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13 NZMJ 30 October 2015, Vol 128 No 1424
ISSN 1175-8716 © NZMA
www.nzma.org.nz/journal
EDITORIAL
Bullying culture: Valuing the
teacher-student relationship
Elizabeth Berryman
The New Zealand Medical Students’
Association (NZMSA) is calling on all
clinical teachers and students to take
a new approach to teacher-student relation-
ships in the light of medical students report-
ing high levels of bullying when on clinical
placements. The NZMSA 2015 survey found
that 54% of students reported being bullied.
Other New Zealand and international stud-
ies have shown similar results.1-3 Such high
levels have been received with disbelief by
some of the medical profession, and some
have doubted whether what was being cap-
tured was indeed bullying.4 This indicates
the need to clearly dene what is appro-
priate behaviour, and what is not.5 NZMSA
believes that if both parties place a higher
value on the teacher-student relationship, a
bullying culture could not exist.
The NZMSA survey
In August this year, the NZMSA conducted
a nationwide survey of fourth, fth and
sixth year medical students studying in
New Zealand. The survey found that 54%
of students had experienced what they
perceived as bullying when on clinical
placements and 76% had witnessed another
student being bullied. The 772 responses
were from a pool of 1,536 NZMSA clinical
students. The survey allowed students
to anecdotally share their experiences
of bullying if they wished. Many of these
experiences were signicant, with teachers
blatantly crossing professional bound-
aries and breaching codes of ethics and
workplace health and safety policies.4,6,7
However, students commonly reported
more subtle forms of bullying, such as
isolation, rudeness, inappropriate humour,
humiliation and intimidation, which holds
the same negative outcomes.1,8
Students’ experiences
The results show that a large proportion
of students are encountering what they
perceive as bullying, and we know that this
behaviour has negative impacts on students
learning and wellbeing.3,7 It tells us that
we are not creating a safe environment
for students, we are not fostering positive
teacher-student relationships, and we
are not placing a high value on the teach-
er-student relationship, even though it is
one of the main factors known to contribute
to ‘good learning’.9,10
The statistics capture the extent of the
problem, but the stories shared by the
students illustrate it better. Here are a few
of them.
Racism
A staff member refuses to learn the
names of his Asian students, despite
the students wearing name badges and
having names that are easy to pronounce.
Instead, he refers to them as “Bob” or “Bill”,
regardless of whether they are male or
female. Three students from different years
told this story:
“He would refer to me in third
person in theatre...such as saying,
‘It’s Bill’s fault—she keeps making
mistakes.’”
“It made me feel annoyed and
that I was in some way inferior
to the other student I was paired
with (a European male) whom the
consultant addressed by his proper
name and didn’t make jokes about.
I knew I had to take it because that
was the price of passing.”
“If you don’t pull hard enough
[assisting in theatre], I’ll send you
back to Hong Kong.”
14 NZMJ 30 October 2015, Vol 128 No 1424
ISSN 1175-8716 © NZMA
www.nzma.org.nz/journal
EDITORIAL
Sexual harassment
“The registrar said a few of the team
were going for drinks after work on
Friday and he asked if I would like to
join them. I agreed, but when I got
to the bar it was just him. I asked
where the others were and he said
they had all pulled out last minute.
He then proceeded to buy me an
alcoholic drink and pressured me to
have more. I kept making excuses
to leave but was told, ‘I will tell the
consultant you haven’t been good
on this clinical run if you don’t have
another drink with me.’ I made an
escape, but the rest of the run he
would make inappropriate sexual
jokes out of earshot of others and say
things like, ‘You won’t get very far
in a career in medicine if you don’t
know how to have a bit of ‘fun.’”
Intimidation
“I was grilled by consultants
constantly from day one; on ward
rounds, in clinic, in front of patients
and other staff. I was questioned
intensely and embarrassed by not
being able to verbalise the answer
adequately. The style of questioning
was not friendly and sounded like
an interrogation. I can remember
one ward round vividly: one of my
discharged patients from a few
weeks ago came in overnight and I
was told to present him to everyone
on the team at the patient’s bedside
during ward round. I did not have
his notes on me and I couldn’t
remember much about him. I
tried presenting but I fumbled
and couldn’t quite get it right. The
consultant then started interro-
gating me about the condition that
the patient had come in with, ring
question after question; eventually
I just had a blank. I stood there for
what seemed like several minutes
not doing anything. The worst thing
was when the consultant said, ‘this
patient must not have made a big
impression on you then?’ My heart
sank. I felt as though whatever
shred of condence I had left was
destroyed and I felt like I let down
the patient. The embarrassment
in front of the entire team and the
patient made me want to leave and
cry. I went to the patient after and
apologised. He said not to worry,
but he seemed quite concerned
about the events that occurred.”
Differing expectations
We all agree that we should not tolerate
blatant bullying of the kind exemplied in
the racism and sexual harassment examples
above.11 However, what about the more
commonly reported perceived bullying of
isolation, rudeness, inappropriate humour,
humiliation and the kind of intimidation
described by the last student? Do we all agree
that these kinds of behaviours are no longer
acceptable in the clinical learning envi-
ronment? We believe that the survey results
indicate that students and teachers have
differing expectations of what is acceptable.12
This produces an uneasy tension between
teachers and students, and erodes the teach-
er-student relationship.10 If this difference is
not dealt with, it will continue.
Valuing the
teacher-student
relationship
Of course, many factors affect the
teacher-student relationship, including
wider system pressures, and we cannot
possibly cover them all in this article, but
we acknowledge the impact these.13,14 The
apprenticeship model of clinical medical
education means that the relationship
between the teacher and the student is
pivotal, so we will focus on this.10 It is
personal interaction that determines the
quality of a relationship, and like all good
relationships we need to dedicate time
and effort into developing it and value its
importance to see improvement.10 We will
focus on three key things we can do right
now to place value on the teacher-student
relationship.
Firstly, we should acknowledge that each
relationship is unique. Every teacher and
every student is different, and each rela-
tionship requires a different set of skills.12
Educating both students and teachers
in how to deal with these differences is
important. Currently, there is very little
15 NZMJ 30 October 2015, Vol 128 No 1424
ISSN 1175-8716 © NZMA
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EDITORIAL
training provided for clinical teaching staff,
and students are not taught how to be an
effective clinical student.8 We have work-
shops for ‘dealing with dicult patients’,
but we have nothing for dealing with
‘dicult team dynamics’.
Secondly, as with the doctor-patient rela-
tionship, there is a clear power difference
between teacher and student. The hierar-
chical structure of the system increases
the power disparities.13 Compounding the
issue is what the literature describes as
the ‘hidden curriculum’, in which teachers
unconsciously try to teach students about
‘real-life medical culture’.9 An article by
Haidet & Stein states that sometimes this
hidden curriculum includes premises
such as a:
“demand for ‘right’ answers
(avoidance of uncertainty); intim-
idation, public shaming, and
humiliation (doctors must be
perfect); the treatment of students
as objects to be ‘lled up’ with
knowledge and facts (outcome is
more important than process);
unhealthy competition (medicine
takes priority over everything else),
and deference to experts, regardless
of their teaching abilities (hierarchy
is necessary) p. S17.”10
Teachers must acknowledge this power
difference and this unconscious hidden
curriculum, and try to reduce its impact so
that accurate and constructive feedback,
both teacher-to-student and student-to-
teacher, can be given.13 Simple things, like
learning students’ names, giving student’s
opportunities to ask questions, saying ‘Good
Morning’ directly to students or acknowl-
edging them with a smile around the
hospital, are a start.
Some teachers are already adapting these
kinds of practices:
Allowing feedback from students:
“I had some trepidations going into
my nal attachment for the year in
light of the recent NZMSA showcase
on bullying, however two days into
the attachment our surgeon said the
following to me and my classmate:
‘I know that my style of teaching
can be quite abrupt and blunt and
I will push you both hard. I’ve
found this to be an effective way for
students to learn. However if this
is too much, or if you think that
it crosses a line, then I want you
both to feel comfortable in letting
me know that and I will adjust my
approach accordingly.’ The doctor
then went on to ask if we were
happy to continue with this style of
teaching and we both agreed that we
were, but that we would like another
opportunity to give feedback midway
through the attachment.”
Developing the relationship
“She [doctor] greeted us with a
warm welcome and big smile on our
rst day. She took us on a tour of the
ward and introduced us to all the
staff and made sure they knew who
we were. We then went to a small
room and she asked us questions
about what schools we went to, what
we did before medicine, and what we
wanted to learn from this placement.
She told us a bit about herself, her
hobbies and her children. It felt like a
safe place to discuss what we needed
to do on the placement and to ask
questions. This took 30 minutes.
During the attachment she was
quite strict and sometimes asked us
dicult questions on the spot, but it
was okay ‘cos we knew her and that
she wasn’t going to think we were
idiots for getting it wrong.”
Thirdly, students must take responsibility
for their own learning.12 If we don’t under-
stand something, or we don’t like something
a teacher is doing, we have to raise it with
the teacher. We must show our teachers
that we recognise it is an enormous priv-
ilege to be involved in clinical practice, and
that we appreciate the generosity of the
many teachers who go above and beyond
to help us to learn, despite many other
pressures, but that we must take initiative
ourselves to make the most of learning
opportunities.15 We must also learn to ask
what is expected of us in each new rela-
tionship and how to give constructive
feedback to our teachers about how we
individually learn.
16 NZMJ 30 October 2015, Vol 128 No 1424
ISSN 1175-8716 © NZMA
www.nzma.org.nz/journal
EDITORIAL
Conclusion
The blatant bullying needs to stop, that
we all agree on. But the survey results show
that less obvious behaviour is having just as
much negative impact on students, and it is
because of differing expectations. Teachers
and students need to agree on what is
acceptable behaviour in the teacher-student
relationship, then work on developing it. A
medical taskforce workgroup has been set
up to form recommendations for change,
but it starts now with each and every
interaction we have. We need all parties to
discuss openly and honestly with each other
how we can do things better.
A new approach is needed to the teach-
er-student relationship. We call on all
teachers and students to value and respect
the relationship as much as we do the
patient-doctor relationship.10 We cannot
change the culture overnight, but with this
renewed approach the teacher-student
relationship in time can develop into a rela-
tionship of trust, communication, improved
learning and positive outcomes.
1. Wilkinson TJ, Gill DJ,
Fitzjohn J, Palmer CL,
Mulder RT. The impact
on students of adverse
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R, Le Fevre J, Perry A.
Bullying and harassment
of trainees: An unspoken
emergency? Emergency
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2015;27(5):464-7.
3. Scott J, Blanshard C,
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4. Tran V. Dealing with bully-
ing and harassment: a
practical guide for Austral-
asian emergency medicine
trainees. Emergency
Medicine Australasia.
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5. Wearn A, Wilson H,
Hawken SJ, Child S,
Mitchell CJ. In search
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Competing interests: Nil
Author information:
Elizabeth Berryman (4th year Medical Student), President 2015, New Zealand Medical
Students’ Association
Corresponding author:
Elizabeth Berryman (4th year Medical Student), President 2015, New Zealand Medical
Students’ Association
president@nzmsa.org.nz
URL:
www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2015/vol-128-no-1424-30-
october-2015/6705
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EDITORIAL
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