Patients mistreating medical students and residents is, unfortunately, not uncommon, particularly with trainees of color and women trainees. While faculty have received training for years on how to respond when supervisors and colleagues engage in misconduct, until fairly recently there was no guidance available when patients mistreated trainees.
In 2017, three colleagues then at Yale School of Medicine (YSM), Kali Cyrus, MD, MPH, assistant professor, Johns Hopkins University School of Medicine; Matthew Goldenberg, MD, MSc, associate professor of psychiatry and co-director, medical student clerkship, Biopsychosocial Approach to Health-Psychiatry; and Kirsten Wilkins, MD, associate professor of psychiatry and director of medical student education, Psychiatry, saw that mistreatment by patients was a significant issue, based on curriculum evaluations and informal conversations. They responded by creating a tool, known as ERASE, to help faculty and trainees recognize and address this concerning behavior.
Cyrus, Goldenberg, and Wilkins were spurred to act not only because they were concerned about the mistreatment itself, but also because trainees reported they were not always supported by supervisors and other members of the health care team who had witnessed the mistreatment.
In their efforts to address the problem, Cyrus, Goldenberg, and Wilkins first reviewed the limited literature on mistreatment by patients and considered anecdotal reports about this problem from the perspectives of trainees and faculty. They knew intervention in the moment of mistreatment would be a key component of any framework they created, as well as supporting mistreated individuals. But, as Wilkins explains, they realized that “these steps alone would be insufficient if we wanted to enact culture change around this issue.”
To successfully change the culture, they needed to prepare people to have the skills to effectively intervene and to recognize all the different forms mistreatment can take. They also knew institutional support would be critical to empower clinicians to speak up, to ensure adequate resources for reporting and monitoring, and to communicate a broader message about expectations for mutual respect between patients and providers.
The result of Cyrus, Goldenberg, and Wilkins’ collaboration was ERASE — an acronym for expect, recognize, address, support, and establish/encourage — or more fully stated: expect that mistreatment will occur; recognize episodes of mistreatment; address the situation in real time; support the learner after the event; and establish/encourage a positive culture.
These steps alone would be insufficient if we wanted to enact culture change around this issue.
Kirsten Wilkins, MD, associate professor of psychiatry and director of medical student education, Psychiatry
Between November 2017 and January 2018, 69 YSM faculty and a few senior trainees attended an ERASE workshop. Cyrus, Goldenberg, and Wilkins found that nearly 80% of attendees reported having had no prior training in managing patient mistreatment of trainees and they noted significant changes in attendee confidence in recognizing and responding to episodes of mistreatment after the training session.
In addition to these positive findings, the collaborators have found it rewarding to hear individual stories of how ERASE has helped. A clinician shared with Wilkins that she was glad to have had ERASE training when a patient made an inappropriate comment on her physical appearance. The clinician explained that prior to her training, she probably would have ignored it or laughed it off, but she now felt prepared and empowered to set appropriate limits. Goldenberg says a student recently reported that a patient experiencing psychosis had made offensive statements on the unit. While this was a concerning incident, the student also reported feeling very well-supported, sharing that the resident, who had had ERASE training, had responded well, advising the patient directly that such comments were not appropriate and debriefing with the student after the incident.
While ERASE originally was designed to educate faculty who supervise medical students and residents on how to recognize mistreatment and support trainees, as bystanders, Cyrus, Goldenberg, and Wilkins also have created a modified training workshop to provide skills for all health care providers who are targets of mistreatment. They have delivered ERASE workshops to several YSM departments including Psychiatry, Internal Medicine, and Pediatrics, as well as to health care staff at the VA Medical Center in West Haven and Yale New Haven Hospital (YNHH).
Beyond expanding to educate all health care providers, ERASE now is being used far beyond Yale and YNHH. The collaborators have received requests for the workshop materials and the workshop itself from several academic medical centers across the country. ERASE also is spreading on its own, as reflected by an experience Goldenberg had in August 2019. Goldenberg’s mother is a dean at the University of Southern California Keck School of Medicine. When she was meeting with a group of students, she saw they had a small card describing the ERASE model, which cited it was adopted from the work of Goldenberg and his colleagues. She texted a photo of the card to Goldenberg who says, “neither she nor I had realized, until she texted me that photo, that our work had been adopted for use at the school.”