|Year : 2012 | Volume
| Issue : 2 | Page : 214-219
Experiences of mistreatment among medical students in a University in south west Nigeria
ET Owoaje, OC Uchendu, OK Ige
Department of Community Medicine, College of Medicine, University of Ibadan, University College Hospital Campus, Queen Elizabeth Road, Mokola, Ibadan, Oyo State, Nigeria
|Date of Acceptance||05-Sep-2011|
|Date of Web Publication||16-Jun-2012|
E T Owoaje
Department of Community Medicine, College of Medicine, University of Ibadan, University College Hospital Campus, Queen Elizabeth Road, Mokola, Ibadan, Oyo State
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: This study was conducted to assess the experiences of mistreatment and harassment among final-year clinical students in a Nigerian medical school.
Materials and Methods: A self-administered questionnaire was used to obtain information on the various forms of mistreatment experienced by 269 students in the 2007 and 2008 graduating classes of a medical school in Nigeria.
Results: Almost all the respondents (98.5%) had experienced one or more forms of mistreatment during their training. The commonest forms experienced by the students were being shouted at (92.6%), public humiliation or belittlement (87.4%), negative or disparaging remarks about their academic performance (71.4%), being assigned tasks as punishment (67.7%), and someone else taking credit for work done by the student (49.4%). Religious or age discrimination was reported by 34.2%, sexual harassment and other forms of gender-based mistreatment by 33.8%, and threats of harm by 26.4%. These incidents were mainly perpetrated by physicians and occurred mostly during surgical rotations. The effects included strained relationships with the perpetrators, reduced self-confidence and depression.
Conclusion: Most medical students experienced verbal forms of mistreatment and abuse during their training. Appropriate strategies for the prevention and reduction of medical student mistreatment should be developed.
Keywords: Final-year medical students; mistreatment; south west Nigeria
|How to cite this article:|
Owoaje E T, Uchendu O C, Ige O K. Experiences of mistreatment among medical students in a University in south west Nigeria. Niger J Clin Pract 2012;15:214-9
|How to cite this URL:|
Owoaje E T, Uchendu O C, Ige O K. Experiences of mistreatment among medical students in a University in south west Nigeria. Niger J Clin Pract [serial online] 2012 [cited 2017 Oct 24];15:214-9. Available from: http://www.njcponline.com/text.asp?2012/15/2/214/97321
| Introduction|| |
In a profession that trains people to be caring and compassionate, it would be expected that similar attributes would be displayed in the training of health professionals. However, the situation is not same in most medical schools. Medical education has been charged with a transgenerational legacy of aversive teaching methods such as public belittlement or humiliation, physical and sexual abuse, racial or ethnic discrimination, and verbal abuse.  Medical student abuse is an international phenomenon that has been documented by several studies. ,,,, Reports from medical schools in the United States, ,, Pakistan,  Finland,  Spain,  Israel,  and Australia  indicate that it occurs frequently. The overall prevalence of abuse ranges from 74% to 98%, with verbal abuse being the most common form ranging from 87% to 98%. ,
Though some teachers have stated that these abuses are an unavoidable part of medical education,  abusive behaviors have been shown to have negative effects on the attitudes, behavior and learning capabilities of students.  Reports indicate that more than one-third of the students in medical school have considered dropping out, and one-fourth would have chosen a different profession had they known in advance about the extent of the mistreatment they would experience.  Perceived abuse has also been associated with long-term mental health consequences such as depression, alcoholism, and suicidal attempts. The majority of students reporting abuse during their training are more cynical about their educational experience and the medical practice.  Furthermore, there is a possibility of a cycle of abuse whereby medical students who have been abused become the perpetrators of abuse in future. 
Despite the extensive research on medical student abuse in Europe, North America and Asia, there is little or no documented literature on the subject from African countries including Nigeria. This study was conducted to assess the experiences of final year clinical students in a Nigerian medical school.
| Materials and Methods|| |
The study was conducted in the College of Medicine of the University of Ibadan that is the oldest medical school in Nigeria. Participants were the final-year medical students of the 2007 and 2008 classes who were undergoing their last clinical posting before the final examination. Permission to conduct the study was obtained from the Head of Department in which the students were having their rotation and informed consent was obtained from the medical students. A formal ethical review was not sought as this study was noninvasive in nature and was a voluntary, anonymous survey of consenting adults. Written informed consent was obtained from all subjects. All ethical concerns of the Helsinki Declaration were followed.
Immediately after a lecture, a brief explanation of the survey and its purpose was given to the students. Thereafter, the self-administered questionnaires were distributed to the students and research assistants were available to clarify any queries. The students were not allowed to discuss with each other while filling the questionnaires but were instructed to give their personal and honest responses to each question anonymously. A total of 269 questionnaires were administered and all were returned.
The questionnaire was a semi structured 54 item modification of the instrument used by Rautio et al., in a similar study conducted among students at the University of Oulu in Finland.  Only five questions were open ended, and all others were closed ended. The first 13 questions obtained data on the student's sociodemographic characteristics and year of study, parents' level of education and occupation. The rest of the questions obtained information on the forms and frequency of mistreatment or harassment experienced during the course of their medical education, as well as the source of the mistreatment. Items included being shouted or yelled at; being belittled or humiliated; being assigned tasks for punishment rather than for educational value; having someone take credit for the respondent's work; being physically threatened; being hit, slapped, kicked, or pushed; and being threatened with an unfair grade; as well as experiencing sexual harassment, exploitation, or ethnic discrimination. For each item, respondents were asked to indicate how often this experience had happened specifically to them: never, rarely (one or two times), sometimes (three or four times), or often (five or more times). Students were asked to indicate the source of each type of perceived mistreatment from a list that included fellow students, resident doctors, consultants, nurses, and laboratory staff. Those who had experienced mistreatment were asked to indicate how much it bothered them.
The data were analyzed using SPSS version 11 and differences between the males and females were compared using the Chi- square test. The level of significance was set at P ≤ 0.05.
| Results|| |
The mean age of the respondents was 26.1 ± 2.5 years and 61.3% were males. Almost all the respondents (98.5%) had experienced one or more forms of mistreatment during their training. There was no gender difference in the overall proportions. Majority (66.3%) of the students experienced between four to ten types of mistreatment, although the proportion of male students who reported four or more types of mistreatment from staff was higher (70.9%) compared to 61.5% of the females; this difference was not statistically significant [Table 1]. The commonest forms of mistreatment experienced by the students were being shouted at (92.6%), being publicly humiliated or belittled (87.4%), receiving negative or disparaging remarks about academic performance (71.4%), being assigned tasks as punishment (67.7%) and someone else taking credit for work done by the student (49.4%). Religious or age discrimination was reported by 34.2%, while sexual harassment and other forms of gender-based mistreatment or harassment and threats of harm were reported by 33.8% and 26.4%, respectively. The least experienced form of mistreatment was being slapped, hit, or kicked (18.2%). The frequency of occurrence of the various forms of mistreatment also followed the same pattern: the verbal forms of mistreatment occurred more frequently than physical mistreatment and threats [Table 2].Higher proportions of male students reported being humiliated (89.1% of males versus 84.6% of females), threatened to be harmed, (30.3% of males versus 20.2% of females), threatened to fail or given a low mark (41.2% of males versus 23.1% of females; P < 0.05) and slapped, pushed, kicked, or hit (20.6% of males versus 14.4% of females). However, more females reported being shouted or yelled at (94.2% of females versus 91.5% of males) and experiencing sexual harassment (40.4% of females versus 29.7% of males).
|Table 1: Total number of episodes of mistreatment experienced by students from staff and fellow students|
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Medical student abuse by staff and fellow students
The commonest form of medical student mistreatment perpetrated by the various staff involved in the students' training as well by other students was shouting or yelling. Belittlement and humiliation followed by negative and disparaging remarks were also commonly experienced [Table 2]. These acts were mostly perpetrated by the lecturers/consultants and the resident doctors. The occurrence of mistreatment of students by the various staff was similar by gender except that female students were more likely to have been mistreated by the nurses (P < 0.05)[Table 3]. Most of the students (57.3%) who were mistreated reported that the episodes occurred mainly during rotations in the surgical units.
Overall 78.8% of the students had reportedly experienced some form of mistreatment from other students during their training; the proportions were similar for males (78.2%) and females (79.8%). The commonest form of mistreatment from fellow students was being shouted or yelled at 61.2% followed by being humiliated or belittled and having someone else take credit for the student's work that was reported by 41.2% and 34.2%, respectively.
Sexual harassment and discrimination
One-third (33.8%) of the medical students had personally experienced acts of sexual harassment or gender-based mistreatment. This was more commonly reported by the female students (40.4%) compared to their male counterparts 29.7% (P < 0.01). The main perpetrators were resident doctors (27.5%) and consultants (25.2%). Student colleagues were also cited as the perpetrators by 18%. The main types of sexual harassment or gender-based mistreatment experienced by the female students were sexual advances (23.1%) while males were more likely to report denied opportunities and favoritism based on their gender (20.0%). A significantly higher proportion of the females experienced unwanted sexual advances (P < 0.05) [Table 4].
Effects and perception of mistreatment
The reported effects of the mistreatment on the medical students are shown in [Table 5]. Stress (64.0%) and strained relationships between the affected student and the perpetrator of the abuse (63.4%) were the main effects reported. Others included loss of confidence (45.4%), depression (40.5%), lowered academic performance (24.4%) and sleeping problems (22.1%). Regret of career choice and alcohol use was also mentioned by 18.7% and 7.7% of the students respectively the students.
Almost all, 92.6% of the respondents thought that medical student mistreatment should not be emulated, and 82.9% felt that it was unacceptable behavior. However, 28.3% felt that mistreatment was a normal part of the training in medical school while 19.7% felt that it was a normal display of power.
| Discussion|| |
This is the first documented report of medical students' experiences of mistreatment from a Nigerian medical school. The results of this survey indicate that it is common occurrence which had been experienced by almost all of the students who were interviewed. These results are consistent with the findings of Maida et al., who reported a prevalence of 91% among medical students in Chile  and that from a 16 school survey conducted in the United States of 84%.  The prevalence is however much higher than the rates reported from studies conducted in Finland, Japan, and Pakistan. ,,
The commonest form of mistreatment experienced by the students was verbal that included being yelled or at, belittled or humiliated, and being targets of negative or disparaging remarks. Similar patterns have been observed in studies conducted in the US, Europe, and Asia. ,,,,, Though these incidents of mistreatment were perpetrated by students' colleagues, nurses, and other staff involved in the medical training, they were most commonly perpetrated by clinical consultants and residents. This appears to be a common pattern seen among medical students in clinical years of study. ,, It has been attributed to the greater one on one interaction and small group teaching methods required during clinical teaching that results in close proximity between the medical students and the physicians. , The higher frequency of these occurrences during surgical rotations also seems to be a universal phenomenon. ,, It has been speculated to be due to the male predominance in the surgical specialty and a greater power-driven authority within the setting. 
The medical students' overall experience of the mistreatment did not differ by gender but on subgroup analysis males were more likely to experience threats of being failed or given a low mark and physical violence, while females were more likely to experience sexual harassment. Most of the previous research has documented that female students were more likely to be mistreated than their male counterparts. ,,, However, Frank et al. reported that there was no significant sex difference in the overall experience of US students.  While Uhari et al. reported that male students were more likely to report harassment from their classmates, lecturers, clinicians, and patients.  The findings of our study are consistent with those of other researchers who have observed that studies that examine general abuse find less striking differences than studies looking specifically at sexual harassment or gender-based mistreatment. 
Medical student mistreatment has been shown to have adverse effects on students' health and function. , Students in this study reported strained relationships with the perpetrators, reduction in self confidence, and depression as the main effects of the abuse experienced. Combined with reports of pervasive negative comments about medicine as a career by the consultants and staff, these results suggest that medical education may be occurring in an insensitive and unfriendly environment. These factors have been shown to contribute to the psychological stress experienced by the students who are already mentally and physically taxed by the intensity of the undergraduate medical curriculum. 
Although this study provides useful information on the prevalence of medical student mistreatment, its limitations are well recognized. Medical student mistreatment has been described as a subjective experience that individuals judge and categorize according to their perceptions; thus, judgment may differ among respondents.  Furthermore, the retrospective cross sectional design of the study could have resulted in recall bias. The fact that a specific time frame was not set may have resulted in overestimation and might have contributed to the high prevalence of mistreatment observed. Finally, the report is from a single medical school and therefore the results cannot be generalized for all the medical schools in Nigeria. Despite these observations, this report provides preliminary information and a reference point for future research in an area which has hitherto received little attention in Nigerian and other African medical schools.
| Conclusions|| |
Almost all the medical students interviewed had experienced one or more types of mistreatment during their training. The most prevalent type was verbal while the least prevalent was physical. Male students were more likely to experience all the various forms of mistreatment except sexual harassment. The main perpetrators were consultants and resident doctors. Negative mental health consequences and poor academic performance were attributed to these experiences by the affected students. Apparently medical student mistreatment is capable of compromising the learning environment, impairing the well-being of these students, and may establish poor modeling of the medical profession. These experiences may also negatively affect the students' future attitudes and behavior as physicians, causing them to be perpetrators of mistreatment in future. This situation could in turn increase the risk of a perpetual cycle of medical student mistreatment, which would only serve to undermine the medical profession in future.
These findings emphasize the need to cultivate a supportive environment for students during the medical training and to develop appropriate strategies for the prevention and reduction of medical student mistreatment. A lot of attention has been paid to increasing professional behavior and competencies of medical students through professional training; however, these efforts will be thwarted unless the learning environment espouses the underlying values and professional cultural norms being taught.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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