Confronting Student Mistreatment and Neglect

Podcast Transcript

Dr. Tony Tizzano:

Hello, and welcome to MedEd Thread, a Cleveland Clinic Education Institute podcast that explores the latest innovations in medical education and amplifies the tremendous work of our educators across the enterprise.

Hi, welcome to today's episode of MedEd Thread. I'm your host, Dr. Tony Tizzano, Director of Student and Lerner Health and Assistant Clinical Professor of Surgery here at Cleveland Clinic in Cleveland, Ohio. Today I'm very pleased to have Christine Warren, Associate Dean of Admissions and Student Affairs at the Cleveland Clinic Lerner College of Medicine, of Case Western Reserve University, an Associate Professor of Dermatology, along with Doctor Robert Wilson, chair of Physician Advisors at CCLCM, Director of Neurology Clerkship, and Director of the Autonomic Center in the Department of Neuromuscular Medicine at Main Campus, here to join us.

Doctor Warren, Doctor Wilson, welcome to the podcast.

Dr. Christine Warren:

Thanks for having us.

Dr. Robert Wilson:

Yeah, thank you.

Dr. Tony Tizzano:

If you would take a minute, both of you, to kind of introduce yourselves, tell us a little bit about, you know, what you do here at the Cleveland Clinic and your path thus far.

Dr. Christine Warren:

Sure. I can start. So as you mentioned, I'm the Associate Dean for Student Affairs and Admissions at the Cleveland Clinic Lerner College of Medicine, and what's unique about being in that position now, is that I am actually a graduate of the school. I was in the inaugural class of the Cleveland Clinic Lerner College of Medicine, and so for me, I have always supported our trainees at every level, but I have really a soft spot in my heart for our CCLCM students, and I am a medical dermatologist. I enjoy seeing patients with very complex dermatologic diagnoses. I'm here at the Main Campus. After graduating from school here, I did travel to some other locations for my residency training at Georgetown and D.C., and then Yale, before coming back to the Cleveland Clinic as staff.

Outside of my professional career, I'm proud to say I'm a mother of three young kids, who keep me busy and proud to be a Clevelander. True Clevelanders boomerang back, so I was born in Cleveland, left, and lived on both coasts, but of course came back to Cleveland.

Dr. Tony Tizzano:

Fabulous. And I have to say, I think having been in that inaugural class has to give you a perspective in the role that you have now that would be hard to duplicate any other way. Rob, what about you?

Dr. Robert Wilson:

Well, I've been at Cleveland Clinic now for about 10 years, and I've always had a role in education through my 20 plus years. I'm now the chair of physician advisors at the medical school here, which is a very unique role, there's probably not enough time to describe it in the time that we have, but it's mentor, coach, academic advising, and I'd say it's probably the most privileged role I've had in my career as a physician, to be part of the students' journey. And I think they make me better, and grow, and I think it helps me a better educator and maybe I always say that my role physician in education is almost we are guardians. We're medicine for the next generation. I'm also the director of the Neurology Clerkship for the medical school here, which really is teaching students about neurology, and maybe really about how to navigate patient care, communication, uncertainty, the value, the physical exam skills. I'm not from Cleveland originally. I was raised in the East Coast of Florida. I view Florida as my home state. But I truly have fallen in love with Cleveland, and winter. There's a beauty here of the seasons. I'm happy to be here.

Dr. Tony Tizzano:

We definitely have those, as we're about to see, I'm afraid.

So today's podcast focuses on medical student mistreatment and neglect, and Rob, if you would kind of get us started by sort of framing that topic, and maybe with some definitions.

Dr. Robert Wilson:

Mistreatment and neglect can be very broad and expansive. I knew we were coming here today and I was trying to do some preparation work, and I think the key is how we talked about that, maybe willing to be fluent and open and expansive. You know, one is we have a committee here that meets monthly, and I think even when we do this podcast today, we're gonna have to be very willing to maybe be expansive, and also be willing to partner up with the people that we're training, how we look at this. So I think mistreatment's also in terms of how it impacts people, how it's viewed, and the regard. There's definitely aspects of generational differences. Neglect is actually ignoring someone in their goals and achievements, and what long term impact it can be to them. And I think it's much more amorphous. So as the question's being asked, I think all of us have to be very mindful that, there's clearcut examples, you know, we hear about maybe sexual, physical harm. We have to be very willing, as we approach this topic, to be willing to talk about what may be viewed as softer, or maybe not as overtly accepted concepts as mistreatment and neglect.

Dr. Tony Tizzano:

Yeah. I would agree. And I do agree also that generational differences. I look at myself, and I look at the trainees, and I think to myself, I sometimes feel I have my finger on the pulse of things, and begin to realize very quickly, I'm not even close. And I have to re-gauge what I'm thinking.

So, Christine, you hear the invisible student mentioned, and focusing on neglect and mistreatment, and this is sort of out of some of the data coming from the Surgical Education Journal. And I wonder how you would comment around that.

Dr. Christine Warren:

Well, students, unfortunately, can find themselves in learning environments where they are ignored. It's as if they are not even in the room, or engaged in participating in the care of a patient. And this is something that I think previously was not recognized as much, that neglect as a form of mistreatment, but as our services become busier, as the stress level increases in many different areas of medicine and surgery, I can say that I do see that neglect aspect increasing. And that, of course, contributes to students feeling like they're not part of the team, that they really don't have a role on the team or they perhaps don't have the skills necessary to contribute, or the knowledge to contribute. And that impacts their confidence level, their feeling of whether or not they made the right decision in going into medicine, and even it could change their career goals or aspirations. A bad experience on a clerkship can completely change the trajectory of their future.

Dr. Tony Tizzano:

Yeah, I certainly have a sense of that. You know, not here, but at another venue, students were talking about their surgical clerkship. And one said, "You know, I don't even know if there was value to me even doing it. I would've been better off had I just been at home and studied." And I thought, "Wow." And then all of a sudden, the remainder of the group chimed in, "Yeah, we feel about the same way." And I think surgery is one of those tough areas, because it's changed. Surgery's become very much of it is endoscopic, so you're not at the table holding a retractor, looking into an incision. And so there's a tendency to be up against the wall. I think it's almost harder to train. Would you see that the same way?

Dr. Christine Warren:

I would. In some ways I think it is more difficult. I think it's really time pressures as well, to figure out how do I bring the student and incorporate them into the patient care and give them some autonomy, knowing that I then have to come in and repeat what was already done, and I only have 10 minutes to see a patient. And so in that regard, I can see that as our clinical expectations and workload is increasing, that perhaps it has become more of a challenge for educators to figure out how they can incorporate the student into the regular workflow.

Dr. Tony Tizzano:

And what's the feedback loop for that? When you have students that are on a clerkship, you know, the feedback that the, the professor or the attending physician might get. How does that work?

Dr. Robert Wilson:

In the neurology clerkship, that's a great question, because there's supposed to be this loop that students here give feedback on faculty, and as a clerkship director, I know from neurology, we meet with our students weekly to really see how they're doing, what could be done better, and to really have that interaction, because we really ask them to give us feedback in real time, you know, if something's not happening, if they're being neglected, things are not being achieved. There are certain milestones we wanna make sure that we're doing, like learning to do a neural exam, there are certainly core conditions they need to learn and see, like, multiple sclerosis, stroke, Parkinson's. If they're not seeing that, we want to know, they have my email, they have my phone number. Because we have these metrics, and we know that with time demands, especially during the COVID phase, and we're still going through things, and pressure demands, that a lot of these things might not happen. It's not because of them, there’s a lot of pressures around their teaching environments at that level.

And also, I think sometimes, or with the residents and the faculty, things are on them also for their own demands, and have to think about maybe a student can learn a different way, that they maybe not need to do everything in this aspect, there could be an opportunity for them to learn. Maybe they just need to do the physical in this one moment. And then the next opportunity is learn how to do the med review for the neurologic consultation for example. Like, tell me how these medications can make someone confused, or why they had a seizure? So really partnering up. So I think what we've learned in the neurology clerkship is how to reduce mistreatment and neglect. We have a very high score of not having mistreatment and neglect, by really just asking the students how we can do it better, and really, really revising it back in real time, really breaking down a lot of the conventional models and seeing like, how you talked about earlier about some of the old models of teaching, and saying what was ineffective. We don't want them home. We want them there.

Dr. Tony Tizzano:

Sure. So it sounds like you're really trying to foster kind of a bi-directional communication between students and faculty.

Dr. Robert Wilson:

Oh yeah.

Dr. Tony Tizzano:

Which is a key, and I think, you know, at whatever level of education, if you can really begin to engage individually with faculty, your teacher from high school on up, there's great value in that, and I think Lerner does a good job at building that from the perspective I have.

Dr. Robert Wilson:

We've created this culture, and I know one of the clerkships, OB/GYN, is high acute procedure-based areas where emotions are high, the patients have high expectations, same as where stroke, where minutes can make a difference of permanent deficits. The students are present. So we set the stage that, you know, things will be intense. There's pressure on you. The students know what it's gonna be like. It might be more passive, it's more educational. That we know that there's an opportunity where mistreatment and neglect can happen, we prepare everybody, the students more vulnerable. So this reduces things from happening. So we really set the stage, and even OB/GYN's been doing this work. We acknowledge this can happen in these scenarios so we prepare in advance, this sort of collaboration.

And we've created a culture saying we know in medicine, the clinical years, that these are vulnerable places. Instead of talking about mistreatment and neglect as taboo, as almost like a quality project. You know, so when things happen, let's just talk about it. How could we make this better for everybody? It's not like a, a danger zone or you did something wrong. Let's all grow together.

Dr. Tony Tizzano:

Yeah, and I think there's an opportunity there, at the beginning of a clerkship, for the attending physician and faculty to say to the students just what you've just said, that sort of sets the stage for communication back and forth. Even when it comes to micro-aggressions, for example, saying, "Look, I'm open to hearing about this and I hope in the appropriate venue, we can have a conversation around this." That immediately opens the door and sets a playing field, I think, that's important. You know, even so, I think that students are reluctant. You know, we talk about anonymity and so forth, and we hope we have ways to guarantee that. But the common response would be, "But the situation is so specific that when they hear about it, they'll know it was me. And it's an area I'm interested in." What do you do to work around that, Christine?

Dr. Christine Warren:

That is 100 percent true. Retaliation is a concern of students. Their grade, even in a pass/fail system, and they are looking ahead at their careers or letters of recommendation and concerned about raising their voice or drawing attention to the situation, or discussing it. In terms of what we do about it, to your point, talking about it as early as we can and as frequently as we can in orientation, in second year, before they go onto clerkships as well. And talk with the faculty, the residents, and the students about this, because what we're seeing is mistreatment is not just by the faculty members. It's by other trainees in the program too, fellows and residents, to other learners. Have as many options for students to report as well, so they can report it anonymously. Of course it's confidential, so that even if we're unable, I guess I should say, to loop back and talk directly to the student if it's anonymous, we at least can track it for the department or perhaps an individual, and we can reach out and provide some coaching or training to that faculty member or that resident.

Students openly tell us that there are things happening that they know have happened to their classmates, and they have not reported it, and they don't intend to report it, because of the fear surrounding this.

Dr. Tony Tizzano:

Yeah, and I would agree. I was looking at some literature from the American Association of Medical Colleges, and they talked about roughly 80 percent of mistreatment is not reported. And yet, about 39 percent of students report it. So there's a lot more than meets the eye. And I think it, perhaps, revolves around a lot of that. Do you think that, you know, setting up the stage, again, at the beginning of clerkships, saying, "Look, these things are usually not purposeful. They're usually based on maybe some implicit bias that we don't recognize." And I think it cuts both ways. A student can feel offended, but the faculty member can also be taken aback, thinking, "I did not mean that." And feel that they're in a bad spot.

Dr. Robert Wilson:

I mean, that's just the work that we do. Mostly as, as a physician advisor, that's sort of a lot of the conversations one-on-one with my own students that I have. I've had students assigned to me for over five years, and these are the intimate conversations I have with them, but in the clerkship orientation, we discuss this, and in the weekly meetings, to really try to almost thing what you're bringing up, is demystifying it, to try to change that mind space. So, you talk about mistreatment and neglect as, let's bring it forward, let's talk about it, let's not have it concealed. We'll help you through this. It might not seem like a big deal to you, but it probably is a big deal to you, because you're afraid about things like your grade, end of rotation, which might go into your dean's letter.

You know, and I think also you look at people who become doctors. These are high achievers, perfectionists, people who take care of patients are people pleasers. So that's a big thing a lot of times, this career. Nurses, doctors, APPs, psychologists. They don't wanna let people down. So there's a culture of us that will not say things. You know, we conceal, we hold on, and just will not speak up. So it's part of the issue. When I meet the students as the chair of the, of the physician advisors, I always say one of the reasons why that I meet with all of you is one of the reasons why you're here, and then they see. Perfectionism, the over-achievements, they're eager to please. So that's one of the reasons why I think people don't speak about mistreatment neglect is we just don't want to be a bother, also.

Dr. Tony Tizzano:

Yeah. Clearly I can see that. You know, and you weave into all of this social media. So, you know, there's, I always see it, there's a tendency to report or play out things in social media that seem really outrageous, and things that were really great. But the majority of us are somewhere in the middle. How do you think students reflect on that and thinking, "Boy, the good stuff isn't happening to me," or, "Boy, that's awful."

Dr. Robert Wilson:

I just know that my colleague and I, the neurology clerkship and that we really try just to talk about it as much as possible and try to make it a very common conversation, and we, our clinical cases, we talk about bias. And our patients are treated as bias, so where things will come forward more often. And we thank them and acknowledge it. And it helps.

Dr. Christine Warren:

And as we track our mistreatment reports, because that is something we do at the School of Medicine, and we report back to the School of Medicine community. Our hope is actually that over time, we'll see an increase in the mistreatment reports, knowing that they are currently under-reported, and people might think that's a little strange to say, but we have discussed this as a leadership team, and if people are reporting it more, then they are feeling more empowered to step forward. And students tend to second-guess themselves and think, "Well, maybe this is supposed to happen," or, "Maybe this is me just being overly sensitive," and on the flip side, we have faculty that say, "I went through this in my training. This is what made me who I am today and made me such a great physician." Or, "The students today are just over-sensitive and they have to get a little bit tougher to survive in this profession." And we have to find a way to bring them together.

Dr. Robert Wilson:

That builds on that whole concept of healthcare, this generational collision or collaboration. Very few careers have so many generations of Boomers, Gen X, Millennials, Gen Z coming together, where you have very intimate relationships of these different cultural beliefs in one space, and it has to be figured out together, these concepts. It needs to be hard for you to be a good doctor. It might not be accurate at that level. And I think one think that helps students out too is when the physicians who are older, generations share what they've been through also. And they realize, "Oh, wow, that has happened." And not sharing that, I need it to be hard to make me a better doctor. Maybe these things made me choose paths that impacted my career choice.

Dr. Tony Tizzano:

Sure. Boy, I can see that. I remember clearly, I hate to pick on surgery, but, you know, I remember getting sent to the library, because I couldn't answer a question, twice. But at the same time, on the other hand, when we would do rounds, this is gonna date me for sure. There was still smoking in the hospital. So, at the nurses' station, the nurse might have a cigarette dangling from her mouth, there were ashtrays, and rounds, the Chair of Surgery smoked. And when we would go to the VIP room, it was always a distinct pleasure to be able to hold his cigarette while he went in to see the patient. So, he'd hand you the cigarette and say, "Hold that upright, because I want it to burn evenly. And we'd stand in the hallway holding that cigarette, waiting to get back. And you'd look at that as perhaps a micro-aggression today, but we were proud then, like, "I got to hold the cigarette."

Dr. Robert Wilson:

Well, even these terms like micro-aggression are very confusing to different generations.

Dr. Tony Tizzano:

Yeah. I would agree. And, I've been involved in a little bit of that work here at the Clinic, so I think I have a better feel, but, you know, it's not usually purposeful. It's based on implicit bias. We're wired in such a way that these things occur. If you have that conversation ahead of time, and I'm not gonna go back there, because I think that's really perhaps one of the keys. I think, Rob, you were talking, and something I read from you, about restorative justice. And the idea that this decision-making process, where there's an offender, and I hate to use the word offender, or one of these misadventures have occurred, and the student are actually brought together. Is that something that actually happens?

Dr. Robert Wilson:

That's a rare phenomenon. I think the key is, I think what, and Christine brought this about, is the person who may be, who's done this, often you'll meet with that person, and they are often, like, "I didn't mean that." It's usually that micro-aggression, a slip, and they go, "I wanna work on this." I know in my department there's been a situation, and I spoke to this person about a comment that was made, and they're like, "Oh my god, Rob, I never meant that. And I was probably just over-exhausted, it was the hard phase of the 2020 pandemic. That was not my intent." And that person was mortified. And to this day, this person comes to me and says, like, "I still look at you, Rob, and I still think about that, and it had an impact on me." And this person's a very good educator. So, I, you know, often people don't necessarily come together, but I think a lot of times where my role would be more of the liaison, coming back to that trainee student saying, "This is what the impact has, this is what you've done, there's a lasting impact." You know? Knowing that your voice, your word, besides what you've done is help yourself, you may have had this ripple effect long term, generationally.

Dr. Tony Tizzano:

Yeah, I could certainly see that. You know, I look at Lerner at the College of Medicine, and I, I think to myself, the leadership has done such an extraordinary job at building trust, which is the platform for team work. And, you know, I knew Jim Young pretty well, but Isaacson I've gotten to know pretty well. And I'm looking at the leadership there, I feel like there is a transparency that I didn't see when I was in training, and Christine, comment on that, because I think that is really the fertile soil for all of this to develop.

Dr. Christine Warren:

Yes, I think a key point is trust is built. It's not something that we can expect off the bat from our students or from a team. And letting them know early on that we are open to feedback, as hard as it may be to hear sometimes, that we can't work on what we don't know about or have not recognized ourselves within our learning community. And with our assessment system, based on feedback and our portfolio system and a growth mindset, I think that really sets the stage for us to be able to have those conversations.

Dr. Tony Tizzano:

Sure, and that willingness they talk about, are we are fearless organization? Can we have this exchange both ways? Do you think we are?

Dr. Christine Warren:

Mm-hmm.

Dr. Tony Tizzano:

You know, I feel that we are, and I think that's one of the things that makes us unique. So, Rob, are there actual courses for faculty that they can take?

Dr. Robert Wilson:

Yes. You know, we've been doing this CME and grand rounds to the OB/GYN clerkships. We've been on tour since 2020 on Zoom, and we have, actually, a few coming up. We deal with the Paeds, OB/GYN, we're doing the neurology. We've done it for the clerkship retreat, and we've moved the term from mistreatment neglect, so when you ask the question how to define it, it's hard to define. It's almost like professionalism. It's easier to measure when you don't see it. So we talk more about healthy workplace psychology, and so we've been doing a lot of opportunities for people to come, discuss, and teach out mistreatment neglect through that modality. And actually, a lot of people who are showing up are not the people who already know about it. Some people actually are coming, like, you know, "I've been a person who maybe has not been ideal."

Dr. Tony Tizzano:

Yeah, self-recognition is a key step, and that speaks to at least beginning to develop an environment where that comes forward. You know, you mentioned OB/GYN, and that you're partnering with them and they've had some programs surrounding this. And I think one of the things I noticed as an obstetrician gynecologist in training is our male students didn't always get, especially in the office the kind of exposure that women would get. And so I always try to make a point to be the one who approached patients, and I always wondered if that was fair, because, you know, when I go in the room and say, "You know, we've got this student, he's a male, and this is the only way they learn." But I've seen students come to our offices and find out in the week they've been there, they've only done one or two pelvic exams. So, you know, we have to work on things like that. That's not easy, and we are a teaching organization, but how do you address that and feel comfortable with the patient as well? Where's that line?

Dr. Robert Wilson:

That's a big area, mistreatment neglect, and it's sort of the next taboo, a very controversial where the patient or the patient's support people can be the use the word offender, of mistreatment neglect, and you have to sort of look at your own specialty and see where this can happen. You know, in neurology, sometimes people have compromised thinking, and tangential thinking, and you realize where a student in training can be vulnerable to that. We've had situations in neurology with our female trainees, very off-color comments, and one of our residents that was one of our students, and she reported to me some things, said, "I thank you, we're gonna deal with and talk" We dealt with it very clearly, but I think you have to realize each of your specialties where those vulnerable areas could be. And then also, you know, where that can happen. Psychiatry's dealt with that very well in their clerkship, because it's a very vulnerable area also.

Dr. Tony Tizzano:

So this has been a fabulous conversation, I'm sure there's things I've missed. For either of you, there's some things that you'd like to bring forward that we should've talked about and I neglected to?

Dr. Christine Warren:

I was just gonna add to the previous conversation about expectations and setting expectations of the faculty member and the students, and if you have expectations, you need to create that environment that the student can fulfill them, and that then leads to feedback and observation, and in the end, their assessment. If they're not given the opportunity to perform a task or a role or a skill, then how can you truly provide meaningful feedback to them?

Dr. Tony Tizzano:

Spot on.

Dr. Robert Wilson:

That's well said. And I think the other thing, when we were doing this CME for a healthy workplace, we've been seeing a lot of literature being studied and published, one was about surgery, and how we treat each other in the workplace impacts the patient care. So, people who might be disbelievers to this idea, and think it needs to be hard for the next generation for them to be good doctors, it might not be really adding up in that direction. So, there's been research about surgeons, nursing, other patient care scenarios, how we treat each other is correlating to less ideal patient outcomes.

Dr. Tony Tizzano:

Yeah. Perhaps it impacts empathy. You know? I could see that in, in a number of other factors where that would be the case.

Well, I'd like to thank you both for what I think was a very stimulating podcast and I hope our listeners enjoyed it, and we look forward to seeing you again. I think you both very much.

Dr. Christine Warren:

Thank you.

Dr. Robert Wilson:

Thank you.

Dr. Tony Tizzano:

This concludes this episode of MedEd Thread, a Cleveland Clinic Education Institute podcast. Be sure to subscribe to hear new episodes, via iTunes, Google Play, SoundCloud, Stitcher, Spotify, or wherever you get your podcasts. Until next time, thanks for listening to MedEd Thread, and please join us again soon.