System dynamics modeling to understand mental model of public humiliation in medical education

Mistreatment in medical school is a wicked or complex problem demonstrating inter-relatedness and dynamicity of factors that affect students. Many studies have outlined the causes, perceptions, and negative consequences of mistreatment; however, a comprehensive mental model of public humiliation, the most common type of mistreatment, is still incomplete. This study aims to provide insight into the reasons why public humiliation in medical school continues to be a problem despite existing for decades, and to propose a shift in paradigm that potentially improve these incidents.

A systems thinking approach is used to conceptualize related components of public humiliation and student behavior. System dynamics modeling was conducted through narrative review, developing a causal loop diagram (CLD), and validation of results with 60 medical students and 40 medical educators.

Findings from the narrative review outlined key variables, interconnections and five emerging themes: etiology, eustress, motivation, distress, and self-esteem. The themes were conceptualized and constructed into feedback loops as a basis for the CLD. Finally, the mental model proposes three major systems underlying the consequences. The "No Pain, No Gain" illustrates the perception that stress positively drives learning, while "Stress Overload" displays the negative consequences of public humiliation. Lastly, "The Delayed Side Effect" refers to long-term side-effects on self-esteem.

The mental model illustrates how public humiliation has both immediate and delayed side-effects, simultaneously succeeding and failing at motivating student growth. Therefore, public humiliation requires continuous changes in perspective along with multiple interventions to overcome the vicious cycle.