The Cross-Cockpit Authority Gradient in Medical Teaching

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I came to medicine late, following a career as an Air Force and airline pilot. After this experience, my expectation of being the recipient of bullying during medical training was nonexistent. Unfortunately, however, over several months during my last year as a medical student I was to be overtly targeted by a senior clinician. Naturally this caused emotional discomfort and significantly affected my ability to learn. Moreover, I was astounded that this conduct still occurred in medicine.
I was shocked by this experience because aviation had identified these behaviors as potential safety issues decades earlier. Military instructor pilots (of which I was one) were taught early that students were poor learners when subjected to bullying. Moreover, civilian aviation had noted years ago that a “cross-cockpit authority gradient” (colloquially known as “egos in the cockpit”) was directly associated with an increased incidence of incidents and accidents. This was addressed in a multifactorial manner which included training in crew resource management. This in turn culminated in a safer work environment for those who were qualified and a positive educational atmosphere for those undergoing training.
These issues are familiar to many in medicine, but solving them is not easy.
I am now in the second year of my obstetrics–gynecology residency and I have the pleasure of being closely involved with medical student teaching; in my unit we have a number of students from various stages of their training at any one time. In an attempt to identify and correct nascent intimidating behavior I have asked my final-year medical students to become involved in teaching their juniors, to supervise, observe, and critique minor interventions (while I am present). Of course, I have noted a range of natural instructional abilities amongst the final-year medical students, but occasionally I have noted that some tend towards aggressive or overbearing behavior towards their juniors. When this occurs, I make sure that I take these students aside and encourage more effective and less censuring ways to provide feedback.
For both patient safety and to give students an environment that is threat free in respect to learning, we need to address aggression towards juniors. I sincerely hope that this is an area that we can greatly improve upon, and, as such, I wonder if teaching senior medical students basic instructional and debriefing skills might assist in this.
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