Universal barriers in medical education: A narrative review of reporting mistreatments in global perspective
Creators: name: Natchaporn Namsirikul
name: Pasit Komonsuwan
name: Peerasit Sitthirat
name: Winitra Kaewpila
Publisher: name: F1000 Research Limited
Year: 2024

description: Through the years, the majority of research regarding mistreatment in medical schools has successfully concluded a high global prevalence, along with yielding information such as types, sources, characteristics, and consequences. However, in recent years, statistics suggest a high prevalence with only a small amount reported, despite the extensive establishment of reporting systems. Given the context of diverse global cultures and values, understanding the barriers to reporting might be the key to an effective reporting system.<br>
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In this narrative review, we searched databases such as Medline and ASME in January 2024. Key search terms used were "medical student," "mistreatment," "reporting system," and "barriers." As a result, we were able to compile 40 total papers from the search. Abstracts were screened for relevance, and full articles were retrieved and scrutinized when necessary. After the process, we were left with only five papers published from 2006-2020 with relevance to our initial question. Subsequently, we compared and contrasted factors and reasoning associated with the reluctance to report abuse in medical education across diverse global contexts using thematic analysis. The process was done by one researcher (LO).<br>
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Five papers were found to be relevant to our question, including two qualitative studies, two cross-sectional quantitative studies, and one innovation report. Despite being conducted in different places around the world, the results were highly similar, with different rankings among reasons for not reporting mistreatment. These results can be categorized into three main groups. The first being the fear of reprisal (e.g., poor evaluation, damaged relationships with teachers, hindered career progression, and being labeled a troublemaker) as well as poor teacher-student relationships and poor learning environments. The second is the lack of trust in the reporting system. This manifests as students not believing in the confidentiality, fairness, and effectiveness of the reporting systems. Moreover, fear of not being believed by the reporting bodies is also present among all these reasons. The last is misunderstandings and lack of knowledge among students, such as the false belief that mistreatment and abuse are part of medical culture. Additionally, a lack of knowledge results in failure to recognize non-persistent mistreatment and more subtle forms of mistreatment. In the same way, some incidents are seen as not important enough to report by the victims. Students not knowing where to report or how the reporting system works are also part of the barriers in this group. Reasons categorized into different groups are also found to co-exist, together influencing medical students' decision not to report mistreatment.<br>
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An important point to consider is the lack of research in this area. The scarcity of research on barriers to reporting mistreatment and potential solutions is preventing the medical community from addressing mistreatment and its effects. This is also a limitation of this review due to a lack of research data.<br>
Moving on, we initially questioned how much of an impact context, culture, and the unique characteristics of different communities would have on the reasons for not reporting mistreatment. For example, Asian communities tend to have greater hierarchy compared to the West. However, the findings were highly similar and consistent across the five papers from four different countries, answering the question that barriers arise from universal characteristics of medical schools and existing reporting systems, rather than any particular regional backgrounds. The first group of barriers suggests that the immense power of staff and hierarchical culture in the medical field drives strong fear of reprisal among the victims. The abuser is often the person grading the students or affecting career progression and evaluation. With this power imbalance, reporting becomes less of a choice. These fears persist even when confidentiality is promised, leading to the second group of reasons. Lack of trust in confidentiality potentially suggests that there is a structural problem within reporting systems. This is crucial because if victims were convinced that their identity would be kept confidential, they might have less fear of reprisal. Lack of trust can potentially be the result of not seeing any effective examples, while distrust in fairness might stem from the abuser's high power. Misunderstanding among victims can result from a medical culture that still exists within the community, such as the “concept of self-sacrifice” or “no pain, no gain” culture, where abuse is normalized in the field.<br>
Nevertheless, there is a severe lack of research in this area.<br>
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These analyses and associations require much more research to explore and understand the relationship between certain characteristics of medical education and reporting barriers. Student decision-making and stakeholder involvement also need to be investigated to obtain suggestions that could effectively combat mistreatment.<br>
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We need to shift our focus toward refining reporting systems and ensuring their effectiveness, as well as investigating stakeholders, identifying barriers, and developing prospective solutions to end mistreatment in medical schools.