A Respectful Learning Environment: Avoiding Student Mistreatment

1. A Respectful Learning Environment: Avoiding Student Mistreatment G. Anne Cather, MD Associate Dean Student Services and Professional Devolvement March 2007

2. Objectives • Discuss current national data on student mistreatment in medical school • Review the WVU SoM AAMC GQ data on student mistreatment • Analyze the SoM policy on Student Mistreatment • Identify how faculty actions influence student's learning • Explain generational differences in perceptions and actions • Define methods to create a nurturing, respectful educational atmosphere for all

3. Historical Timeline • 1988 AMA studied sexual harassment/exploitation • AMA recommended to ACGME & RRC to identify and eliminate instances of sexual harassment &/or sexual exploitation in academic and clinical training programs • “Teacher-learner relationship should be based on mutual trust, respect/responsibility, carried out in a professional manner, in a safe learning environment, that places strong focus on education, high quality patient care & ethical conduct”

4. Historical Timeline • 1990 the AAMC Graduating Questionnaire (GQ) has included questions on student mistreatment (every other yr) • Originally asked 2 questions: Sexual (30%) and racial/ethnic (12%) harassment or discrimination • Consistent results  mistreatment does occur (gender, ethnicity or sexual orientation often cited) • Slurs, favoritism, poor evals, perceived hostility, ostracized/ignored, insensitivity, denied opportunities, malicious gossip

5. Historical Timeline • 1999 LCME established a new standard on mistreatment: each medical school • Define & develop standards of conduct (teacher-learner relationship) • Develop & widely promulgate written procedures to allow students to report violations without fear of retaliation • Develop mechanisms for prompt handling of complaints • Develop educational methods aimed at preventing student mistreatment

6. Medical School Procedure must have… • A non-threatening/easily accessible mechanism to submit and process reports or allegations • A means to determine if further investigation is warranted • Equitable methods to investigate & adjudicate complaints • Guaranteed rights of due process • Appropriate protection of complainant and accused

7. Mistreatment • Alleged, perceived or real incidents of inappropriate behavior or mistreatment of individuals • Sexual harassment • Discrimination or harassment based on race, religion, ethnicity, gender, sexual orientation, physical handicap, or age • Humiliation, psychological or physical punishment • Use of grading and other forms of assessment in a punitive manner

8. Mistreatment Why? What? • Social and behavioral diversity of the students, faculty, residents & staff + the intensity of the interactions between them • Intentional or unintentional occurrence results in • disruption of the spirit of learning • breach in the integrity and trust between teacher and learner

9. WVU SoM Student Mistreatment Policy Examples of mistreatment of students may include but are not limited to: • Harassment of a sexual nature • Discrimination based on age, race, gender, faith, national or ethnic origin, disability, sexual orientation, and veteran status • Exclusion from any usual and reasonably expected educational opportunities for any reason other than the student’s performance • Any physical or verbal misconduct inflicting bodily injury or emotional harm • Requirement to perform a menial task or tasks with the intent to humiliate

10. WVU SoM Student Mistreatment Policy Reporting Procedure • The individual considering making a report of mistreatment should first, if at all possible, attempt to resolve the matter directly with the alleged offender. • Students may consult with an Associate/Assistant Dean for Student Services at any time for assistance. • Such informal consultation will be confidential, unless precluded by safety of the student or University policy and procedure. • Students have the right to report such incidents without fear of retribution or retaliation.

11. WVU SoM Student Mistreatment Policy Reporting Procedure • Should this not adequately resolve the situation a formal report may be filed in writing with an Associate/Assistant Dean (AD) for Student Services. Upon receipt of such a report the person receiving it may: • Review the situation and alleged violation with the accused, and the accused Department Chair, and if necessary then, call into session the Standards of Behavior Committee, to review the facts and make a recommendation for disciplinary action to the Dean of the School of Medicine.

12. Standards of Behavior Committee • members appointed annually by the Dean • consists of 2 BS & 4 CS faculty (2 Mgtn & 2 Chas.) & AVP for Social Justice HSC • convenes & solicits facts from the victim, the alleged perpetrator & any key witnesses • reports findings & recommendations to the AD within 10 days of the meeting • AD reviews & forwards the findings to the Dean for action.

13. SoM Policy continued • Retaliation against any member of the School community who comes forward in good faith with a complaint will not be tolerated. Such action will be cause for disciplinary action under this policy as a separate incident of mistreatment. • A student alleging sexual harassment or unlawful discrimination will ordinarily be referred to the HSC Office for Social Justice. • Phone numbers • Student Services 293-2408 • Social Justice: 293-1651

14. Early studies • 10 schools, 581 returned surveys (59% response) • 96.5% reported at least 1 perceived mistreatment/harassment • Majority were psychological- publicly humiliated or belittled • 55% sexual harassment • 54% someone taking credit for their work • Source: Residents (85%) Faculty (79%) West J Med. 1991 August; 155(2): 140–145.

15. Student Mistreatment Perception trends GQ ’96 vs.‘99 • Reported denied opportunities due to gender • 4.38.7% • Subject to racial/ethnically offensive remarks • 3.8% 7.2% • Believe lower evals were due to sexual orientation • .4%  .8% • Reported mistreatment incidents • 27%  12% (Dean 17% 4%: Faculty 26% 7%) Contemporary Issues in Medical Education July/Aug 2000 Vol 3 No 4

16. AAMC 2003 GQ- 125 schools • #1 form of medical student mistreatment public humiliation or belittling 59.6% (>1X) • clinical hospital faculty or house staff most common source • 12 % subjected to racially/ethnically offensive remarks or names directed at them personally (>1X) • Fear of reprisal was the most common reason not to report an episode of mistreatment (47%) • Acts of severe abuse are much less common now than a decade ago

17. GQ 2000 & 2005

18. Often not want to pursue, just want it to stop GQ 2000 & 2005

19. Consequence of mistreatment • Wide ranging and well documented • Headaches, memory loss, post-traumatic stress • Workplace mistreatment: • ↓worker productivity • ↑employee turnover • Psychological mistreatment research in educational settings • ↓ levels of self-esteem • ↑ levels of stress

20. Negative Interactions with Faculty: Graduate Student Experiences • 138 students Wayne State University looked at 4 scales • Negative Incidents • Measure Coping with Harassment Scale • Intention to Turnover Scale • General Health Questionnaire Jagatic & Keashly, Conflict in Management Higher Education Report Vol 1, No 3 Aug/Sept 2000

21. Mistreatment (WSU) • Mistreatment behaviors reported students were primarily neglectful • Little /no feedback • No guidance • No clearly defined goals, despite repeated requests • Lack of concern for progress • May be as damaging as more overtly hostile behaviors

22. Coping (WSU) • Coping mechanisms are different based on the type of mistreatment. • Talking to friends/family was the most frequent coping response for both minor and major incidents • Otherwise coping responses differed for minor and major incidents • Emotion focused coping (managing emotions internally vs. outward action about the problem) was used for minor negative incidents most often. • Problem-focused coping (solving the problem directly) was used for major negative incidents.

23. Talk to friends and family about it** Ignore it Tell the professor how I feel about the situation** Assume there is some explanation for the behavior which I don't understand Try to forget the whole thing Tell myself it is not really important Talk to my advisor or another faculty member about it** Treat it like a joke Talk to the chair of the department or the dean** Arrange things so that I do not have to deal with the professor** Assume the professor doesn't know any better Take someone with me if I have to see him or her** Make a formal complaint** Accept that it is part of being a student Seek legal advice or counsel** Blame myself for what happened MINOR

24. Talk to friends and family about it ** Talk to my advisor or another faculty member about it ** Talk to my advisor or another faculty member about it ** Make a formal complaint ** Tell the professor how I feel about the situation ** Seek legal advice or counsel ** Take someone with me if I have to see him or her ** Arrange things so that I do not have to deal with the professor ** Assume there is some explanation for the behavior which I don't understand Try to forget the whole thing Ignore it Tell myself it is not really important Treat it like a joke Assume the professor doesn't know any better Accept that it is part of being a student MAJOR

25. Intention to Leave and General Health (WSU) • The greater the frequency of mistreatment the stronger the intention to leave the program and the university in general • Students' general health was negatively affected by mistreatment.

26. Gender Discrimination & Sexual Harassment • MS4s at 12 schools asked for written descriptions of personal experiences 290 wrote 313 descriptions perceived as discriminating or harassing • 7 response categories: educational inequalities; stereotypical comments; sexual overtures; offensive, embarrassing, or sexually explicit comments; inappropriate touching; sexist remarks; not classifiable Witte, etal. Acad Med Vol 80, No7, July 2006

27. Gender Discrimination & Sexual Harassment • Educational inequalities most frequent & more frequently reported by men (often OB-GYN) • All other categories of experiences were more frequently reported by women • Formal antiharassment policies should provide examples of unacceptable behavior based on examples

28. Gender Discrimination & Sexual Harassment- examples • Educational inequalities: differences in training environment between men and women • Stereotypical comments: women should be nurses rather than doctors: a students gender would prevent him/her from doing well; women aren’t as smart as men (pea sized brains, fluff in their heads); • Sexual overtures: request for dates, requests for sexual contact; kiss a hand • Offensive, embarrassing, sexually explicit comments: usually sexually oriented joke or comments about genitalia

29. Gender Discrimination & Sexual Harassment- examples • Inappropriate touching; unwanted physical contact, often breasts or buttocks • Sexist remarks: refer to a female student as “honey” “babe” or “girl” “good little girl”

30. Mistreatment of university students most common during medical studies • Humiliation and contempt (40%), negative or disparaging remarks (34%), yelling and shouting (23%), sexual harassment and other forms of gender-based mistreatment (17%) and tasks assigned as punishment (13%) • Females more commonly reported mistreatment than males; and were more disturbed by it. • 51% females & 46% males reported having experienced mistreatment from fellow students at least once • 25% of the females & 19% of the males reported contempt, humiliation & derogatory remarks concerning the career chosen; & for students taking credit for someone else's work Rautio, BMC Med Educ. 2005; 5: 36.

31. Student Treatment on Clerkships Based on Their Specialty Interests • MS4 students at 6 schools; 75% response rate • Mistreatment triggered by clinical interests = 2X national rates for mistreatment triggered by race or sex • Primary care students mistreatment < focused specialty • Common: • hearing deprecating comments about their interests • being denied learning opportunities • receiving lower evaluations • being discouraged from pursing their interests • needing to be evasive for self-protection • some clerkships & types of teachers were special problem sources. Woolley, et.al. Teaching and Learning in Medicine 2006, Vol. 18, No. 3, Pages 237-243

32. Does exposure to Gender Discrimination & Sexual Harassment affect Specialty Choice? • 14 public and private schools • Students reported frequency of GD/SH & assessed impact on choices (none, little, some, quite a bit, deciding factor) • 83% men, 93% women experienced, observed or heard of at least 1 incident (personally 10% men, 27% women) • Women who reported experiences said GD/SH influenced their specialty choice (45% vs 16%) and residency rankings (25% vs 11%) than men • Women experienced GD/SH most in general surgery, men in OBGYN • Top 4: OBGYN, General Surgery, Emergency Medicine, Pediatrics Stratton, et al, Acad MedVol 80, No 4, April 2005

33. Differences in Clinical Experiences Based on Gender • Family medicine clerkship, 451 MS3 students • Majority of skills, no gender differences • Women received more experience with 7/12 female- specific skills: Men received more experience with 2/3 male-specific skills • Women preceptors more likely to provide female-specific skills: Men preceptors provided more experiences with procedures • Highest level of exper. students in pairs and preceptor all of same gender. Lowest levels 1 student and opposite gender preceptor. Levy, et al, Acad Med Vol 77, No 12, Dec 2002

34. The Nexters 1980-2000 • Core Values: optimism, civic duty, confidence, achievement, sociability, morality, diversity • Trends: child focus, technology, stress, busy, over-planned • Assets: collective action, optimism, tenacity, multitasking capabilities, technology savvy • Liabilities: need supervision & structure, inexperienced (esp. with handling difficult people issues) Generations at Work, Zemke et al, 2000

35. Nexters • Veterans (1922-1943) “good manners, smart critters, need to toughen up, they watch too much tv (with crude language & violence)” • Boomers (1943-1960) “cute, need, more discipline from their parents, can set the time on the VCR, need to learn to entertain themselves, they need too much attention, can they do my webpage for me?” • GenXers (1960-1980) “another self-absorbed generation of spoiled brats”

36. Nexters: Messages to Motivateor How to Handle with Care • “You’ll be working with other bright, creative people” • “You and your coworkers can help turn this company around. You can be a hero here.” • Budget plenty of time for orienting, Create a clear picture of the work environment. Learn about their personal goals. • No preconceived notions about traditional gender roles – they are gender benders • Potential for conflicts between Nexters and GenXers- big gaps. Nexters will work well with mentors, especially more seasoned people.

37. Agree that treating others with respect is what its all about Legitimatize the issue by a statement from the Dean Review school GQ data qoyr Establish a committee to define abuse & establish Standard of Conduct Focus on respect for the teacher and learner roles Think (+) how to treat others with respect rather than (-) punitive 7. Everyone needs to know the rules Everyone should be held to the same standards Have a fair adjudication process- someone will err View this as the “appropriate culture”. Be a leader. Spread the word. Develop ongoing educational programs that assume everyone wants to treat everyone with respect Provide for evaluation and continual improvement of ongoing programs 12 Steps to SUCCESS