disadvantage UIM learners, prompting appropriate concern about structural and interpersonal bias in assessment.32 For example, standardized patients who are frequently a part of clinical skills evaluation can influence learners' grades, and they often do not comprise a diverse group or represent a wide demographic range.33
Curriculum evaluations allow learners and educators to give direct, candid feedback; however, obtaining a high response rate representative of the school's demographics is challenging.25 The emotional consequences for learners bridge into curriculum evaluations and necessitate change because students perceive inequitable education and assessment.25 Learners who experience mistreatment are less likely to complete assignments, including evaluations.57 The voice of these learners is inherently silenced.
A comprehensive approach to addressing mistreatment in medical education must address oppression from the ideological, institutional, interpersonal, and internalized frameworks.
Ideological oppression is a core system of beliefs or ideas that one group is better than and has the right to control another group.
Institutional oppression uses the education system, medical system, legal system, hiring policies, public policies, housing development, media images and messaging, and political power to maintain oppressive ideology.
In interpersonal oppression, individuals of a dominant group personally disrespect or mistreat those in an oppressed group, even if done subconsciously. Internalized oppression occurs when oppressed individuals internalize inferiority because of what is believed ideologically, embedded in institutions, and experienced by members of a dominant group.34
Since each framework is interrelated, they mutually reinforce one another.34 Thus, any effort to dismantle oppression must consider each framework while simultaneously working from the top- down and bottom-up to reform medical education.
Research uncovers three priority areas that significantly affect learner mistreatment – culture, representation, and curriculum. Examination of those priority areas through the lens of the four I’s of oppression (ideological, institutional, interpersonal, and internalized) supports recommended action.
Many systems, including medical education, were built upon and perpetuate ideological oppression, which becomes embedded institutionally and creates an environment with policies and procedures that perpetuate a cycle of mistreatment.35 A comprehensive approach is needed to transform the existing culture and the ideology of medical education. The hierarchy and power differential between learners, educators, and leaders must be recognized and remedied to make this transformation.36
Advancing DEI into the medical education culture requires an integrated, longitudinal approach involving individual, program, institutional/organizational, and community stakeholders.
Replacing the existing culture with one based on compassion, tolerance, and respect for learners, educators, and leaders can transform the culture and end the cycle of mistreatment.37
Institutional action steps include:
When an ideology exists that one group is superior to another, it offers individuals the security and permission to inflict personal harm on others. On an interpersonal level, education about various human perspectives can value individuals and make superiority and mistreatment unacceptable.
Interpersonal action steps include:
If medical educators fail to address the preceding levels of oppression, we will ultimately see a prevalence of internalized oppression, whereby members of an oppressed group internalize an ideology of inferiority. Negative and oppressive thoughts become internalized and are often believed to be accurate by individuals. On the opposite side of internalized oppression is internalized privilege, whereby members of those who benefit from privilege accept the narratives or stereotypes and false assumptions of oppressed groups, creating an unearned sense of entitlement. To address internalized oppression, an anti-oppression culture can help those with internalized privilege to recognize their privilege and learn how to undo the internalized beliefs, attitudes, and behaviors that propagate oppression and to be an ally to UIM groups and individuals.34
If medical educators wish to change the culture and become an inclusive environment dedicated to education and patient care and free from harassment, mistreatment, and discrimination, we must ensure that all levels of oppression are addressed. Failing to address a singular level of oppression is a failure to address oppression and a failure to overhaul the culture of medical education
In 1910, the Carnegie Foundation hired Abraham Flexner to visit 155 U.S. medical schools and study and report on five aspects of medical education in the U.S. and Canada43:
In the report, now known as the Flexner Report, Flexner concluded that African American schools were deficient, which led to the ideology that African American physicians had less potential and ability.21,44
The impact of ideological oppression catalyzed by the Flexner Report is still felt today, exemplified by the lack of representation of diverse groups in medical education at all levels and increased mistreatment of UIM learners.21 It is imperative to move beyond the Flexner Report, recognize and rectify the devastating effects it caused, and commit to an ideology where DEI is valued. The learning environment must be based on a core belief that all students have a right to respect, a culture of belonging, and engagement in the education process.37
An ideology where physicians who are not white males are seen as inferior is entrenched in medical institutions, demonstrated by institutions' histories, infrastructure, policies, learning environment, and composition. To address learner mistreatment and increase the representation of diverse groups, learners, educators, and leaders must collaborate and reinforce a shared commitment to a respectful learning and clinical care environment.45
Institutional action steps include:
There are different dimensions of the medical learning environment – psychological and behavioral.51 The psychological dimension is related to the individual. The behavioral dimension consists of general social interaction, the interaction between and among people from different racial and ethnic backgrounds, and intergroup relations.51
The quantity and quality of engagement that learners experience from diverse people, information, and ideas significantly affect the behavioral dimension. Learners who studied with someone from a different racial or ethnic background are more likely to report greater cultural awareness, greater tolerance of people with different beliefs, a greater ability to work cooperatively with others, and greater critical thinking skills.51 Conversely, when learners do not engage with people from different backgrounds, it negatively affects their views towards others and their success in key educational outcomes.51
Interpersonal action steps include:
Bias and discrimination remain a reality in medical education, leading to individual oppression. The psychological dimension of the medical learning environment includes individuals' views of group relations and institutional responses to diversity, perceptions of mistreatment, and attitudes towards other individuals from diverse groups.51 A person's position and power within the institution contribute to differing views, and their perceptions determine future interactions and educational outcomes.51
Internalized action steps include:
“Curriculum ideologies are personal beliefs about what educational institutions should teach, for what ends, and for what reasons.”52 Steps to discover and enhance the curriculum ideology should include reflecting on the current curriculum in medical education; addressing DEI and social justice issues throughout the curriculum; maintaining humility around race, orientation, and cultural beliefs; understanding how social constructs begin at the level of education and become productive allies in work towards injustice in education, remaining open to expect and accept non-closure; and committing to reflection and constant growth in curriculum guidelines and content and offering anti-bias and anti-discrimination training for all learners, educators, and leaders.13
Learners from both underrepresented and well represented groups should be exposed to the historical context and maintenance of the United States’ deeply entrenched system of structural oppression. Learners, educators, and leaders should understand how their personal and social identities significantly influence others' opportunities in the health professions.
The curriculum ideology stems from the ideals of the institution. The institution must ensure an equitable learning environment and acknowledge its own history of structural biases that impact the learning environment and the populations it serves.
Institutional action steps include:
Educators are uniquely positioned to be allies to students in their medical training. This interpersonal connection facilitates personal relationships and interpersonal working groups in learning environments to diminish the mistreatment of learners.
Interpersonal action steps include:
Internalized action steps include:
Learner mistreatment in medical education can have serious and long-lasting consequences11 and can only be eradicated with long-term positive change. Institutional change can be assessed and monitored with regular surveys about learner, educator, and leader perceptions of institutional DEI. The survey can ask about the culture, representation of diverse groups, curriculum, and questions to assess the four frameworks of oppression: ideological, institutional, interpersonal, and internalized. Results from the regular surveys can provide additional areas of focus to address learner mistreatment.
American Academy of Family Physicians (AAFP) Resident and Student Education, Discrimination In
Association of American Medical Colleges (AAMC)
Appropriate Treatment in Medicine: A Compendium on Medical Student Mistreatment
Council on Medical Education (CME)
Report of the Council on Medical Education: Student Mistreatment
(APRIL 2022 BOD) (September 2022 COD)