Original Research Articles

Medical students in Aboriginal Community Controlled Health Services: identifying the factors involved in successful placements for staff and students


Background: To identify the facilitators and barriers to positive medical student placements at Aboriginal Community Controlled Health Services (ACCHSs).

Materials and Methods: A total of 15 focused interviews were conducted with medical students from Victorian universities and staff from two Victorian ACCHSs. Staff and students were asked about their expectations of students’ placements; the learning outcomes for students; the structural elements that have an influence on student placements; and the overall benefits and challenges of placements within these settings. This data was then thematically analysed.

Results: The study found that student placements in ACCHSs were of benefit to both the student and the organisation. However, areas for improvement were identified, including avenues for administrative assistance from universities in managing placements and clarifying expectations with regard to learning objectives. Overall, it was the opinion of participants that placements in this setting should be encouraged as a means of medical and cultural education.

Conclusion: The study contributes to building an understanding of the elements that lead to good practice in student placement design, and developing relationships between medical schools and ACCHSs. The study provides grounding for further research into the development of a framework for assisting successful student placements in the ACCHS setting.



Medical education can be a powerful tool for social reform [1]. The teaching that occurs within medical schools, and the manner and context in which it is delivered, has the potential to influence the practice of future doctors and have an effect on addressing social inequities. One of the greatest heath inequities in Australia is between Indigenous and non-Indigenous Australians [2].

In an effort to address this health disparity, there has been increasing emphasis on the teaching and learning of Indigenous health issues in medical schools within Australia, with a range of initiatives guiding the development and improvement of the medical curriculum and associated activities [3,4]. One of the most significant is the inclusion in 2006 of Indigenous health in the Australian Medical Council’s guidelines for Assessment and Accreditation of Medical Schools [5]. An important element of the Standards for Accreditation is the emphasis on offering student placements in Aboriginal Community Controlled settings and the development of relationships between medical schools and Aboriginal Community Controlled Health Services (ACCHSs) to facilitate this (see Standards 1.6.2 (regarding effective community partnerships) and 8.3.3 (regarding exposure to culturally competent healthcare) [6].

Student placements in such a setting offer an opportunity for students to develop cultural competency in the area of Indigenous health. This was outlined in the National Best Practice Framework for Indigenous Cultural Competency in Australian Universities as a critical area of need, and defined as:

“Student and staff knowledge and understanding of Indigenous Australian cultures, histories and contemporary realities and awareness of Indigenous protocols, combined with the proficiency to engage and work effectively in Indigenous contexts congruent to the expectations of Indigenous Australian peoples [7]”.

While ACCHSs have played host to medical students for some time, there has been little formal research regarding ACCHS as a setting for student placements, locally or at other universities across Australia [8-11]. The purpose of this study is to investigate the key facilitators and barriers to positive medical student placements in this sector.


Methods and analysis

Participants for this research included Victorian medical students who had completed a placement at an ACCHS and staff members of Victorians ACCHSs who had been involved in medical student placements. Students were recruited on a voluntary basis by responding to an electronic noticeboard announcement. ‘Snowball’ sampling was also employed. A total of seven student interviews were recorded. Of these, six had been involved in placements in ACCHSs, and one in a remote Aboriginal community government-run health service. The duration of placements ranged from one to six weeks, and were conducted in ACCHSs located across Australia in Queensland, Victoria, New South Wales, Western Australia, and the Northern Territory.

The ACCHSs involved in this study were all located in Victoria and selected on the basis of having a pre-existing relationship with the University of Melbourne. Each organisation provided approval for involvement in the research following internal protocols, and staff members were nominated by the ACCHSs on the basis of their direct involvement in medical student placements. A total of eight interviews were conducted with the staff members from Victorian ACCHSs.

Data for this project was collected through a series of one-on-one semi-structured interviews with participants, conducted by the first author, either in workplaces of participants or university campus interview rooms. Interviewees understood the context and purpose of the research, as explained prior to interviews. Interview questions focused on the benefits and challenges both groups experienced during student placements at the services. Transcripts were returned to participants for comment and correction.

The data gathered from the transcribed interviews was arranged according to questions asked, and then further under thematic headings. Shared themes were derived from the data, without use of supportive software.

This project was conducted as part of the Scholarly Selective program of the University of Melbourne Doctor of Medicine. The first author at time of writing was a fourth-year postgraduate medical student, supervised by two experienced researchers. Ethics approval for this project was obtained through School of Population and Global Health Human Ethics Advisory Group of the University of Melbourne (approval no. 1443395).



In total, 15 interviews were recorded for this research. All students were studying medicine at universities in Victoria. The ACCHS placements were undertaken as either GP placements or electives. Staff from the ACCHSs had a variety of roles including general practitioner, nurse, Aboriginal health worker, medical director, clinical director, and executive director of health services. Points of discussion arising from the data fell largely under six major themes:

  • Student exposure
  • Burden on health services
  • Interpersonal value
  • Community benefits
  • Educational value
  • Student engagement

All participants, on direct questioning, agreed that medical student placements in ACCHSs are important. The data was, therefore, considered on the basis that there is strong support from both students and staff to make these placements a positive and constructive experience for all.

Student exposure

A strong theme that emerged from the responses of both groups was that these placements offered medical students practical exposure to Indigenous health, culture, and community, with several students stating that they offered an important insight into Indigenous health that was not possible through theoretical teachings delivered elsewhere in the curriculum:

“I mean, you hear it, you read it, and so you know it superficially, but when you’re sitting in front of multiple people who can tell you the details of their story, you get a much better understanding as to why these families have had opportunities denied to them” (Student 6).

Students and staff also recognised that placements provided an opportunity to teach students about the ACCHS model of healthcare, which involves not only the delivery of medical services, but also health prevention, social outreach and advocacy programs that address the social determinants of health [12-15]. For one Aboriginal health worker, the value lies in teaching the principles of self-determination upon which ACCHS are founded [15]:    

“I just like the fact that they’re in our setting, our community, and learning from us, not being told by someone else that this is how it is” (Staff member 6).

Community benefits

Staff and students cited the potential benefits for Indigenous communities, such as recruiting medical staff and strengthening ties between the medical profession and Indigenous communities, as a primary benefit of student placements:

“… we see it as an opportunity to expose people to what it’s like working in Aboriginal health, and that helps us with recruitment” (Staff member 8).

Several staff and students commented on the role of placements to promote awareness of ACCHSs amongst the medical community, thereby increasing the likelihood of referrals and support for the services:

“… it’s very good for the organisation and the community to see that students come here to learn because it gives them the message that this is a place of excellence … I think that builds confidence on their part in the service” (Staff member 8).

In addition, placements provided ACCHSs and their patients the opportunity to engage in the medical education process:

“… it makes medical education more transparent for Aboriginal people … and in turn I think that has the potential to create more trust between the patient and the doctor in Aboriginal health centres” (Student 6).

Participants also saw that placements could have a broader impact on the healthcare system outside of the ACCHS setting, in that the students who have had this experience would go on to work in practices and hospitals across the country in a more culturally appropriate way. As such, these placements are “… seeding the medical workforce with people who have some understanding and experience in Aboriginal health” (Staff member 4).

Burden on health services

Participants recognised that the administrative and organisational duties required for placements were very time-consuming, and that supervising students put pressure on practitioners’ time, increasing delays for patients and overall demand on the practice. The administrative duties for ACCHS staff include scheduling time for teaching, co-ordinating the student’s timetable to allow them to spend time in various parts of the organisation, and working through requests for placements from different universities and faculties.

Many of the challenges that students experienced in their placements related to how well the organisation was able to handle these tasks. This was, as several students noted, a feature of clinical placements that is not unique to the ACCHS setting. Challenges for some students included an apparent lack of structure to the placement, staff being unaware in advance of the student’s arrival, finding the clinic to be underprepared for the student or understaffed, or doctors simply not having the time available to teach the student. As one student commented, the service was, “… definitely very welcoming … but they were very space-limited and time-limited in terms of how much attention they can pay to students” (Student 6).

Several students mentioned the value of a careful introduction and orientation to the practice as a way of helping students to feel comfortable in the new environment, and as a result, improving student engagement and relieving some of the administrative stress on the organisation:

“If the host organisation gives a good introduction to the student, it will be easier for them right the way through the placement because the student will know what they’re doing and where they fit, so they won’t be constantly having to direct them” (Student 6).

Educational value

Responses in regards to the education value of the placement varied both between and within the two groups. Most staff at the ACCHSs were generally very happy with the educational experience they provided, not only in terms of general practice knowledge, but also holistic care, community medicine, and Aboriginal culture. Several staff, however, recognised that the emphasis placed on cultural and holistic care may not have been in line with what students expected from placements:

“… I don’t know if they come with that same perspective of the holistic model of care … yes, the clinical side is important, but that’s not the whole reason why they’re coming to [ACCHS]s” (Staff member 2).

Conversely, some of the staff interviewed said that some students were surprised by the degree of emphasis placed on the general practice aspect of the placement.

While all students reported that the placement had been a valuable learning experience, more than half of those interviewed commented that in terms of examinable material for a general practice rotation, the ACCHS placement was perhaps not as rewarding as a placement in a ‘mainstream’ practice:

“I don’t think I learned a lot of examinable material” (Student 3).

One student noted the fact that the longer consultations, which staff regarded as a virtue, meant fewer patients were seen, and the opportunity for learning through repetition was diminished on a purely quantitative basis.

In contrast to the opinions of some of their peers, several students stated explicitly that they believed the educational experience was better for being in an ACCHS setting, and many said that the cultural and community teachings had enriched their learning.

“I can only say that I think if anything it was an advantage because not only did I get the clinical experience I also got the community, social aspect of it as well which might be harder to grasp if you hadn’t done that” (Student 1).

This discrepancy in opinions to some extent reflects a differing of expectations both within the student group and between the students and staff.

Student engagement

Participants were asked what they defined as a ‘successful’ placement. Responses from students varied, and largely focused on basic principles of medical education such as patient contact and fulfilling the curriculum requirements, but also included having clear expectations and an orientation to the ACCHS.

While staff responses also varied, the majority of comments related to student engagement—with the staff, the service as a whole, and with the community:

“If … I get a sense that they’re starting to integrate with the broader team … that sort of marrying in with the team well, I think, is a very good sign” (Staff member 8).

Several staff commented that students who were confident in the ACCHS and able to seek out their own learning opportunities were ‘easier’, more engaged and more likely to be active learners:

“Some of them are much easier and more outgoing. Whereas some of them you have to spend a bit of time engaging and making them feel confident…that’s not a bad thing but it’s harder work” (Staff member 5).

Interpersonal value

The value of the human interactions that arose from placements emerged as a common theme in the interviews. Several students spoke of the relationships with staff, and the trust that developed with community members returning to the clinic, as particularly rewarding experiences:

“I got to see a number of patients quite a few times so that made it a very good learning experience, and a lot of the patients were very trusting, and so I got to do a lot in terms of their care. That … was really rewarding” (Student 6).

Staff from the ACCHSs spoke enthusiastically of having engaged students around the clinics and the organisations more broadly:

“It’s enjoyable, honestly, to see someone who wants to come here and work with Aboriginal people” (Staff member 7).

They cited the benefits of a fresh perspective on health, a new skill set, at times a helping hand, and importantly, a sense of goodwill toward the Indigenous community and the health organisation in the form of a demonstration of interest in Indigenous people and their health.



Major benefits and challenges

This study highlights strong support for student placements in ACCHSs. The most commonly cited reasons for this support centre on the ability to offer students first-hand experience in an Aboriginal community health setting, and the reciprocal benefit to the community in creating a more culturally educated workforce.

The challenges reported by staff and students emphasise areas in need of improvement in the placement process, and provide a foundation for refinement. The foremost of these is the administrative and organisational burden on the health services, how the co-ordination of placements can be improved, and what the implications are for the relationships between universities and ACCHS in this process. Nelson et al [10] suggest that there is a role to be played by university-appointed administrators to assist ACCHSs in the processes required to ensure students and the ACCHSs themselves are adequately prepared for placements. Their study highlights the positive feedback received when such appointments have been made, and the interviews here reinforce the message that good preparation and coordination improves the experience of both staff and students [10].


Ensuring that students feel both socially and culturally oriented in the placement environment is an important element of a successful experience for both staff and students. Students who feel at ease, or more confident in the environment, tend to be more proactive with their learning, and less demanding on the organisation. An important way of fostering this is through a formal orientation.

At the sites where an orientation was undertaken and involved specific cultural awareness training, students felt more confident and engaged. While this responsibility sat with the ACCHS, several participants noted that cultural awareness training should be a core part of medical education in the university environment. Preliminary training would then be the basis for, and be complementary to, the localised and more specific learning provided once students are in the ACCHS setting. Improved coordination between the universities and the ACCHSs is therefore important to ensure that appropriate training and orientation is completed before the student begins their work in the clinical environment.

Educational value of placements in ACCHSs

A successful placement requires that all parties have a clear understanding of the nature and purpose of the placement, with shared expectations of learning objectives. Most placements are either part of general practice rotations or student-initiated electives. While the interviews included positive accounts of both types of placements, the flexibility of student-initiated electives was noted as an advantage in the ACCHS context. Electives, as distinct from other in-semester rotations, are not intended to fulfil precise curriculum requirements, and allow students to engage more freely in learning about Indigenous health and culture and the broader healthcare delivery services provided by ACCHS. However, participants also noted the importance of ACCHSs being included in general practice rotations. It must also be recognised that the medical curriculum is not limited to clinical decision-making, and the educational value of these placements should not be restricted to these domains.

Selection of students

The administrative burden and over-demand for student placements in ACCHSs raises the issue of whether students should be required to demonstrate an interest in Indigenous health to be granted a placement, a requirement that already exists in some ACCHSs. The interview data clearly identified that the burden on the heath service was greater if students were unenthusiastic, disinterested, and unable to self-manage. Approximately half the respondents agreed that an expression of interest should be requisite. The remainder of respondents suggested that those students who do not express an interest in Indigenous health placements might have the most to gain from the experience. Adequate orientation may provide a solution in terms of familiarising the student, managing expectations, and facilitating a positive experience for the student and health service.


This study was limited in its breadth by the nature of the research as a University of Melbourne Scholarly Selective project. The study therefore had limited scope and a small sample size, and while strongly-shared themes arose from the data, the interviews did not reach saturation. The authors also acknowledge that students interviewed had all voluntarily selected Aboriginal health placements, and therefore a selection bias may exist with regard to their views of the value of these placements. The authors further acknowledge that while students interviewed were placed in ACCHSs across Australia, the ACCHS staff were from Victorian ACCHSs only, and therefore the placements they describe are not necessarily shared experiences. No community members visiting the ACCHSs were interviewed. Their opinions on the presence of students in the organisations may form a basis for further research.

For ACCHSs to continue to be an active part of medical education, as mandated by the AMC, it is important to ensure that they have the resources to provide a good learning environment, and that the presence of students is not an impediment to the organisations. Placements should contribute to cultivating trust between Indigenous communities and the medical profession, and this is more likely with careful planning and co-ordination of placements. It is hoped that the findings of this research will help guide student placements into the future and contribute to ensuring a mutually beneficial system. Further research and larger trials in this area may include investigation of the perspectives of community members on the presence and engagement of students in ACCHSs, as well as a deeper exploration of the effects of student placements in other settings, including remote areas.


Conflict of interest
None declared.

Abbreviations and notes

ACCHS- Aboriginal Community Controlled Health Service

* Note: the term ‘Indigenous’ is used in this article to refer to the Aboriginal and Torres Strait Islander peoples of Australia.

St x– student no. x

Sf x– staff member no. x



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Original Research Articles

Mistreatment in Australian medical education: a student-led scoping of experiences


Evidence of bullying and harassment of medical students and junior doctors has existed for over 30 years. However, there has been little attempt to explore the dimensions of this issue in Australia to date. Given the evidence which indicates that experiencing abusive behaviour has a detrimental effect on professional identity formation and on mental health, the Australian Medical Students’ Association (AMSA) undertook a national scoping study to better understand the experiences of Australian medical students.

We conducted a mixed methods survey of the 16,959 students enrolled in a medical degree at an Australian university in 2015. An anonymous, voluntary online questionnaire was distributed through AMSA’s social media, email newsletter and website, and medical students’ societies.

We received 519 responses, including 194 (37%) detailing at least one incident of bullying or harassment. 335 (65%) survey respondents were women and 345 (67%) were in the clinical years of their training. 60% of all respondents reported experiencing or witnessing mistreatment during their medical education. The most common theme in the free text was belittlement of the student’s competence and capacity to be a good doctor. Some gave details about how universities failed to prevent or appropriately respond to students’ experiences of bullying and harassment.

In line with international data, this study shows that many Australian medical students perceive mistreatment as an important problem that is not always managed well by faculties. Multi-pronged policy and practice responses are needed to instigate cultural change in Australian medical education.



“How can we care for our patients, man, if nobody cares for us?”
— Chuck the Intern, The House of God, Samuel Shem [1].

Evidence of bullying of medical students and junior doctors has existed for over 30 years in the United States and the United Kingdom [2-7]. In Australia over the past two years, the topics of bullying, teaching by humiliation, and sexual harassment in Australian medical training have attracted attention both from the mainstream news media and within the profession. There is also some formal evidence about the extent of this problem nationally. A recent local study of “teaching by humiliation” found 74% of medical students reported experiencing this practice and 84% witnessed it [5].

Worldwide, similar studies have shown that any student can be affected, regardless of gender or race [8-10]. The most common form of mistreatment reported is covert, mostly in the form of belittling, exclusion or humiliation, rather than overt yelling or violence [4-6,11]. Sexual harassment is the most common form of documented incident [12-14]. The perpetrators of bullying are most commonly senior male clinicians [4,15]. Under-reporting is the norm, especially when the perpetrator of mistreatment is the student’s clinical supervisor, due to fears about the possible impact on career progression [4,10].

There is evidence that experiencing abusive behaviour causes harm both to the student and later, potentially, to their patients (and colleagues). Other research has demonstrated how a student’s developing identity affects their subsequent career progress, employability, and performance [17-19].

Mistreatment may be a contributor to the high levels of psychological distress found among medical students. Studies have shown that rates of such distress are three times higher among medical students than the general population (9.2% and 3.1% respectively), and that female medical students were more likely than male students to have considered suicide in the past twelve months, with 4.5% having attempted suicide. In particular, Indigenous students found bullying to be a substantial source of stress [16].

The exact nature of bullying and discrimination can be difficult to define. Through this research, we determined which incidents students found distressing, and what they considered to be bullying or discriminatory behaviour.

Prompted by an increase in reports of mistreatment from Australian medical students following media attention to the issue, the Australian Medical Students’ Association (AMSA), in association with the Sydney School of Public Health (SSPH), undertook scoping research to better understand the experiences of Australian medical students.

Rather than confirm the prevalence of abuse, demonstrated by previous research and by the Report of the Senate Inquiry into Medical Complaints Processes (2016) [20], we aimed to explore aspects of students’ experiences and their responses.


Study design and sample
As the only other previous survey of this issue in Australia was distributed to students from two medical schools only [5], our study aimed to reach a wide variety of students from all Australian medical schools and to confirm that previously published findings were generalisable nationally. For this reason, a survey was chosen as the medium for this research as it could be easily disseminated nationally online.

Medical students aged 18 and older who were enrolled in an Australian University between the 25th of August and the 5th of November 2015 were surveyed. The survey was an anonymous, voluntary online questionnaire using REDCap survey software (Vanderbilt University, Tennessee, USA) (see Supplementary Materials online).

The survey link and description were distributed through AMSA’s official Facebook page, Twitter account, website, and email newsletter (“Embolus”). Some medical schools’ student societies, as well as individual participants also shared the survey link.

The questionnaire contained four parts. Part one collected demographic information. In part two, respondents rated their perception of the extent of five categories of mistreatment — “general bullying”, “sexism”, “disability discrimination” (including mental illness), “racism”, and “homophobia” — in Australian medical education, by moving a pointer on a scale from 0 to 100. In part three, respondents rated the attributes of incidents they had witnessed or experienced and were then invited to use free text boxes to describe these incidents. They were also asked about their response to these incidents. In part four, students could describe what actions they felt AMSA could take in response.

The project received ethics approval from the Human Research Ethics Committee (HREC) of the University of Sydney [Protocol number 2015/642].

Data and statistical analysis
Basic demographic information about the respondents was reported, along with the proportions who reported experiencing or witnessing mistreatment. We tested whether experiencing or witnessing mistreatment was associated with gender, age, enrolment, sexuality, and training stage using Fisher’s exact test and Pearson’s chi-squared test. Boxplots were created based on the levels of agreement scales in part two. Differences in levels of agreement between subgroups of respondents were tested using two-sided exact Wilcoxon rank sum tests (gender, enrolment, and sexuality) and Kruskal-Wallis test (age), as the data were negatively skewed (Figure 2). These analyses were performed in R version 3.2.4 [21]. No adjustment has been made for multiple statistical comparisons.

Authors A-KS, EB and KI independently conducted an initial close coding of the open text responses with advice from CH. The taxonomies and categories developed in this process were then reviewed by the research team for comparison and reliability, and a primarily taxonomic thematic coding structure was agreed upon [22,23]. This was then applied to the free text data.


We received 531 completed surveys. Twelve surveys (2%) were excluded as they contained demonstrably unreliable answers or answers unrelated to medical education, leaving a sample of 519 surveys (Figure 1). The respondents were predominantly female (65%), young (median age of 24 years), local students (90%), and at the clinical stage of their training (67%) (Table 1). Each Australian medical school was represented.

Figure 1. Number of surveys included and number of incidents of mistreatment described in check box responses or free text.

It was reported by 60% of all respondents that they had witnessed or experienced adverse treatment (Table 1). Adverse treatment was more likely to be reported by: female than male students (64% vs 53%), older than younger students (79% for 35 years and older vs 55% for 20-24 years), non-heterosexual than heterosexual students (75% vs 58%), and clinical than pre-clinical students (70% vs 40%).

For the five categories of mistreatment (general bullying, sexism, disability discrimination including mental illness, racism, and homophobia), females reported greater problems in medical education than males (p≤0.004) (Figure 2). Non-heterosexuals tended to report greater problems than heterosexuals, particularly regarding homophobia (p<0.001). International students believed mistreatment was less of an issue in medical education than local students for all categories, except racism, though differences were small (p>0.05), and there were no consistent patterns with age (data not presented).

Figure 2. Boxplots of responses of 519 medical students to statements that general bullying, sexism, disability discrimination, racism and homophobia are a problem in medical education.

Information about 301 incidents involving mistreatment was given by 194 students (Figure 1). In 92% of incidents, the victim was a student (Table 2). The respondents nominated consultants as the primary instigator in 46% of the incidents. Belittlement, condescension or humiliation were present in 65% of the incidents. Most students (68%) reported they did not react (that is, take action in response) to the event. Two major reasons for not reacting were not knowing what to do, and fear of repercussions. Most students were bothered by the incident, with only 4% moving the slider scale from “a little” bothered to “not at all”. Over a third moved the slider to the lowest tenth of the scale, described as “very much”.

Table 1. Demographics of 519 survey respondents and the proportion who witnessed or experienced mistreatment in medical education.
Reported p values are for tests of independence between experiencing/witnessing mistreatment and gender, age, enrolment, sexuality and training. Fisher’s exact test was used for gender and training, and Pearson’s chi-squared test for enrolment, sexuality and training.
*There is 1 missing value.

Of the 519 respondents, 168 submitted text descriptions of individual events (Figure 1). Of these, 41 described two events, 14 described three events, and ten described four events. In total, 267 events were described. Themes captured by coding the text responses included the type of event, the perpetrator, the situation and context, aspects that compounded the situation, and any potential outcomes of the event.

The most common theme was the denigration of the student’s competence and capacity to be a good doctor.

“The senior registrar in this instance verbally abused the student regularly, claiming that it was inconceivable that she would one day be a doctor and would cause great harm to potentially anyone she would treat.”

A commonly used framing motif was that the recipient was unworthy, should not have been allowed entry into medical school, or should make way for those who are actually fit to be doctors. The stories included examples of discrimination in all the social categories we investigated. One of the most common was the perceived incompetence or unworthiness of women.

“When we got it wrong, he would tell us we were stupid, we should drop out of medicine because we’d never make a good doctor, or there was no point trying, because we’d quit later to have babies like women should.”

“I was a new mother… and was told by another student I should be at home looking after my child instead of wasting a place at medical school that would have been better off given to someone else.”

A minority of the comments were on non-medical themes such as attractiveness, racial stereotypes, or perceived promiscuousness of the student.
“I would hear jibes about ‘Indians taking over the healthcare system of Australia’ and how ‘No one could understand their curry accent so they shouldn’t be able to work in this country.”

“All the women in our class [were] being scaled on ‘crazy versus hot.’ [The respondent was] followed into a women’s toilet and told to get down on my knees and ‘suck my dick’ while [a male medical student] grabbed his crotch.”

The more the abuse was related to medical practice or competence, the more respondents constructed it as acceptable or understandable.
“The taunts were often unrelated to medicine which made it even more unprofessional.”

Harm and suffering
Implicitly or explicitly, almost all of the 267 free text stories indicated that the recipient(s) of mistreatment were negatively affected as a result. Some accounts directly indicated that teaching by humiliation inhibited rather than enhanced medical learning, decreasing confidence and stopping the student from seeking out further educational opportunities from medical staff.
“Instead of attempting to teach the student in any way, she would harangue the student with increasingly difficult questions — lambasting her further with every question she answered incorrectly… this destroyed the confidence of the student in question quite quickly, to the point where she was afraid and unwilling to go to her clinical placement and learn for fear of the treatment she would receive the next day.”

“I understand that his motivation is to encourage us to be thorough, safe doctors. However, I was so scared at being yelled at for getting an answer wrong in his tutorials that I didn’t learn anything.”


Of the 38 responses indicating students as perpetrators, the same frame of medical incompetence and unworthiness was common.
“A fellow student kept on telling me that I was stupid and inept and kept saying things like if you don’t know this that (sic) you [don’t] belong in medicine … he threatened to hit me if I continue (sic) doing idiotic things.”

We did not include the faculty as perpetrators in our questionnaire. Nevertheless, we received 22 responses citing medical school faculty (including both non-clinical staff and clinical staff in non-clinical roles) as reported perpetrators. These most often related to mishandling of reports of bullying, refusal, or inability to make reasonable allowances for mental illness or disability, and instances of discrimination against students.
“I was told that I was at risk of failing, had my depression called ‘your condition’ the whole time, making me think it was dirty or bad since it couldn’t even be addressed … They said to ask them any questions and the school of medicine would do everything it could to support me, but when I directly asked what they could offer they had nothing.”

Some respondents expressed disappointment and frustration at feeling unsupported by staff.
“The direct inaction by my university nearly led to my suicide … For me the only way I thought the Uni would notice my problem would be if I was to kill myself. Thankfully I pulled myself out of it and am still fighting week in week out to keep myself going.”

Often, students reported faculty promising support to the student, but providing no support or enacting no change. Other responses cited direct bullying or discriminatory action from the faculty towards the student.
“We get mistreated by the very people that are in control of our assessment/progression. How can you complain against the very person that controls your future? It’s just easier to endure it.”

Table 2. Details of 301 incidents of mistreatment reported by 194 medical students.
*The number of incidents with this question answered. **More than one response could be selected therefore the percentages do not sum to 100. *** “Other” includes (from most to least frequently reported) intrusive/unwanted questions, refusal to make reasonable allowance for the needs of others, threatening failure/low grade, receiving lower evaluations/grades, asking to perform personal/inappropriate tasks, spreading malicious rumours, being coerced into unprofessional behaviour, other, and actual/threatened physical punishment. **** “Other” includes (from most to least frequently reported) not there at the time, other, chalked it up to experience, told not to respond, it wasn’t that bad, didn’t have the time, my fault, didn’t care, not intentional, not important, and the data field not being filled in.


Our study indicates that a significant proportion of medical students across the country experience or witness mistreatment, extending existing evidence of this issue, which had been previously confined to only two Australian medical schools. In line with other studies [4,11,24], our study shows that bullying and discrimination are commonly “medically themed”, in ways that belittle a student’s core identity and competency. This fits with sociologies of medicine that have shown that surviving humiliating treatment is often a ritual of socialisation into the profession [25]. Our study also extends our understanding of which students are affected and identifies a wider range of perpetrators than had earlier studies [5,14], including professional and support staff in their clinical schools and other students.

A limitation of our study was the sliding response scale for which the default setting was in the middle of the scale. If the respondent did not touch the slider, we could not be sure if they had elected to forego answering the question entirely (because they did not have an opinion or they did not want to answer) or if they were agreeing with the default mid-range answer.
While our low response rate and methods of recruitment mean that our results cannot be regarded as necessarily representative of the whole Australian medical student population, our data strengthen worldwide trends and provides confirmation that Australian medical students often experience serious mistreatment. It also reflects the findings of the Inquiry into Medical Complaints Processes, released in December 2016 [20,26].

Our study underscored that these behaviours can be damaging to students’ mental health. Our data also confirmed the widespread reluctance to disclose, report, or confront mistreatment as students fear direct educational and professional disadvantage as a result.

This research demonstrates that mistreatment is justified by the idea of upholding professional competence in medical students. It has also shown that, for some students, the mistreatment has a negative effect on their mental health and their willingness to perform. While there will be no single intervention solution for this problem, the authors suggest that clinical teaching staff may find an evidence-based short course on adult education and effective and constructive criticism, useful training for teaching medical students. This could include clear guidelines for both staff and students on the difference between effective teaching and bullying. Indeed, as teaching is often considered an integral part of clinical medicine, targeted preparation for this could commence in medical school. This should be paired with effective policies ensuring that staff who have been reported repeatedly for bullying behaviours are removed from teaching positions and receive appropriate training to improve their skills before resuming work.

We also saw that under-reporting is often due to fear of educational and professional disadvantage. We can address this by encouraging the production of university and hospital policies ensuring anonymity and protection for those who report, and providing alternatives such as switching the student to a different rotation.

Another finding was how some students felt that universities were failing to take action to support them. This was particularly linked to students with a disability or mental health conditions. The reports detail either a perceived choice by the university to not support the student or the admission that university staff did not have the ability or resources to support the student.

The authors suggest that universities enact stronger policies with safety nets available for struggling students (such as changing rotations, alternate exam arrangements, or taking time off) and ensure they have the necessary resources to do so. We also suggest the creation of policies that monitor how many students are struggling, detailing the issues, and taking steps to ensure the problem does not continue. The authors suggest that medical school accreditation processes should include a more rigorous examination of institutional performance on this issue.

These recommendations run alongside those handed down by the Inquiry into Medical Complaints Processes, which specifically identified the government, hospitals, colleges, and universities as parties with responsibility for addressing bullying and harassment in the medical profession [26].

Changes in policy and training educators on effective criticism would be strengthened by slowly incorporating cultural change through encouraging positive professionalism training. Such programs use creative techniques such as acting skills to build core professional values and behaviours. They can also reveal the impact of bullying on others without directly shaming perpetrators or exposing victims [27-29].

Further research is required to determine the effectiveness of these approaches to change. It is as yet unknown whether a pre-emptive educational approach or more capacity to remove perpetrators from teaching roles would be most effective in reducing mistreatment. Further qualitative research would better capture the dimensions and effects of mistreatment, which may be experienced differently by male and female students, on the basis of mental health status, or with respect to sexuality or ethnicity. Such research could assist in identifying institutional barriers to managing poor behaviour among teaching and non-clinical staff, and identify the best strategies by which the effects of mistreatment in medical education can be ameliorated.

We thank Rita Shackel for her assistance with the ethics approval process.

Conflict of interest
None declared.

A Szubert:


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