Abuse and shame in Homer and medicine

ABSTRACT

Learning through ritual humiliation used to be standard in work-based medical education as a rite of passage, a militaristic hardening. More enlightened pedagogies have emerged, but such abusive and shaming practices still linger, especially in surgery. Humiliation now includes harassment of women trainees through overt and covert sexism. We explore the resilience of such “compulsory mis-education” through “thinking with Homer.” Returning to Homer’s Iliad and Odyssey as Ur-texts for shaping the human imagination, we re-read shame and abuse in medical contexts, suggesting that these are products of historical shaping by metaphors of violence and conflict. It is only when such primary metaphors shift and more liberal metaphors emerge that a more collaborative and feminine medical culture will be shaped. We draw on distinctions between “honor–shame”/“tradition-directed” and “guilt”/“inner-directed” behaviors to explore medicine’s lingering authoritarianism. The former rely on gaining respect from peers or being ostracized (losing face), where as the latter depend upon an internalized moral code expressed as pride or guilt (conscience). While structural changes will enable a more democratic medical culture to emerge, medical education can facilitate such change through promoting learner-centered techniques such as supportive and constructive feedback.

KEYWORDS:

• Abuse
• Homer
• medical education

Notes

1. Howard S. Becker et al., Boys in White: Student Culture in Medical School (Chicago: University of Chicago Press, 1961); Simon Sinclair, Making Doctors: An Institutional Apprenticeship (Oxford: Berg, 1997); Akhil Narang, “Cynicism in Medicine—Insights on Residency Training,” NEJM Journal Watch April 28, 2014, http://blogs.jwatch.org/general-medicine/index.php/2014/04/cynicism-in-medicine/.

2. Ulf H. Lindström, Katarina Hamberg, and Eva E. Johansson, “Medical Students’ Experiences of Shame in Professional Enculturation,” Medical Education 45, no. 10 (2011): 1020.

3. Becker et al., Boys in White.

4. Dewitt C. Baldwin, Steven R. Daugherty, and Edward J. Eckenfels, “Student Perceptions of Mistreatment and Harassment During Medical School: A Survey of Ten United States Schools,” Western Journal of Medicine 155, no. 2 (1991): 140–5.

5. Richard S. Mangus, C. E. Hawkins, and M. J. Miller, “Prevalence of Harassment and Discrimination Among 1996 Medical School Graduates,” JAMA 280, no. 9 (1998): 851–3.

6. Henry K. Silver and Anita D. Glicken, “Medical Student Abuse,” JAMA 263, no. 4 (1990): 527–32.

7. Donna A. Rosenberg and Henry K. Silver, “Medical Student Abuse,” JAMA 251, no. 6 (1984): 740.

8. Frank E. Carrera et al., “Experiences of Belittlement and Harassment and Their Correlates Among Medical Students in the United States: Longitudinal Survey,” BMJ 333 (2006): 682.

9. Michael Greger, Appendix 16—Medical Student Abuse, 1999, http://upalumni.org/medschool/appendices/appendix-16.html.

10. Robert H. Coombs, Drug-Impaired Professionals (Cambridge, MA: Harvard University Press, 1997).

11. Francis J. Kane, “Faculty Views of Medical Student Abuse,” Academic Medicine 70, no. 7 (1995): 563–4; Dewitt C. Baldwin and Steven R. Daugherty, “Do Residents Also Feel ‘Abused’?” Academic Medicine 72, no. 10, Suppl. 1 (1997): S51–3.

12. Kane, “Faculty Views of Medical Student Abuse.”

13. Heidi Lempp and Clive Seale, “The Hidden Curriculum in Undergraduate Medical Education: Qualitative Study of Medical Students’ Perceptions of Teaching,” BMJ 329 (2004): 770–3.

14. “Medical Students ‘Humiliated by Senior Doctors,’” The Guardian, October 1, 2004, https://www.theguardian.com/education/2004/oct/01/highereducation.uk1.

15. Jenny Firth-Cozens and Jamie Harrison, How to Survive in Medicine Personally and Professionally (Hoboken, NJ: Wiley-Blackwell, 2010), 11.

16. Claire L. Wendland, A Heart for the Work: Journeys through an African Medical School (Chicago: University of Chicago Press, 2010).

17. Kaji Sritharan and Muhunthan Thillai, Royal Society of Medicine Career Handbook: ST3 Senior Doctor (London: Routledge, 2012).

18. Ildiko Gágyor et al., “Frequency and Perceived Severity of Negative Experiences During Medical Education in Germany—Results of an Online-Survey of Medical Students,” GMS Zeitschrift für Medizinische Ausbildung 29, no. 4 (2012): Doc55. http://doi.org/10.3205/zma000825.

19. General Medical Council, National Training Survey 2013: Undermining (London: General Medical Council, 2013), http://www.gmc-uk.org/NTS_2013_autumn_report_undermining.pdf_54275779.pdf.

20. Karen M. Scott et al., “‘Teaching by Humiliation’ and Mistreatment of Medical Students in Clinical Rotations: A Pilot Study,” Medical Journal of Australia 203, no. 4 (2015): 185, 185e.1.

21. Expert Advisory Group (EAG), Report to the Royal Australasian College of Surgeons on Discrimination, Bullying and Sexual Harassment, September 28, 2015, http://www.surgeons.org/media/22086656/EAG-Report-to-RACS-FINAL-28-September-2015-.pdf.

22. Julia Medew, “Medical Students Under Pressure Amid Reports of Bullying in Australian Hospitals,” Sydney Morning Herald, May 24, 2015, http://www.smh.com.au/national/medical-students-under-pressure-amid-reports-of-bullying-in-australian-hospitals-20150524-gh8jq5.html.

23. Dharmaraj Karthikesan, “Dear Doctors, Be Kind to Each Other,” Dharmaraj Karthikesan’s Blog, May 9, 2015, http://dharmarajkarthikesan.com/2015/05/09/dear-doctors-be-kind-to-each-other/.

24. “Medicine and Culture and the Strange Way We Learn,” stringsandfretboards.com, May 26, 2015, https://stringsandfretboards.wordpress.com/2015/05/26/medicine-and-culture-and-the-strange-way-we-learn/.

25. Naif Fnais et al., “Harassment and Discrimination in Medical Training: A Systematic Review and Meta-Analysis,” Academic Medicine 89, no. 5 (2014): 817.

26. Alan Bleakley, Robert Marshall, and David Levine, “He Drove Forward with a Yell: Anger in Medicine and Homer,” Medical Humanities 40, no. 1 (2014): 22–30.

27. Alan Bleakley, Patient-Centred Medicine in Transition: The Heart of the Matter (Dordrecht, Netherlands: Springer, 2015).

28. David Binning Monro and William Allen, eds., Homer: The Iliad (Oxford: Oxford University Press, 1959).

29. William Allen, ed., Homer: The Odyssey (Oxford: Oxford University Press, 1962).

30. Homer, The Odyssey, trans. Robert Fagles (New York: Penguin, 1997), line 585.

31. Ibid., line 598.

32. Joel H. Rosenthal, “Ethics and War in Homer’s Iliad,” carnegiecouncil.org, March 27, 2012, http://www.carnegiecouncil.org/publications/articles_papers_reports/0125.html.

33. James Hillman, A Terrible Love of War (New York: Penguin, 2004).

34. Thomas Sydenham, qtd. in Abraham Fuks, The Military Metaphors in Modern Medicine, (2009), 3, www.inter-disciplinary.net/wp-content/uploads/2009/06/hid_fuks.pdf.

35. Robert J. Marshall and Alan Bleakley, “Putting It Bluntly: Communication Skills in the Iliad,” Medical Humanities 34, no. 1 (2008): 30–4; Robert Marshall and Alan Bleakley, “The Death of Hector: Pity in Homer, Empathy in Medical Education,” Medical Humanities 35, no. 1 (2009): 7–12; Alan Bleakley and Robert Marshall, “The Embodiment of Lyricism in Medicine and Homer,” Medical Humanities 38, no. 1 (2012): 50–4; Robert J. Marshall and Alan Bleakley, “Lost in Translation: Homer in English; the Patient’s Story in Medicine,” Medical Humanities 39, no. 1 (2013): 47–52; Bleakley, Marshall, and Levine, “He Drove Forward with a Yell”; Victoria Rodulson, Alan Bleakley, and Robert Marshall, “Whistleblowing in Medicine and in Homer’s Iliad,” Medical Humanities 41, no. 2 (2015): 95–101.

36. Richard A. Burkhart et al., “Grit: A Marker of Residents at Risk for Attrition?” Surgery 155, no. 6 (2014): 1014–22.

37. Sceptical Scalpel, “Selecting Grittier Surgeons Is Harder than You Think,” kevinmd.com, 19 August 2014, http://www.kevinmd.com/blog/2014/08/selecting-grittier-surgeons-harder-think.html.

38. Kathy Oxtoby, “Do the Classic Specialty Stereotypes Still Hold True for Today’s Doctors?” BMJ Careers, 17 December 2013, http://careers.bmj.com/careers/advice/view-article.html?id=20015762.

39. Michael A. E. Ramsay, “Conflict in the Health Care Workplace,” Proceedings (Baylor University Medical Center) 14, no. 2 (2001): 138.

40. Rosenthal, “Ethics and War in Homer’s Iliad.”

41. Ruth Benedict, The Chrysanthemum and the Sword: Patterns of Japanese Culture (Boston: Houghton Mifflin, 1946).

42. Eric Robertson Dodds, The Greeks and the Irrational (Berkeley: University of California Press, 2008).

43. Ibid., 71.

44. Rodulson, Bleakley, and Marshall, “Whistleblowing in Medicine and in Homer’s Iliad.”

45. David Riesman, Nathan Glazer, and Reuel Denney, The Lonely Crowd (New Haven, CT: Yale University Press, 1950).

46. Michel Foucault, “Technologies of the Self,” in Ethics: Subjectivity and Truth, trans. Robert Hurley and others, ed. Paul Rabinow (New York: The New Press, 1994), 223–51.

47. Lindström, Hamberg, and Johansson, “Medical Students’ Experiences of Shame in Professional Enculturation.”

48. Dodds, The Greeks and the Irrational, 18.

49. Douglas L. Cairns, Aidōs: The Psychology and Ethics of Honour and Shame in Ancient Greek Literature (Oxford: Clarendon Press, 1993), 93.

50. Ibid., 2–3.

51. Christopher Watling et al., “Understanding Responses to Feedback: The Potential and Limitations of Regulatory Focus Theory,” Medical Education 46, no. 6 (2012): 593–603.

52. Baldwin, Daugherty, and Eckenfels, “Student Perceptions of Mistreatment and Harassment During Medical School,” 144.

53. Coombs, Drug-impaired Professionals.

54. British Medical Association (BMA), “Doctors in Difficulty/Doctors' Well-being,” http://www.bma.org.uk/support-at-work/doctors-well-being/websites-for-doctors-in-difficulty.

55. EAG, Report to the Royal Australasian College of Surgeons on Discrimination, Bullying and Sexual Harassment, 2–5.

56. The Shorter Edition of the Oxford English Dictionary (Oxford: Oxford University Press, 1971).

57. Hannes G. Pauli, Kerr L. White, and Ian R. McWhinney, “Medical Education, Research, and Scientific Thinking in the 21st Century,” Education for Health 13, no. 2 (2000): 15–25, 165–72, 173–86; Alan Bleakley, John Bligh, and Julie Browne, Medical Education for the Future: Identity, Power and Location (Dordrecht, Netherlands: Springer, 2011); Bleakley, Patient-Centred Medicine in Transition.

58. David Pendleton et al., The Consultation: An Approach to Learning and Teaching (Oxford: Oxford University Press, 1984).

59. Suzanne Kurtz, Jonathan Silverman, and Juliet Draper, Teaching and Learning Communication Skills in Medicine (Abingdon, U.K.: Radcliffe Medical Press, 1998).

60. Maria-Teresa Claridge and Tony Lewis, Coaching for Effective Learning (Abingdon, U.K.: Radcliffe, 2005).

61. Anne-Marie Curtis, “Is It Ever Right to Tell off Trainees in Public?” British Medical Association, February 20, 2014, http://www.bma.org.uk/news-views-analysis/work/2014/february/is-it-ever-right-to-tell-off-trainees-in-public.