As it’s the third month of the year, let’s focus on an element from the third LCME Standard. Everyone’s favorite:

LCME Element 3.6 – Student Mistreatment

A medical school develops effective written policies that define mistreatment, has effective mechanisms in place for a prompt response to any complaints, and supports educational activities aimed at preventing mistreatment. Mechanisms for reporting mistreatment are understood by medical students, including visiting medical students, and ensure that any violations can be registered and investigated without fear of retaliation.

Hidden Curriculum

There are several things that can easily escape you when you are getting caught up in your Mistreatment GQ results.

Make sure you have incentives to “catch em when they’re good” as a fellow pediatrician once said.

Meaning – reward positive behavior in faculty (e.g., faculty awards), not just have punishments for those who aren’t behaving as you’d like.

Teach faculty about mistreatment.

So don’t wait until the year before the visit to do this. There are multiple ways to accomplish this. Deans can have Close the Loop Sessions with students; sponsor Grand Rounds in departments on Creating Positive Learning Environments; give an update at each department on the GQ and do a little teaching session – share the data widely! Get it scheduled on your CQI calendar!

Continuous Quality Improvement

CQI plans for monitoring mistreatment should including the following:

1. Specific timeline for informing students, residents, faculty, and staff at all locations about your school’s mistreatment policy and mechanisms for reporting mistreatment.  Include in the timeline a person responsible for ensuring plan is executed, e.g.  Policies and procedures for the positive and negative learning environment are provided at yearly and course/clerkship orientations, in every course/clerkship syllabus, in the student and faculty handbooks, in semi-annual emails from leadership, and annual mandatory HR training.  Include in your plan a process for providing the information to visiting students.
2. Monitor student awareness of policies & reporting procedures on end-of-course/clerkship evaluations, end-of-year evaluations, Y2Q, GQ.  Track this longitudinally in order to see if you are making progress in getting the information out.
3. Specific timeline for reporting summative data to individuals and groups on the frequency of medical students experiencing mistreatment. Be sure to document what data is being collected, who is reviewing and analyzing it, any implemented changes, and the outcomes.
4. Specific timeline for educational activities for medical students, faculty, and residents that are directed at preventing student mistreatment and creating a positive learning environment.  Be sure to document what strategies were implemented, the data collected, who is reviewing and analyzing it, any implemented changes as a result, and the outcomes.

Best Practice

We know that student reporting of mistreatment increases as students progress through medical school and enter clinical settings.  However, some students are reluctant to report mistreatment because they are worried about faculty or resident feedback on their reciprocal evaluations or potential damage to future relationships especially if interested in that specialty.  Even though direct mistreatment may not be reported, there can be clues on the overall evaluations. 

Identify a person/committee with general oversight of monitoring the learning environment.  They should read all the student feedback with eye towards comments students make about negative influences in their learning environment – including those that did not trigger a mistreatment alert.  For example, “Sometimes the energy coming from Dr. X was really negative and he made me feel disrespected. Not sure that anything can be done about this, but often the negativity was passed down onto the medical students. I want to learn but I do not want to annoy the resident who is also evaluating me.”  This comment was on the end-of-clerkship evaluation and not on the student evaluation of the resident.  The student did not state he was mistreated, so the comment could have easily been disregarded.  The resident may have never seen the comment or received this feedback because it wasn’t given to the resident in his aggregate student evaluation report. Create a tracking mechanism and document each instance of negative feedback from students on specific faculty, residents, staff or training sites.  The comment above may have been viewed as an isolated incident, but if you have longitudinal tracking, it’s much easier to identify problems, e.g. Dr. X has had five concerning comments in the last two years.  Once identified, measures can be taken to work with Dr. X to make him aware of how students perceive his behavior and develop a plan for creating a positive relationship with students.