A recently published study – the first of its kind – found that medical student mistreatment was highly prevalent at a South African medical school in 2018, with trainee doctors showing signs of high levels of psychological distress, and reporting that the mistreatment affected their mood, their personal relationships and their studies.
However, Stellenbosch University says it has since instituted measures to reduce trainee doctor mistreatment, reports GroundUp.
One of the researchers now hopes to expand the study to cover all medical campuses across South Africa over a number of years.
Nearly 80% of medical students who took part in the study kind said they had experienced mistreatment from doctors, the highest level of mistreatment reported in any similar study worldwide, say Stellenbosch University researchers, who also uncovered high rates of racial and gender discrimination against students in the medicine and health science faculty.
The paper, published in the journal Teaching and Learning in Medicine, recorded the responses of 443 medical students to a 19-question online survey.
The researchers, who say the “highly prevalent” mistreatment had “significant perceived negative effects on mood and academic performance”, have urged medical schools to be aggressive in 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 then, 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 Stellenbosch’s medicine and health sciences faculty said the campaign was launched in 2021 after the study “highlighted the presence of bullying behaviour in its own training environment”, and was endorsed by the SA committee of medical deans and shared with all 10 medical school deans countrywide.
In a statement, the Western Cape Health Department noted the “serious nature of the findings”, saying it had taken steps to improve the environment at Tygerberg Hospital, where Stellenbosch students do their practical training.
Worldwide, studies have found 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 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 a national survey 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 participating 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 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 10 said they had been physically abused.
Those dishing out the mistreatment were mainly registrars and consultants, but more than half they had also been targeted by nurses, clerks and hospital managers.
“Registrars were the most frequent perpetrators, possibly due to the fact that students work closely with them … and registrars 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”, 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 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 of the students said they did not report mistreatment because of fear of their grades being lowered. Other prominent fears included victimisation, conflict and breaching confidentiality.
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 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.”
Study details
Medical Students’ Experiences of Mistreatment by Clinicians and Academics at a South African University
Kathleen Crombie, Kenneth Crombie, Muneeb Salie and Soraya Seedat.
Published in Teaching & Learning in Medicine on 17 January 2023
Abstract
Phenomenon
Tertiary education in post-apartheid South Africa has faced many challenges regarding class, language, and race. Even though previously white Afrikaans-rooted universities now have a diverse student population, recent student protests have highlighted the ongoing need for decolonisation in higher education. In addition, the majority of public hospitals in the country function under significant staffing, infrastructure, and equipment shortages. Although the mistreatment of medical students has been well described internationally, to date no South African data exists. The aim of this study was to identify experiences of mistreatment of medical students by clinicians and academics at a South African university and to describe the type of mistreatment experienced, the perceived mental health effects, and the influence on academic performance, resilience, and students’ knowledge of current reporting systems.
Approach
A cross-sectional study was conducted through a locally developed online survey of 443 medical students at a South African university in May to June 2018, comprising both open and closed ended questions. Levels of psychological distress (K10) and resilience (CD-RISC -10) were measured. Chi-square and student t-tests were used for the analysis of associations, and linear regressions were used to assess predictors of psychological distress. Qualitative data were analyzed thematically using the approach described by Braun and Clarke.
Findings
Of 800 eligible medical students at Stellenbosch University, 443 students (55.4%) completed the survey. Mistreatment, comprising of being ignored/excluded (83.4%), offensive gestures (75.0%), verbal abuse (65.1%) and discrimination (64.4%), was prevalent and pervasive, and was perpetrated mainly by registrars (46.7%) and other medical staff (43.8%). Mistreatment was associated with psychological distress, which was generally high and more severe for females. Resilience, which was higher for males, moderated the effects of gender and perpetrator type on distress. Only 15% of students who had experienced mistreatment, either directly or indirectly, reported it, of which more than half (52.8%) were not happy with the outcome. Most students (80.9%) were not aware of the systems in place to report mistreatment.
Insights
Student mistreatment is more highly prevalent among medical students at a South African university compared with studies conducted internationally. Despite over 20 years of democracy in South Africa, high rates of racial and gender discrimination were reported and descriptions of racial, language and gender discrimination were particularly concerning. Since the findings of this study, an anti-bullying poster-campaign has been initiated at the university as well as an online reporting system.
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Large mental health study finds 21% of SA students have symptoms of PTSD
Burnout – a forerunner to depression – starts at medical school