Five years ago 80% of Stellenbosch medical students said they were mistreated. What has changed?

Nearly 80% of medical students who took part in the first South African study of its kind said they had experienced mistreatment by doctors.

• A recently published study found that medical student mistreatment was highly prevalent at a South African medical school in 2018.
• Trainee doctors showed signs of high levels of psychological distress and reported the mistreatment affected their mood, their personal relationships and their studies.
• One of the researchers hopes to expand the study to cover all medical campuses across South Africa over a number of years.
• Stellenbosch University says that they have instituted a number of measures to reduce trainee doctor mistreatment in recent years.

This is the highest level of mistreatment reported in any similar study worldwide, say researchers at Stellenbosch University, who also uncovered high rates of racial and gender discrimination aimed at students in the university’s medicine and health science faculty.

The paper, published in January this year in the journal Teaching and Learning in Medicine, recorded the responses of 443 medical students to a 19-question online survey.

The researchers say the “highly prevalent” mistreatment had “significant perceived negative effects on mood and academic performance”, and they call on medical schools to be aggressive in their efforts to prevent mistreatment and provide support to students who experience it.

But they acknowledge that since the research was conducted in 2018, the situation at Stellenbosch may have improved. “Since the conduct of this study, the university has made efforts to address the findings by introducing an anti-bullying poster campaign as well as an online reporting system,” they say.

A statement from the medicine and health sciences faculty at Stellenbosch says the campaign was launched in 2021 after the study “highlighted the presence of bullying behaviour in its own training environment”.

It adds: “This anti-bullying campaign was endorsed by the South African committee of medical deans and shared with all ten medical school deans in the country.”

In a statement, the Western Cape health department says it has noted the “serious nature of the findings” in the study and taken steps to improve the environment at Tygerberg Hospital, where Stellenbosch students do their practical training.

“The department has a zero-tolerance stance towards any form of bullying, discrimination, and sexual harassment, in any form, in the workplace,” it says.

Worldwide, studies have found that trainee doctors experience more mistreatment than students in other faculties, and Stellenbosch lead author Kathleen Crombie says this may be because the medical profession relies heavily on apprentice-type learning techniques.

The hierarchical relationships involved lend themselves to abusive behaviour, she says, and “trainees may feel that they cannot speak out against abuse out of fear of punishment or discrimination”.

Crombie, now a GP in Johannesburg, conceived the research project when she was an undergraduate medical student at Stellenbosch and developed it with psychiatrist Professor Soraya Seedat.

Seedat now plans to conduct a nationwide longitudinal study “so that we can gain a better understanding of temporal patterns and track change”.

She told GroundUp: “We believe that a national survey that is inclusive of all medical campuses, of medical students across the six years of study and medical interns, and which includes qualitative interviews conducted with a subset of students/interns, will be most informative.

“I am hoping to identify a doctoral student to lead the project and to secure funding in 2023.”

The students that participated in the study were between the second and sixth years of their studies but 72% had reached the fourth year. Three in four were female.

“Overall, 78.2% (344) of medical students reported having experienced some form of mistreatment by senior doctors or other hospital staff,” says the paper. Nearly 81% of the women students reported mistreatment, compared with 71% of men.

The departments of internal medicine and surgery accounted for the largest number of cases, and mistreatment was lowest in radiology and dermatology.

A third of the students reported gender and racial discrimination, while 11 respondents said they had been sexually abused and ten said they had been physically abused.

“Overall, being ignored/excluded (83.7%) was reported as the most common form of mistreatment … followed by behavioural gestures (eye-rolling, scoffing or glaring) and verbal abuse,” says the paper. “The main themes described by students included condescending remarks, threats and fear, and discrimination.”

A doctor in the obstetrics and gynaecology department “constantly rolled her eyes, sarcastically replied to my answers and singled me out in front of patients and students”, one student wrote.

Another said: “I enter every consultant ward round with anxiety due to a system that has, over years, shaped me to fear a consultant ward round.”

Describing discrimination, students wrote about “consultants refusing to teach in English when there was just one Afrikaans-speaking person in the whole group.”

The perpetrators of mistreatment were mainly registrars and consultants, but more than half the students said they had also been targeted by nurses, clerks and hospital managers.

“Registrars were the most frequent perpetrators of mistreatment. This could be due to the fact that students work closely with registrars in the hospital and that registrars are known to experience significant levels of stress and burnout,” says the paper.

Of the 318 students who answered a question about how mistreatment affected them, 98% said it had a negative effect on their mood, 82% said it reduced their enthusiasm for a career in medicine, 70% said it demotivated them in their studies, 58% said it harmed their personal relationships and just over half said it lowered their academic performance.

The 341 students who completed a depression and anxiety screening tool had “high levels of psychological distress”, says the paper, with 61% meeting, the criteria for a mood or anxiety disorder and 42% evaluated as having severe disorders. Mistreated students had significantly more psychological distress than those who reported no mistreatment.

Three-quarters of students who were aware mistreatment had occurred to them or others did not report it. “More than half of students who reported mistreatment felt that the situation had not been dealt with effectively by the person to whom they reported it,” says the paper.

Four out of five students “were unaware of any system in place to report the mistreatment of students by senior doctors”.

More than half the students said the reason they did not report mistreatment was fear of their grades being lowered. Other prominent fears included victimisation, conflict and breaching confidentiality.

Discussing her findings, Crombie says the previous highest rate of mistreatment recorded worldwide – 61% – came from a questionnaire completed by Canadian medical graduates in 2021, and more research was needed into why the rate detected at Stellenbosch was so high.

“One can deliberate whether possible factors playing a role include the current heightened awareness of mistreatment due to social media, historical gender and racial inequalities that are still pertinent today, as well as the overburdened South African healthcare system.

“Particularly concerning in the post-apartheid context were reports of ongoing sexism and racism. It must be acknowledged that senior doctors would have grown up in that era with racial and sexual discrimination being the norm.

“This highlights, however, the need for urgent transformative measures in addressing the attitudes and behaviours of clinicians and academics.”

Yumna Moosa, who made headlines in 2016 after posting a YouTube video that included recordings of the mistreatment she experienced as a University of Cape Town medical student, says she is not surprised by Crombie’s findings.

“I had a sense that the numbers (of mistreatment cases) are high, but it’s kind of amazing to see them written down,” she says. “And I have no doubt that the situation is worse for [community service] interns because it’s just much more stressful and they’re even more vulnerable.”

Moosa says the Stellenbosch findings are “very much consistent with my experience and consistent with the idea that it is overwhelmed people who are doing the bullying. They are not able to deal with themselves, and the people around them become the collateral damage.”

After being denied her medical degree in the aftermath of her video, and appealing successfully to the Health Professions Council of SA, Moosa decided not to work as a doctor. She is completing a PhD in bioinformatics at the Africa Health Research Institute in Durban and studying tuberculosis.

But she says she is considering a return to medicine. “I have great hope for a more caring health care system to emerge, as we become more aware and make the courageous choice to heal our relationships with ourselves, our colleagues – junior and senior – and our patients,” she says.

Stellenbosch University’s statement on Crombie’s paper

Human dignity holds a central place at Stellenbosch University, and the principles of respect, equity and compassion are enshrined in its values. The university takes a strong stance against bullying or any other behaviour that violates the dignity of another person or group.

International literature has shown that the mistreatment of healthcare workers in training is a common occurrence worldwide. According to research, most instances of bullying occur in the clinical (rather than academic) environment, and most perpetrators are senior colleagues tasked with training junior healthcare workers.

In 2021, Stellenbosch University’s Faculty of Medicine and Health Sciences launched an anti-bullying awareness campaign after a study highlighted the presence of bullying behaviour in its own training environment.

The poster campaign, which was rolled out on the faculty’s social media channels, aimed to create awareness of and discourage bullying behaviour and highlighted procedures and channels for reporting complaints. This anti-bullying campaign was endorsed by the South African Committee of Medical Deans and shared with all 10 medical school deans in the country.

The faculty also launched an anti-gender-based violence task team which ran a poster and Instagram campaign and hosted a webinar and open discussion forum for staff/students.

Students and staff of Stellenbosch University have multiple options for reporting and obtaining advice regarding discrimination, harassment and bullying. These include an online system where complaints can be reported (anonymously if required), consultations with equality champions, or reporting to the Equality Unit where counselling, training and other support can be obtained. In addition, students also have access to counselling with psychologists through Student Support Services.

The Western Cape health department statement on the paper

The Western Cape Department of Health has stated clearly that it views any allegations of bullying or discrimination in a very serious light and that such behaviour will not be tolerated.

Tygerberg Hospital management and the department take note of the serious nature of the findings in this study and have embarked on additional measures to improve the hospital environment in this regard.

It is important to contextualise that medical students, while spending time in the hospital for clinical training, fall mainly under the supervision of the university. While their well-being is very important, this is to be mainly addressed via the university structures.

To support medical interns, who are registered staff members of the department, Tygerberg has a dedicated intern curator who holds regular scheduled meetings with the intern representatives, so that the intern reps are able to raise issues, challenges and concerns.
This is done without the presence of supervising medical consultants or registrars, nor the intern coordinators for each clinical discipline; this is to ensure that any matters of discrimination or bullying may be freely raised in a safe space.

For registrars, the department of medicine has set up an integrity and diversity committee. As the name suggests, there is broad representation to ensure appropriate racial and gender diversity, and an appropriate mix of registrars and consultants. Quarterly meetings are held to discuss emerging issues and these are addressed timeously and in general effectively with the relevant role players. If matters are urgent a meeting will be called on a priority, ad hoc basis.

All staff (including interns) are also eligible to use the employee wellness and assistance programme, giving them direct (as well as online) access to a range of psycho-social services and support.
Additionally, Tygerberg Hospital has a designated in-house psychologist who students, interns and registrars are able to access daily and also telephonically. There has been a significantly positive impact of this service, especially on those staff members who felt anxious and were experiencing psychological distress.

For cases of sexual harassment, there are dedicated staff trained to investigate and advise via our people management office and labour relations units. This is another important element in providing a fair and equitable working environment, which is a critical priority of the hospital’s management team.

While a hospital environment such as that of Tygerberg is by nature extremely busy and pressurised, the management of the hospital is committed to providing a human, caring and healthy environment for all who work within it.

The department has a zero-tolerance stance towards any form of bullying, discrimination, and sexual harassment, in any form, in the workplace. All employees and other persons who have dealings with the Western Cape Government health department have the right to be treated with dignity, equity, respect, and humanity.

It is clearly stated in the policy statement on sexual harassment in the workplace that the department has an obligation to protect anyone who enters its premises. The department has highlighted this stance in a circular to all labour unions and associations.

Published originally on GroundUp | By Dave Chambers