Crystal clear or tin ear: how do medical students interpret derogatory comments about patients and other professionals?

PURPOSE To assess the learning environment at our medical school, third-year medical students complete an 11-item survey called the Learning Environment for Professionalism (LEP) at the end of each clerkship. The LEP survey asks about the frequency of faculty and resident professional and unprofessional behaviors that students observed; two of the items specifically address derogatory comments. This study used focus group methodology to explore how medical students interpret the derogatory comments they reported on the LEP survey. METHODS Seven focus groups were conducted with 82 medical students after they completed the LEP survey. Analysis of focus group transcripts was performed to better understand the nature and meaning that students ascribe to derogatory comments. RESULTS The study results provide insights into the types of derogatory comments that medical students heard during their clerkship rotations, why the comments were made and how they were interpreted. Emergent themes, labeled by the authors as 1) 'onstage-offstage', 2) 'one bad apple', and 3) 'pressure cooker environment', highlight the contextual aspects and understandings ascribed by students to the derogatory comments. Incidentally, students felt that the comments were not associated with fatigue, but were associated with cumulative stress and burn-out. CONCLUSIONS The results suggest students have a clear understanding of the nature of unprofessional comments made by role models during clerkships and point to important systems-related issues that could be leveraged to improve clinical learning environments.