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Teaching by Humiliation Needs a Healthy Dose of Humility | MDA National Student eNews

21 Oct 2015

by James Lawler

Young woman looking upset as others talk behind her back

I wrote on opinion editorial earlier this year for Fairfax on discrimination, bullying and sexual harassment in the medical profession1. The comments made by a female vascular surgeon earlier this year, regarding women in surgical training, have put this topic on the agenda of every medical student and doctor.

Among other things, I took aim at “teaching by humiliation”, proposing that it was commonplace in medical training but needed to stop.

The first comment on the article was:

I’ve been a doctor for over 40 years, l learnt and taught by humiliation and intimidation. This was an effective form of learning, after all it is people’s lives we are discussing. The student who did not know the answer one week certainly knew it by the next.

This is a common perception in medicine, particularly in the procedural specialties. In a study2 of two Australian medical schools, it seems that 74% of medical students experience teaching by humiliation. In high stress environments, doctors tend to believe that the risk of patient death means the “hierarchy” of medical training must be enforced strongly, and some believe that not doing so risks patient death.

In fact, the opposite is true. Poor communication within hospitals accounts for the overwhelming number of healthcare errors in our system. In an age where patients are treated by multidisciplinary teams rather than just individual doctors, we should be fostering environments where we encourage both doctors in training and allied health professionals to raise the issues they see in delivering patient care.

However, if the fear of retribution of reporting errors or questioning doctors who are “at the top of the totem pole” dominates the decision-making of these team members, potential mistakes go unchecked.

In essence, teaching by humiliation is about ego and enforcing order. Some doctors do not like to be questioned about their work – it’s a threat to their place at the top of the hierarchy.

As President of the Australian Medical Students’ Association, I’m a big fan of humility in leadership. Whenever I meet with my Executive team, we first “celebrate success” by talking about the wins we’ve achieved since we met last. We then “praise humility”, by bringing up instances where we made mistakes, where we admitted we were wrong, or admitted we didn’t know the answer to a question we’ve been asked – and we then deferred to someone who does.

It means that members of my team, as well as any medical student, can question the decisions I make, and question them often. It’s important, because I can make mistakes or errors of judgement – and every time someone points them out to me, I not only learn how to do things better, but I also break down any potential barriers which exist as part of the hierarchy, and remove any fear of retribution for people who question what I do.

I’m certainly no saint though. Sometimes, after a long day, when I’m tired, when I’m down and I feel vulnerable, I can be sent a critical email and feel a flash of anger: Do people understand who I am? Why do I constantly get questioned? I’ve made a decision, and people should stick to it.

Of course, when I take a deep breath and look at the bigger picture, it’s easier for me to control my emotions. I remember that I’m not perfect. I remember that even though I’m President, I’m only working to improve the experience of medical students studying in Australia. I note that every time I’m criticised or questioned, I have an opportunity to reflect on what I’m doing and make better decisions.

Again, I’ve never worked in procedural specialties – perhaps I’m idealistic. But I hope that when I’m a junior doctor I will question my supervisors, regardless of how brave I may need to be. And when I supervise other doctors and work in multidisciplinary care in the future, I hope that I will encourage people to question what I’m doing.

After all, it is patients’ lives we are talking about.

James Lawler (MDA National Member) 
Medical Student, University of Newcastle

James Lawler is the President of the Australian Medical Students’ Association (AMSA).

You can follow James on Twitter @jmslwlr.

References

  1. Lawler, J. Doctor Hierarchy Makes it Hard to Fight Sexist or Inappropriate Behaviour. Available at: smh.com.au/comment/doctor-hierarchy-makes-it-hard-to-fight-sexist-or-inappropriate-behaviour-20150407-1mfocs.html.
  2. Scott KM, Caldwell PHY, Barnes EH, Barrett J. “Teaching by Humiliation” and Mistreatment of Medical Students in Clinical Rotations: A Pilot Study. MJA 2015;203(4):185. Available at: mja.com.au/journal/2015/203/4/teaching-humiliation-and-mistreatment-medical-students-clinical-rotations-pilot?0=ip_login_no_cache%3D4efb2abfc2ccc9ea145c3793bf3e6e02.
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