A New Tool to Report Medical Trainee Mistreatment Reveals Thorny Issues

With the introduction of an online tool at an academic medical center, trainees there were able to report incidents of mistreatment and show that a small number of faculty were responsible for the bulk of unprofessional behavior, according to a cohort study.

From a pool of 4,200 medical students, residents, clinical fellows, graduate students, and postdoctoral fellows at Mount Sinai Health System in New York City, there were 196 reports submitted to the institution’s novel reporting system from its launch in October of 2019 to December 2021.

Nearly 90% of the reports described unprofessional interactions, and over 60% described behavior from faculty. Under 1% of the 2,900 faculty members who interact with trainees accounted for half of the reports describing unprofessional behavior, reported I. Michael Leitman, MD, a surgeon and graduate medical education dean at Icahn School of Medicine at Mount Sinai, and colleagues in JAMA Network Open.

The most common reported behaviors were related to:

• Public embarrassment or humiliation (54.9%)
• Offensive remarks related to gender, sexual orientation, national origin, race, color, or religion (32.9%)
• Denial of opportunities like training or rewards on the basis of membership in a protected group (9.2%)

The vast majority of the reports (94%) were handled by a discussion with the subject. Ten reports were escalated to a written warning or change in duties, and 14 reported faculty were referred for a physician wellness evaluation.

“We continue to be challenged by a perception, particularly among some students, arguably more so among graduate students as well as postdoctoral trainees, that the system is inaccessible, that nothing will be done, and that it is not safe to report these behaviors. Concerns about retaliation and psychological safety might discourage reporting,” Leitman’s group wrote.

“We managed to overcome initial substantial resistance to explicitly acknowledging and addressing mistreatment and unprofessional behaviors directed at trainees,” the authors added, noting that buy-in from stakeholders in developing and implementing the online reporting tool “has allowed us to begin shifting the mental models that are at the heart of historical inertia related to mistreatment.”

Research has found that mistreatment of medical trainees is both prevalent and has negative consequences for mental health and performance.

Mount Sinai’s reporting tool was based on the Association of American Medical Colleges (AAMC) definition of mistreatment. People using the tool could report anonymously, or delay action on the report to reduce fears of retaliation.

Residents and fellows were the most frequent reporters, at 55.5% of all reports. Complaints were directed at faculty in 61.3% of cases and residents and fellows in 13.9%. The majority of negative feedback was centered around just 20 faculty members.

To have so few members of faculty responsible for so much of the negative feedback is notable — but perhaps not surprising, according to Bryan Carmody, MD, a pediatric nephrologist at Children’s Hospital of The King’s Daughters in Norfolk, Virginia, and an advocate for medical students, who was not involved in the study.

“My feeling is that, at most institutions, who the problem faculty are is no secret,” he told MedPage Today. “The issue is that they’re powerful — and anyone in a position to do something about their behavior knows that they can’t go off half-cocked.”

Mount Sinai was initially motivated to create a professional accountability system after an analysis of data collected for accreditation showed “greater than national average mistreatment incidents directed at trainees, lower than national average reporting and awareness of policies, and fear of retaliation,” according to Leitman and colleagues.

Leading up to the implementation of the new tool, a group of stakeholder representatives met for 12 months and designed the feedback form and protocol for triaging reports, providing feedback, disclosing aggregate data publicly, and addressing problems via remediation, formal investigation, or disciplinary action.

Participants could also submit positive experience reports, and did so in 14 reports.

Carmody pointed out that around 20 to 30 reports were submitted in most quarters of 2021, amounting to a report every 3 to 4 days at Mount Sinai.

“Even this represents some fraction of the reportable incidents that occurred,” he said. “Some institutions may think they don’t have a problem with trainee mistreatment — but this goes to show that if you make it easier to hear about bad behavior, you’ll hear about it.”

For the present study, the authors counted 2,900 faculty that interact with trainees, 600 medical students, 2,600 residents and clinical fellows, and over 1,000 graduate students and postdoctoral fellows across Mount Sinai Health System’s medical school, eight teaching hospitals, and over 400 ambulatory practices.

In reporting negative feedback, more reporters remained anonymous (60.1%) than self-identified (39.9%). The reverse was true for positive feedback (60.9% identified vs 39.1% anonymous).

Overall, medical students were aware of policies and procedures for reporting, but fewer actually reported them.

Although an estimated 35.7% of Mount Sinai medical students indicating experience with mistreatment subsequently reported it — higher than the national average at 27.3% — only 33.3% of medical students were satisfied or very satisfied with outcomes of reporting. This is better than in past years, but worse than the national average of 46.3%.

However, student satisfaction scores were hard to evaluate because the authors extrapolated from the AAMC Graduate Questionnaire but did not survey trainees before and after implementing the reporting tool.

Other limitations of the present analysis include not having a method to track patterns of behavior across departments or within different categories of trainees. The study was also conducted in a single, urban institution, and may have limited generalizability.