The Surgical Educational
Environment
Part 1:
Socrates & Halsted
Toby C Tally MD
GRU/UGA Medical Partnership, Athens, GA
Clerkship Directors Workshop
April, 2014
Goals & Objectives
• Attempt to define types of mistreatment.
• Examine teaching methods traditionally used
in surgical training.
• Discuss issues at the intersection of teaching
methods and mistreatment.
Socialization
Tacit
SECI model (Nonaka & Takeuchi 1996)
Years 1 & 2: Teaching professionalism
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Small Group Learning, 6 hours/week
Explicit expectations
Controlled, safe environment
Faculty role models (many non-MDs)
Formative and summative assessments
The Clinical Years
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New environment, new game
Don’t know the rules
Rules keep changing
Told what NOT to do.
Experiences differ from their
classmates’
• No longer all about them
AAMC GQ Definition of Mistreatment
• 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 the use of grading and other forms of
assessment in a punitive manner.
The ‘Never’ Column
AAMC GQ
• >95% checked NEVER for most – the bad ones.
• Handful in range of 85-93%
• 76.7% NEVER Publicly humiliated
• 52.8% NEVER Publicly embarrassed
The ‘Never’ Column
AAMC GQ 2013 Summary
BAD
• 76.7% NEVER Publicly humiliated
• 52.8% NEVER Publicly embarrassed
Not so
bad
Legitimacy Assessment Model of
Rationalization
Socialization.
• we teach this way because it works
– to train surgeons who can think on their feet,
– make critical decisions quickly with incomplete information.
• we teach med students this way
– to show them what surgery is about and
– see if they want to do it, and if they can.
• “There is research to suggest that some stress and anxiety
can be beneficial in learning. There appears to be a certain
level of tension and disequilibrium needed to stretch and
challenge students to learn.” [VM]
Pimping is…
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A useful training tool?
A formative assessment tool?
An initiation ritual?
Socratic teaching method + peer pressure?
Pimping
Benign Pimping
• Teaches
Malignant Pimping
• any question that was
“clearly inappropriate for
• “Encourages you to become
students’ level of
eloquent in being able to
training,” that was meant
verbalize what you have read in
to “trip students up” or
a manner you can share with
“humiliate” them, or that
your colleagues”
was asked “to make
• Identifies gaps in knowledge
students feel stupid”
• Tests how you handle pressure
Military Training
• Hazing in basic training was believed to provide
– socialization
– cohesion-building
– weeding out those unfit or unwilling to serve
• NO HAZING, but “physical and mental hardships associated
with operations or operational training do not constitute
hazing”
• “Eradications of hazing has not diminished the socialization,
camaraderie or commitment of new recruits.”
Raising children
• Why do we torture 9-year olds with thousands
of multiplication problems?
• Why do we let our children beat up on each
other?
• So they can succeed in the real world
so it is with medical students
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•
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This is the real world:
Tell them what to expect
Challenge them
Make them practice
Encourage, don’t coddle
Jessica Hagy, thisisindexed.com
• And they will learn how to handle themselves
with “good” pimping and tough love.
References
1)
Virtual Mentor: The Problem of Mistreatment in Medical Education. AMA Journal of Ethics, March 2014,
Volume 16, Number 3: 153-234
2)
Experiences of belittlement and harassment and their correlates among medical students in the United States:
longitudinal survey. Frank E, Carrera JS, Stratton T, Bickel J, Nora LM, BMJ. 2006 Sep 30;333(7570):682. Epub
2006 Sep 6. PubMed PMID: 16956894; PubMed Central PMCID: PMC1584373.
3)
‘You learn better under the gun’: intimidation and harassment in surgical education. Laura J Musselman, Helen
M MacRae, Richard K Reznick1 & Lorelei A Lingard. Blackwell Publishing Ltd 2005. MEDICAL EDUCATION 2005;
39: 926–934.
4)
Wanted: role models - medical students’ perceptions of professionalism. Anna Byszewski, Walter Hendelman,
Caroline McGuinty, Geneviève Moineau, BMC Med Educ. 2012; 12: 115. Published online 2012 November 15.
doi: 10.1186/1472-6920-12-115
5)
The relationship between verbal abuse of medical students and their confidence in their clinical abilities. M K
Schuchert, Acad Med - August 1998 (Vol. 73, Issue 8, Pages 907-9
6)
Perceived stress during undergraduate medical training: a qualitative study. Christina Radcliffe & Helen Lester,
Medical Education 2003;37:32–38
7)
Delese Wear , Margarita Kokinova , Cynthia Keck-McNulty & Julie Aultman (2005): RESEARCH BASIC TO
MEDICAL EDUCATION: Pimping: Perspectives of 4th Year Medical Students, Teaching and Learning in Medicine:
An International Journal, 17:2, 184-191