UCLA Health Sciences

1. UCLA Health Sciences Mistreatment of Medical Trainees: How Can We Change the Culture? Joyce M. Fried Assistant Dean Chair, Gender and Power Abuse Committee Program Directors’ Conference May 14, 2010

2. Does student mistreatment occasionally occur at your site?? 10 • Yes • No • Don’t know

3. UCLA’s Mistreatment Definitions • Power—Intimidating, dehumanizing, threatening grade, recommendation, career • Verbal—Yelling or shouting, using derogatory name, cursing, ridiculing • SexualHarassment—Making unwelcome or inappropriate physical or verbal advances, creating a hostile environment, stereotyping • Ethnic—Intentionally neglecting, making ethnic jokes • Physical—Slapping, striking, pushing, throwing

4. Have you personally witnessed student mistreatment? • Yes • No 0

5. Personal Stories Describe an incident of mistreatment that you have witnessed. or Think back to your training days and describe an incident that may have happened to you personally.

6. The Data SOURCES: • Well-Being Survey taken by every student at end of third year • Graduation Questionnaire (end of fourth year) • UCLA • USC and UCI • All Schools

7. Students Aware That Their School Has a Mistreatment Policy* (GQ 2009) *All three schools have a mistreatment policy per LCME Standard MS-32.

8. UCLA Well-Being Survey(Students surveyed end of third year) Have you personally experienced this type of mistreatment in the last year? % (Approximate N for each class = 160)

9. Data from 2009 GQ

10. Responded “yes” to whether they had experienced any incidences of abuse

11. Possible Reasons for Significant Decrease • Students become acculturated and lower their expectations? • Time heals all wounds? • More mistreatment in third year than fourth? • Survey instruments? • Protective of institution? • Senioritis?

12. The Rules • LCME Standards • ACGME Competencies • Joint Commission Standards

13. LCME Standard MS-32 Each medical school must define and publicize the standards of conduct for the teacher-learner relationship, and develop written policies for addressing violations of those standards.

14. Annotation for LCME Standard MS-32 • The standards of conduct need not be unique to the school but may originate from other sources such as the parent university. • Mechanisms for reporting violations of these standards -- such as incidents of harassment or abuse -- should assure that they can be registered and investigated without fear of retaliation. • The policies also should specify mechanisms for the prompt handling of such complaints, and support educational activities aimed at preventing inappropriate behavior.

15. ACGME Competencies-Professionalism- Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to demonstrate: • compassion, integrity, and respect for others; • responsiveness to patient needs that supersedes self-interest; • respect for patient privacy and autonomy; • accountability to patients, society and the profession; and, • sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation.

16. Joint Commission Standards LD.03.01.01 Behaviors that Undermine a Culture of Safety July 09, 2008 • Leaders create and maintain a culture of safety and quality throughout the [organization]. Safety and quality thrive in an environment that supports teamwork and respect for other people, regardless of their position in the [organization]. Leaders demonstrate their commitment to quality and set expectations for those who work in the [organization]. Leaders evaluate the culture on a regular basis. Leaders encourage teamwork and create structures, processes, and programs that allow this positive culture to flourish. Disruptive behavior that intimidates others and affects morale or staff turnover can be harmful to [patient] care. Leaders must address disruptive behavior of individuals working at all levels of the [organization], including management, clinical and administrative staff, licensed independent practitioners, and governing body members. • .

17. Joint Commission Standards LD.03.01.01 Elements of Performance for LD.03.01.01 • Leaders regularly evaluate the culture of safety and quality using valid and reliable tools. • Leaders prioritize and implement changes identified by the evaluation. • Leaders provide opportunities for all individuals who work in the hospital to participate in safety and quality initiatives. • The hospital has a code of conduct that defines acceptable, disruptive, and inappropriate behaviors. • Leaders create and implement a process for managing disruptive and inappropriate behaviors. • Leaders provide education that focuses on safety and quality for all individuals. (See also LD.04.04.05, EP 6) • Leaders establish a team approach among all staff at all levels. • All individuals who work in the hospital, including staff and licensed independent practitioners, are able to openly discuss issues of safety and quality. • Literature and advisories relevant to patient safety are available to all individuals who work in the hospital. • Leaders define how members of the population(s) served can help identify and manage issues of safety and quality within the hospital.

18. Our Efforts to Stem Student Mistreatment • Adopted Statement on Supporting an Abuse-Free Environment • Gender and Power Abuse Committee (15 years) • Created South Campus Ombuds Office • Adopted Policy for Prevention of Student Mistreatment • Ongoing survey to monitor prevalence • Bookmarks

19. Our Efforts to Stem Student Mistreatment • Education Program • Required workshop for all starting third years at Clinical Foundations • Presentation to matriculants during orientation • Presentation at house staff orientations • Grand Rounds • Presentation to OR personnel • Draw the Line poster exhibit

20. UCLA Well-Being Survey(Students surveyed end of third year) Have you personally experienced this type of mistreatment in the last year? % (Approximate N for each class = 160)

21. Why does this occur? • Change takes time • Change takes courage • Fraternity mentality • Resident model behavior • Fear of reporting • All of the above

22. Barriers to Reporting • Fear of retaliation • Cultural taboo • Victim self-blame • Not wanting to be seen as complainer • Reporting mechanisms not clear • Others????

23. How do we address this?

24. Provide comments • LIFE curriculum w/ and for faculty development • Joyce to speak w/ residents • Prevention techniques/lessons to learn

25. Suggestions • Be a role model • Have regular, open discussions with housestaff, esp. Chief Residents • Praise those who are willing to speak up • Follow up on issues that are raised • Close the loop with individual who report incidents • Use LIFE Curriculum on GME site as a teaching tool