摘要
目的:调查湖南省医学院校的实习期医学生受虐情况,探讨医学生虐待与受虐者抑郁症状和焦虑症状的关系。
方法:以分层随机整群抽样的方法,共调查了湖南省6所医学院校的8家直属附属医院共329名实习医学生,应用抑郁自评量表、焦虑自评量表和医学生实习事件调查表,对实习生进行以医院为单位的现场施测。
结果:共调查了329名实习期医学生,收回有效问卷312份,有效率为94.8%。在312名医学生中,有244(78.2%)名学生经历过至少一次虐待事件,其中女生有128人(76.6%)、男生有116人(80.0%)经历过至少一次虐待事件.在医学生虐待的五种类型中,有210名(67.3%)学生经历过至少一次的言语虐待事件,排在五种虐待类型中的首位,其他依次为学业虐待(n=165,52.9%)、性别歧视(n=105,33.7%)、性骚扰(n=91,29.2%)和躯体虐待(n=60,19.2%).在施虐者中,主治医师和护士以17%的比例并列排在了首位,其他依次为病人(16.3%)、住院医师(16.2%)、其他(12.7%)、主任医师或教授(9.3%)、学生(5%)、医技人员(4%)和医院后勤人员(2.5%)。在虐待事件发生所在的科室中,外科以29.5%的比例排在众科室第一,其他依次为内科(22.8%)、妇产科(14.4%)、其他(13.5%)、儿科(6.8%)、急诊科(5.4%)、传染科(4.1%)和麻醉科(3.4%)。医学生虐待与学生的抑郁、焦虑症状间的Kruskal-Wallis H检验显示:学业虐待组间(χ~2=9.74,p=0.02)和受虐种类组间(χ~2=33.55,p=0.00)的抑郁自评量表得分有显著性差异;言语虐待组间(χ~2=9.85,p=0.00)、躯体虐待组间(χ~2=9.49,p=0.00)、性骚扰组间(χ~2=15.96,p=0.00)和受虐种类组间(χ~2=37.96,p=0.00)的焦虑自评量表得分有显著性差异。进一步的NemenyO检验显示:学业虐待中组4的抑郁自评量表得分高于组1;受虐种类中组4、组5、组6的抑郁自评量表得分高于组1,组6的抑郁自评量表得分高于组2和组3。言语虐待和躯体虐待中组3的焦虑自评量表得分均高于组1和组2;性骚扰中组4的焦虑自评量表得分高于组1;受虐种类中组4、组5、组6的焦虑自评量表得分高于组1,组6的焦虑自评量表得分高于组2和组3。
结论:在湖南省医学院校中存在较普遍的医学生虐待现象。其中性骚扰的男生比例高于女生,而其他各形式虐待类型均无男女间差异。在各类型医学生虐待中,学业虐待对学生的抑郁症状有一定影响;而言语虐待、躯体虐待和性骚扰对学生的焦虑症状有一定影响。
Objective: To investigate the information of medical student abuse during clinical clerkships in Hunan province. To approach the relationship between medical student abuse and depression or anxiety in abused students.
Method: A questionnaire was developed with vignettes describing abusive situations that medical students could have met during medical clinical clerkships. The questionnaire was handed to students with 2 other rating scales: self-rating depression scale and self-rating anxiaty scale. The study population comprised 329 medical students in 8 teaching hospitals in Hunan province. These questionnaires were answered anonymously and returned as soon as finished to ensure confidentiality.
Result: Of the 329 students surveyed, 312 questionnaires were available, the response rate was 94.8%. Of the respondents, 244 (78.2%) students reported at least one instance of abuse, 80.0% of the men (n=116)and 76.6% of the women(n=128) had experienced at least one instance of abuse. In all five types of medical student abuse we investigated: verbal abuse, physical abuse, academic abuse, sexual harassment and gender discrimination, verbal abuse (n=210,67.3%)was the most common type of medical student abuse which followed by academic abuse (n=165,52.9%) , gender discrimination (n=105,33.7%), sexual harassment (n=91,29.2%) and physical abuse (n=60,19.2%) .In the sources of perpetrators, attending physician(17%) and nurse(17%) were identified the most frequently as the sources of perpetrators which followed by Patients( 16.3%), resident physician(16.2%), others(12.7%), chief physician or professor (9.3%) , peers (5%) , meditech technician (4%) and service personnel (2.5%) . In the sources of abusive site, surgical department(29.5%) was reported the most common abusive site which followed by department of internal medicine (22.8%) , obstetric and gynecologic department (14.4%) , others (13.5%) , department of pediatrics (6.8%), emergency department (5.4%), infection department (4.1%) and anaesthesiology department (3.4%) . Kruskal-Wallis H test showd that self-rating depression scale scores among academic abuse groups (x~2=9.74,p=0.02) and numbers of abuse type groups(x~2 =33.55, p=0.00) were significant; the self-rating anxiety scale scores among vebal abuse groups(x~2 =9.85,p=0.00), physical abuse groups(x~2=9.49,p=0.00), sexual harassment groups (x~2=15.96,p=0.00) and numbers of abuse type groups(x~2 =37.96,p=0.00) were significant. Nemenyi test showed that in academic abuse groups, the self-rating depression scale score of group 4 was higher than group 1; in numbers of abuse type groups, the self-rating depression scale score of group 4、group 5 and group 6 were higher than group 1, the self-rating depression scale score of group 6 was higher than group 2 and group 3. Nemenyi test showed that in verbal abuse groups and physical abuse groups, the self-rating anxiety scale score of group 3 was higher than group 1 and group 2, in sexual harassment groups, the self-rating anxiety scale score of group 4 was higher than group 1; in numbers of abuse type groups, the self-rating anxiety score of group 4、group 5 and group 6 were higher than group 1, the self-rating anxiety scale score of group 6 was higher than group 2 and group 3.
Conclusion: The phenomenon of medical student abuse is common in Hunan province. Male experience more sexual harassment than female, there are no difference between male and female in other types of medical student abuse. Academic abuse can influence depression symptom; verbal abuse, physical abuse and sexual harassment can influence anxiety symptom.
引文
[1] Vitaliano P, Maiuro R, Russo J. Medical student distress: a longitudinal study. Journal of Nervous and Mental Disease, 1989.177(2): 70-76.
[2] Vitaliano P, Russo J, Carr J. Medical school pressures and their relationship to anxiety. Journal of Nervous and Mental Disease, 1984.172(12): 730-736.
[3] Silver H. Medical students and medical school. Journal of the American Medical Association. 1982.247(3): 309-310.
[4] Rosenberg D, Silver H. Medical student abuse. An unnecessary and preventable cause of stress. Journal of the American Medical Association, 1984.251(6): 739-742.
[5] Silver H, Glicken A.D. Medical student abuse: incidence, severity and significance. Journal of the American Medical Association, 1990.263(4): 527-532.
[6] Daugherty SR, Baldwin DC Jr, Rowley BD. Learning, satisfaction and mistreatment during medical internship: A national survey of working conditions. JAMA 1998,279:1194-1199.
[7] Shizuko Nagata-Kobayashi, Miho Sekimoto, Hiroshi Koyama. Medical Student Abuse During Clinical Clerkships in Japan. J GEN INTERN MED 2006; 21:212-218.
[8] Kassebaum DG, Cutler ER. On the culture of student abuse in medical school. Acad Med. 1998; 73:1149-58.
[9} Association of American Medical Colleges. Medical School Graduation Questionnaire Survey Results: All Schools Summary. Washington, DC: AAMC, 2003.
[10] Rebeka Moscarello, Katalin J, Margittai. Differences in abuse reported by female and male Canadian medical students. CAN MED ASSOC J 1994; 150 (3): 357-361.
[11] Ryynen K. Constructing physician's professional identity-explorations of students' critical experiences in medical education. Academic dissertation 650:2001.
[12] Ana Margratita Maida, Alicia Va' Squez, Viviana Herskovic. A report on student abuse during medical training. Medical Teacher, Vol. 25, No. 5, 2003, pp. 497-501.
[13] Rosal MC, Ockene IS, Ockene JK. A longitudinal study of students' depression at one medical school. Acad Med. 1997;72:542-46.
[14] Larsson C, Hensing G, Allbeck P. Sexual and gender-related harassment in medical education and research training: results from a Swedish survey. Med Educ 2003,37:39-50.
[15] Arja Rautio, Vappu Sunnari, Matti Nuutinen. Mistreatment of university students most common during medical studies. BMC Medical Education 2005,5:36-40.
[16] White GE. Sexual harassment during medical training: the perceptions of medical students at a university medical school in Australia. Med Educ 2000, 34:980-986.
[17] Lebenthal A, Kaiserman I, Lemau O. Student abuse in medical school: a comparison of students' and faculty's perceptions. Isr J Med Sci 1996, 32:229-238.
[18] Richardson DA, Becker M, Frank RR. Assessing medical students' perceptions of mistreatment in their second and third years. Acad Med 1997, 72:728-730.
[19] Lee D. Sexual harassment in PhD supervision. Gend Educ 1998, 10:299-312.
[20] Contemporary Issues in Medical Education. Volume 3, No. 4. Washington, DC: Association of American Medical Colleges, 2000.
[21] Daugherty SR, Baldwin DC Jr, Rowley BD. Learning, satisfaction and mistreatment during medical internship: A national survey of working conditions. JAMA 1998,279:1194-1199.
[22] Nora LM, Daugherty SR, Hersh K. What do medical students mean when they say "sexual harassment"? Acad Med. 1993;68:S49-S51.
[23] Nora LM, McLaughlin MA, Fosson SE. Does exposure to gender discrimination and sexual harassment impact medical students' specialty choices and residency program selections? Acad Med. 1996;71:S22-S24.
[24] Nora LM. Sexual harassment in medical education: a review of the literature with comments from the law. Acad Med. 1996;71 :S113-S118.
[25] Nora LM, McLaughlin MA, Fosson SE, et al. Gender discrimination and sexual harassment in medical education: perspectives gained by a 14-school study. Acad Med. 2002;77:1226-34.
[26] Richman JA, Flaherty JA, Rospenda KM, et al. Mental health consequences and correlates of reported medical student abuse. JAMA. 1992; 267: 692-94.
[27] Frank E, Brogan D, Schiffman M. Prevalence and correlates of harassment among US women physicians. Arch Intern Med. 1998;158:352-58.
[28] O'Donohue W, Downs K, Yeater E.A. Sexual harassment: a review of the literature. Aggression and Violent Behavior, 3(2), 111-128.
[29] Dansky B. S, Kilpatrick D.G Sexual harassment: theory, research, and treatment. Needham Heights, MA: Allyn and Bacon.
[30] Ball S, Bax A. Self-care in medical education: effectiveness of health-habits interventions for first-year medical students. Acad Med. 2002;77:911-917.
[31] Newbury-Birch D, Walshaw D, Kamali F. Drink and drugs: from medical students to doctors. Drug Alcohol Depend. 2001;64:265-70.
[32] Schubert M. The relationship between verbal abuse of medical students and their confidence in their clinical abilities. Academic Medicine. 1998. 73(8): 907-909.
[33] Baldwin DC Jr, Daugherty SR, Eckenfels EJ. Student perceptions of mistreatment and harassment during medical school. A survey of ten United States schools. West J Med. 1991;155:140-5.
[34] Kluft RP. The physician as perpetrator of abuse. 1993;20: 459-80.
[35] Matthew R, Thomas MD, Liselotte N. How Do Distress and Well-being Relate to Medical Student Empathy? A Multicenter Study. Society of General Internal Medicine. 2007;22:177-183.
[36] Elnicki DM, Curry RH, Fagan M, et al. Medical students' perspectives on and responses to abuse during the internal medicine clerkship. Teach Learn Med 2002;14(2):92-7.
[37] Stewart SM, Lam TH, Betson CL. A prospective analysis of stress and academic performance in the first two years of medical school. Med Educ. 1999;33:243-50.
[38]Maida AM,Vasquez A,Herskovic V,et al.A report on student abuse during medical training.Med Teacher.2003;25:497-501.
[39]Wolf TM,Randall HM,Von Almen K.Perceived mistreatment and attitude change by graduating medical students:a retrospective study.Med Educ.1991;25:182-90.
[40]Dans PE.Self-reported cheating by students at one medical school.Acad Med.1996;71(1 suppl):S70-S72.
[41]DeWitt C,Daugherty SR,Beverley D.Cheating in Medical School:a survey of second year students at 31 schools.Acad Med.1996;71:267-73.
[42]Rennie S,Rudland J.Differences in medical students' attitudes to academic misconduct and reported behavior across the years-a questionnaire study.J Med Ethics.2003;29:97-102.
[43]汪向东,王希林,马弘,编著.心理卫生评定量表手册.中国心理卫生杂志,1999(增刊):194-196.
[44]汪向东,王希林,马弘,编著.心理卫生评定量表手册.中国心理卫生杂志,1999(增刊):235-237.
[45]Meier DE,Back AL,Morrison RS.The inner life of physicians and care of the seriously ill.JAMA 2001;286(23):3007-14.
[46]MacLeod R,Parkin C,Pullon S.Early clinical exposure to people who are dying:learning to care at the end of life.Med Edue.2003;37:51-58.
[47]Wear DP."Face-to-face with" It":medical students' narratives about their end-of-life education.Aead Med.2002;77:271-77.
[48]Ball S,Bax A.Self-care in medical education:effectiveness of healthhabits interventions for first-year medical students.Aead Med.2002;77:911-917.
[49]Tyssen R,Vaglum P,Gronvold NT.Suicidal ideation among medical students and young physicians:a nationwide and prospective study of prevalence and predictors.J Affect Disord.2001;64:69-79.
[50]Carson A J,Dias S,Johnston A,et al.Mental health in medical students:a case control study using the 60 item General Health Questionnaire.Scott Med J.2000;45:115-16.
[51]Aktekin M,Karaman T,Senol YY.Anxiety,depression and stressful life events among medical students:a prospective study in Antalya,Turkey.Med Educ.2001;35:12-17.
[52]Dunne MP,Legosz,M.The consequences of childhood sexual abuse·In Carmody Childhood Sexual Abuse in Queensland:Selected Research Papers,Brisbane:Queensland Crime Commission,pp 43-58.
[53]陈晶琦,王兴文.239名高中男生儿童期性骚扰调查.中国心理卫生杂志.17(5):345-347.
[54]朱相华,魏贤玉,王成东,等.儿童期虐待对中专学生的心理健康状况及社交功能的影响.中国行为医学科学,2006,15:407-408.
[55]朱相华,李娇,梁光利,等.儿童期受虐待中专学生的身心症状与述情障碍.中国心理卫生杂志,2006,20:643-635.
[56]张敏,王礼桂,邢艳菲.中学生儿童期虐待相关因素及心理影响研究.中国儿童保健杂志.2007,15(1):30-32.
[57]赵幸福,张亚林,李龙飞,等.中文版儿童期虐待问卷的信度和效度.中国临床康复,2005,9(30):105-107.
[58]Yueh-Hsiu Lin.The incidence of sexual harassment of students while undergoing practicum training expedertce in the Taiwanese hospitality industry-individuals reactions and relationships to perpetrators.Tourism Management 27(2006):51-68.
[59]Eckenfels EJ,Daugherty SR,Baldwin DC Jr.A socio-cultural framework for explaining perceptions of mistreatment and abuse in the professional socialization of future physicians.Ann Behav Sci Med Educ.1997;4:11-18.
[60]Oancia T,Bohm C,Carry T.The influence of gender and specialty on reporting of abusive and discriminatory behaviour by medical students,residents and physician teachers.Med Educ.2000;34:250-6.
[61]Geisler JP,Mernitz CS,Geisler MJ.Does gender discrimination exist in a gynecology training program in a private hospital? Clin Exp Obstet Gynecol.1999;26(2):53-5.
[62]Kassebaum DG,Cutler ER.On the culture of student abuse in medical school.Acad Med.1998;73:1149-58.
[63]Firth-Cozens J,Greenhalgh J.Doctors' perceptions of the links between stress and lowered clinical care.Soc Sci Med 1997;44(7):1017-22.
[64]Shanafelt TD,Bradley KA,Wipf JE.Burnout and self reported patient care in an internal medicine residency program.Ann Intern Med 2002;136(5):358-67.
[65]Bellini LM,Baime M,Shea JA.Variation of mood and empathy during internship.JAMA 2002;287(23):3143-6.
[66]Collier VU,McCue JD,Markus A.Stress in medical residency:status quo after a decade of reform? Ann Intern Med 2002;136(5):384-90.
[67]杜召云,王克勤.1597名大学生抑郁症的流行病学调查.中国行为医学科学,1999,8(3):172-173.
[68]曾强,李乐,唐双阳,等.某高校大学生抑郁症影响因素和预防途径分析.实用预防医学,2006,13(6):1412-1413.
[69]高海燕,门伯媛,殷妍,等.某高校大学生抑郁状况调查.疾病控制杂志,2005,9(3):228-230.
[70]周榕,杨翠华,潘集阳.广州地区重点医科大学生抑郁状况及相关因素调查分析.神经病与精神卫生,2003,3(5):367-368.
[71]Bifulco A.Bull Menninger Clin.2002;66(3):241-258.
[72]樊晓光,周东明.某些社会因素与应届大学毕业生焦虑的相关性研究.中国临床心理学杂志,2001,9(3):203-205.
[73]PattonGC,HibbertM,RosierMJ.Is smoking associated with depression and anxiety in teenagers? Am J Public Health,1996,86:225.
[74]Kassebaum DG,Cutler ER.On the culture of student abuse in medical school.Acad Med.1998;73:1149-58.
[75]Contemporary Issues in Medical Education.Volume 3,No.4.Washington,DC:Association of American Medical Colleges,2000.
[76]Heru,Alison M.Using Role Playing to Increase Residents' Awareness of Medical Student Mistreatment.Association of American Medical Colleges Volume 78(1),January 2003:35-38.
[77]Jacobs CD,Bergen MR,Korn D.Impact of a program to diminish gender insensitivity and sexual harassment at a medical school.Acad Med.2000;75:464-9.
[78]Catalan J,Burgess A,Pergami A.The psychological impact on staff of caring for people with serious diseases:the case of HIV infection and oncology.J Psychosom Res 1996;40(4):425-35.
[79]Shanafelt TD,Bradley KA,Wipf JE.Burnout and self-reported patient care in an internal medicine residency program.Ann Intern Med.March 5.2002;136:358-67.
[80]Thomas N.Resident burnout.JAMA.2004;292:2880-89.
[81]Gelfand DV,Podnos YD,Carmichael JC.Effect of the 80-hour workweek on resident burnout.Arch Surg.2004;139:933-38;discussion 938-40.
[82]Rebeka Moscarello,Katalin J,Margittai.Differences in abuse reported by female and male Canadian medical students.CAN MED ASSOC J 1994;150(3):357-362.
1 Rosenberg DA, Silver HK. Medical student abuse. An unnecessary and preventable cause of stress. JAMA JT - JAMA : the journal of the American Medical Association, 1984,251(6):739-42.
2 Silver HK, Glicken AD. Medical student abuse. Incidence, severity, and significance. JAMA JT - JAMA : the journal of the American Medical Association, 1990,263(4):527-32.
3 Wear D, Aultman JM, Borges NJ. Retheorizing sexual harassment in medical education: women students' perceptions at five U.S. medical schools. Teach Learn Med JT - Teaching and learning in medicine, 2007,19(1):20-9.
4 Recupero PR, Heru AM, Price M, et al. Sexual harassment in medical education: liability and protection. Acad Med JT - Academic medicine : journal of the Association of American Medical Colleges, 2004,79(9):817-24.
5 Ogden PE, Wu EH, Elnicki MD, et al. Do attending physicians, nurses, residents, and medical students agree on what constitutes medical student abuse?. Acad Med JT - Academic medicine : journal of the Association of American Medical Colleges, 2005,80(10 Suppl):S80-3.
6 van Ineveld C. Stress in residency training: symptom management or active treatment?. CMAJ JT - CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne, 1994,150(10): 1549-51.
7 Frank E, Carrera JS, Stratton T, et al. Experiences of belittlement and harassment and their correlates among medical students in the United States: longitudinal survey. BMJ JT - BMJ (Clinical research ed.), 2006,333(7570):682.
8 Moscarello R, Margittai KJ, Rossi M. Differences in abuse reported by female and male Canadian medical students. CMAJ JT - CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne, 1994,150(3):357-63.
9 Nagata-Kobayashi S, Sekimoto M, Koyama H, et al. Medical student abuse during clinical clerkships in Japan. J Gen Intern Med JT - Journal of general internal medicine : official journal of the Society for Research and Education in Primary Care Internal Medicine, 2006,21(3):212-8.
10 Maida AM, Vasquez A, Herskovic V, et al. A report on student abuse during medical training. Med Teach JT - Medical teacher, 2003,25(5):497-501.
11 Rautio A, Sunnari V, Nuutinen M, et al. Mistreatment of university students most common during medical studies. BMC Med Educ JT - BMC medical education, 2005,5:36.
12 Larsson C, Hensing G, Allebeck P. Sexual and gender-related harassment in medical education and research training: results from a Swedish survey. Med Educ JT - Medical education, 2003,37(l):39-50.
13 Dyrbye LN, Thomas MR, Huntington JL, et al. Personal life events and medical student burnout: a multicenter study. Acad Med JT - Academic medicine : journal of the Association of American Medical Colleges, 2006,81(4):374-84.
14 Heru AM. Using role playing to increase residents' awareness of medical student mistreatment. Acad Med JT - Academic medicine : journal of the Association of American Medical Colleges, 2003,78(1):35-8.
15 Stratton TD, McLaughlin MA, Witte FM, et al. Does students' exposure to gender discrimination and sexual harassment in medical school affect specialty choice and residency program selection?. Acad Med JT - Academic medicine : journal of the Association of American Medical Colleges, 2005,80(4):400-8.
