Rethinking Residency spoke with Sierra Norman, a fourth year medical student and now activist working to change the culture of medical school and prevent the abuse of power directed at learners. We could tell immediately that Sierra was poised and confident, but that this was a difficult subject. She shared with us an incredibly personal story, one that almost every other medical student in the country would want to bury deep down and hide from. But she was unwilling to let it shame her. 

This is not a story told by an established attending about some terrible experience they went through way back in medical school. There is real risk involved by Sierra coming forward and sharing this publicly. Her desire to explore the subject was inspiring to see, and as she pointed out towards the end of our discussion, well worth it if her story can help others avoid a similar fate and those that have experienced mistreatment feel not so alone. We were impressed with her objectivity and level of self reflection, even for a story that is still so raw. There can be so much at stake for medical students, residents and fellows. Protecting those that are in the most vulnerable positions is the mission of Rethinking Residency, and we could not be more proud to share Sierra’s story here.

I: Walk us through the experience you had during your first surgical clerkship.

Sierra: This was my third clerkship during medical school. My first was on OBGYN, so I felt that I had some decent surgical exposure at that point. I liked the procedural aspect. I liked being in the OR. I knew that I wasn’t going to pursue a surgical residency, so I was excited for the experience since I knew I wouldn’t have the opportunity again. 

On day one, I could tell that this was a very tense atmosphere, based on the way the surgeons, PAs, and OR team spoke to and about one another. For example, the Site Director warned me it might be a good idea to ‘stroke the ego’ of one particular surgeon. The next day, a scrub tech told me to ‘stand behind me and don’t say anything’ to avoid this surgeon’s attention. This surgeon would say things like they would never hire a female surgeon because they hire based on ability. And the Site Director said this surgeon wrote that a patient received a “pornstar shave” prior to the operation.

But most notably early on to me was the way the PAs seemed to attempt to set me up for failure, telling me incorrect times to arrive at cases and misdirecting me on which cases to participate in. 

I: So already off to a rocky start. What happened next?

Sierra: I started to have increasingly negative interactions with the PAs. One PA made a comment in passing, reprimanding me for a question I had asked another PA that this PA was not present for, so I quickly understood that there was talk amongst this group about me. I approached the Site Director to ask about it and he said he wasn’t worried about it and told me I shouldn’t be either. He acknowledged again that there was a fairly toxic environment among the team, but that I should not let it get to me. He also admitted that one of the PAs had a habit of taking a ‘father-like approach’ with some of the medical students. 

At the beginning of the third week, there was a second instance of public humiliation by a PA in the OR. I asked to speak privately with the PA the next morning, as I had four weeks left of the rotation and things were just getting worse. Initially, our conversation was pleasant enough, until he abruptly stopped and said, ‘Actually, I am upset now. I have never been called out by a medical student before. Do you want me to just ignore your existence? Because I can do that!’ I again spoke with the Site Director about the learning environment. He told me again he wasn’t worried about this impacting my evaluation. Due to the escalating pattern, he did try to limit my interactions with the PAs at this point.

I: Had you experienced anything like this during your time in medical school?

Sierra: No, aside from my first surgery clerkship and the circumstances connected to it, I have had an absolutely wonderful time in medical school.

To be honest, I am from a small town in Idaho. I am familiar with a certain level of misogyny and knew I could handle 6 weeks of it and be on my way. I did, however, start keeping notes about my interactions, because I recognized it was not a healthy learning environment. The Site Director had been mostly ambivalent about it during the rotation, but I wasn’t sure he knew that something was happening almost every time I was with the PAs and I didn’t want to bother him with something almost every day. The notes were for feedback at the end of the rotation, to hopefully create a better environment for the next student.

I: Ok so you decided to just try and get through it, while at least keeping a record of what happened. How did it end?

Sierra: On the last day, I had 3 cases with the Site Director. Following the surgeries, I texted him to offer a time to discuss feedback. He did not accept, texting that I ‘finished strong.’ I told him I had notes about the negative interactions and that I would include them in my evaluation. He said again that he wasn’t worried about it. But looking back, I think he may have taken this as a threat, which I did not intend to do. 

A few days later, I received an email from him. This was an email not meant for me, but one that he sent to me in error. In the email, he stated he believed I would be giving him a negative evaluation and he would be failing me.

I: Wait, he sent you an email saying all of that? How did that even happen?

Sierra: There is a bit of a back story to this, but basically I had asked a few weeks earlier if I would be allowed to take a picture scrubbed in outside of the OR to commemorate my clerkship. I had posted recaps of my other clerkships, and wanted to continue the tradition. He told me that was fine, but when I asked a nurse if she could take a picture, she stated that she wasn’t sure if it was allowed. A few days later, there was actually a photographer taking pictures of a robot being used in the surgery. He took one that I was in, and so I asked him following the case if he could send me the picture via email and he said that he would.

I didn’t hear back from him, so on my last day I asked the OR admin about it. After the rotation was over, the Site Director called to tell me he had heard I was taking photos in the OR and posted it on social media and that I had to take it down. But I did not take any photos in the OR on that rotation, so I didn’t have any posted on social media. I did, however, have a recap post from the OBGYN rotation that included a picture taken by my attending of me behind the robot. It was posted a month before my surgery rotation even started and was taken in a different state.

His colleague had emailed me about this alleged photo and CC’d the Site Director. I responded that no policies had been violated and that no patient confidentiality had been compromised. This was ultimately the thread the Site Director responded to with the email stating he planned to fail me, believing he would be receiving a negative evaluation. The email was addressed to his colleague, but since it only came to me it appears he just replied to the last email of the thread. 

I: Wow, that is pretty terrible. Unfortunately not even the first story we’ve heard about an attending arbitrarily making rules about social media usage.

Sierra: Yeah, my university has reposted both the OBGYN clerkship photo and a photo from my second surgery clerkship on their social media page.

I: Ok, so you receive the email, and you know what’s coming. How did you deal with it?

Sierra: I had been speaking with the university’s designated advocate during this time, who was very supportive. I received my official evaluation from the Site Director – a 34.1% clinical grade – Fail and the comment ‘”Failed on a personal and professional level. It’s a matter of time before she hurts a patient and then what do we say? We are not liable if we tell the truth.” This, I didn’t know was coming. There had been no indication of any concerns, much less to this severity, to me or the university. I appealed the evaluation with our Clerkship Director. I was particularly disturbed by the comment “It’s a matter of time before she hurts a patient.” I asked if I could get additional information because even though I knew it was written in retaliation, I wanted to make sure that there wasn’t something that I was oblivious to that was legitimately a danger to patients.

I never received any additional information, but after she spoke with the Site Director, the comment was quietly removed from my evaluation. Still, both Phase 1 and 2 of my appeals process were denied. In her email summary of the conversation she had with the Site Director, there were many things he had told her for which I had evidence to the contrary. For example, he told her that I had not paid attention to the 4 page list of medical student expectations and provided a copy. It was not the same document he had emailed me at the beginning of the rotation. 

At that point, my appeal moved to Phase 3 to be reviewed by the university’s committee. I submitted my written appeal and evidence, and had to de-identify the evidence myself because the committee said they were not used to having that much evidence. And while the committee found it concerning, they saw no reason to overturn the Clerkship Director’s decision. I spoke with several Deans, hoping for answers. They could not answer and all eventually directed me back to the Clerkship Director. She refused to meet with me and directed me to speak with someone who had already directed me to speak with her.

I: That sounds horrible, I am sorry you had to go through that. What has happened since that decision was made?

Sierra: I was in a dark place for a while after that clerkship. But I had to keep going. I completed my Internal Medicine clerkship, receiving a glowing evaluation. I found out a few days before my shelf exam that the university would be taking no action with my surgery evaluation. I was so nervous about how that impacted my performance and was relieved when I found out I passed…only to be notified by my university several days later that there had been a mistake and I had missed passing by 1 question. I successfully retook the shelf exam and finished the rest of my third year clerkships, with continued strong evaluations and passing shelf exams.

I had to re-complete the surgery clerkship, at a different site than my first surgery clerkship.  I absolutely did not want to return to that environment and convinced myself that I would simply survive and make it through 6 weeks by not talking about the first surgery clerkship. On day one, I made it 6 hours until I broke down and told my chief resident how I was feeling, and why. Her response was validating: “That’s fucked up.” Ultimately, I finished the second surgery clerkship with a  93.8% clinical grade.

I mostly kept all of this to myself until about 3 months ago, when I published an article detailing this story in the International Journal of Medical Students. Simply writing about this has been incredibly healing for me, and I have mostly received an outpouring of support from the community. PA students from a different university have even reached out, sharing their similar experiences at this surgery site. I have since been fortunate enough to speak with several national organizations including AMWA and ACS and am developing my own project called ‘A MATTER OF TIME.’ It is designed to support mental health for those on their path to becoming a physician. And it is of course named after the comment from my first surgery clerkship.

I: Well I am glad to hear that you are finding some positives from your experience and looking to help others that might go through a similar situation. It takes a lot of bravery to speak publicly about that, especially while still in medical school. Do you have any advice for other medical students, or things that you may have done differently?

Sierra: I wish I had listened to my gut. I could tell that something was off almost immediately, but did not seek outside help beyond the site soon enough since I was simply being told not to worry about it. I would also encourage others to seek out people that you trust and share these types of things with them. It is all too common in the competitive world of medical school to bottle everything up and refuse to show weakness. But this is how environments like what I was in are allowed to thrive. By opening up and sharing personal experiences, we can change this culture for the better. I also think there needs to be structural changes from an institutional level regarding clerkships and how medical students are protected. There is no reason why an institution should not be notified at some point before the end of a clerkship if that student is likely to fail. This would create more accountability for the clerkship sites and help prevent retaliation at the close of a clerkship. 

Ultimately, I just don’t want to see this happen to anyone else. There are ways we can create a more open and balanced system for medical students, and I hope sharing my experience contributes to that change.