Trash talk and childish pranks: Canadian study sheds light on the hidden culture of medicine

A new Canadian study has offered a rare glimpse inside the culture of , where psychiatrists are dismissed as “flakes,” senior doctors carry out childish pranks on the students they teach and idealism withers away in the face of the profession’s stark realities.

The research by physicians at the University of Ottawa paints a picture of the so-called hidden curriculum: the unwritten attitudes and practices that medical students and residents absorb on the path to becoming full-fledged doctors.

Some of that experience can be enriching, such as observing a compassionate doctor’s bedside manner, the researchers say. Much, though, is contrary to the medical faculties’ official principles of equality, collegiality and patient-centred care.

The authors held focus groups with students, residents and staff doctors, and heard similar observations from all the groups about medical behind the curtain.

Many reported that inappropriate behaviour by the doctors doing the teaching goes unreported and unpunished, a strict hierarchy is observed and certain specialties are routinely portrayed as inferior.

“It’s where the flakes go,” a practicing physician said of the prevailing attitude toward psychiatry.

Academic hierarchy and convenience — not patients — were at the centre of medical education, despite the official stance

The findings echo those from a growing body of research, mostly American, but also including a small 2012 Canadian study that quoted students as saying the doctors teaching them sometimes voiced disparaging views about the obese, immigrants and female physicians.

Such influences are troublesome, not least because they seem linked to a steady blunting of emotion and decrease in empathy for patients among new physicians, says Dr. Asif Doja, lead author of the Ottawa study, just published in the journal Medical Education.

Patients “don’t just want someone who has book smarts,” the neurologist said in an interview. “People want other things from their physicians too … things like empathy, like communication skills, like putting the patient first.”

In fact, the hidden curriculum has been drawing increasing attention from in and elsewhere, with the Canadian Association of Faculties of Medicine urging its members to address the issue.

Many medical schools now teach courses on professionalism, and have tried to combat the bad-mouthing of family doctors to encourage more students to become generalists.

But while some “modest inroads” have been made, dramatic change has yet to occur, maintains Dr. Sally Mahood, a family physician and University of Saskatchewan professor.

“I don’t think medical schools have yet got the message that we need to reward and show our admiration for professionalism,” she said. “We tend to still admire and reify the smart doctor who has all the right answers to the technical questions, as opposed to recognizing and reifying the doctor who is always there for the patient.”

RelatedUntrained and unemployed: Medical schools churning out doctors who can’t find residencies and full-time positionsShowing surgeons ‘massive’ cost of disposable supplies leads to big savings for hospitalsFrom virginity certificates to sweetgrass: Where -care draws the line on meeting multicultural needs

In a frank 2011 commentary, she charged that “academic hierarchy” and convenience — not patients — were at the centre of medical education, despite the official stance.

“Off-hand ridicule of patients’ weight, poverty or ethnicity can juxtapose with talk of cultural sensitivity,” she said in the 2011 article in Canadian Family Physician.

The Ottawa study, also involving the Children’s Hospital of Eastern Ontario, consisted of five focus groups where students, trainees and doctors were asked to discuss the hidden curriculum.

Most commented on the portrayal of some specialties as superior to others, and psychiatry being the most disparaged. That kind of attitude has been blamed in part for lack of interest in those fields by graduating medical students, helping fuel a shortage of both.

“People say ‘Oh, psychiatry is not real doctors, they, like, have no idea what they’re talking about,’ ” observed a resident.

A medical student noted that sub-specialists – physicians who have obtained additional training after their five-year residency — tend to think they are better and “just trash” other specialists.

Focus-group participants also reported that unprofessional behaviour by doctors was tolerated, and that they felt powerless to do anything about it.

The researchers heard about a doctor who insisted repeatedly on calling a medical student by the wrong name, even introducing him to patients by the fictitious moniker. “Then she sort of nudges me and winks at me and laughs,” the student had complained.

Oh, psychiatry is not real doctors, they, like, have no idea what they’re talking about

Such hijinks might be acceptable among peers, but not between an experienced physician and a student, said Doja.

Another student told the researchers of a doctor who “threw all of my stuff” off a desk he considered his own personal space.

Students also pick up unspoken messages from watching doctors or residents — role modeling that can be positive, but isn’t always, the study found. One doctor recalled medical-school colleagues who started adopting what they considered the character of surgeons, even before learning the technical skills of the specialty.

“You would see them walking and not paying much attention to details or not very caring about the, like the social or emotional side of a patient.”

A 2012 Queen’s University study surveyed students at three medical schools, and heard of some striking behaviour by the physicians teaching them.

More than one student said doctors referred to obesity as a moral failing. Another described a doctor introducing her to a patient by saying “this Russian girl will be doing your exam,” and explaining how to ethnically profile patients.

Others recounted sniping between specialists, surgeons saying internists were “not real doctors,” and generalists referring to well-remunerated “ear, nose and wallet” doctors.

And women “were described as unfit surgeons, both because they were assumed to lack manual skills and because they would never put surgery before parenting.”

Dr. Susan Phillips, the Queen’s professor who headed that study, stressed that most doctors mean to do well by their patients and can often be an inspiration to students. But she is particularly concerned by one theme running through all the hidden-curriculum research: that the idealism students bring into medical school has largely been chipped away by the time they start practicing.

“If doctors are learning that they can’t really pay attention to ideals and emotions, I think it’s very easy to see how that affects patients,” she said. “Patients will often say, ‘Well, I felt like that doctor wasn’t even talking to me.’ That’s not so good.”

About Tom Blackwell