[version 1; peer review: 1 approved with reservations]
No competing interests were disclosed.
Daily interactions between faculty members and students in medical education and clinical training environments directly influence learning, motivation, mental well-being, and the development of professional behavior. Evidence indicates that lack of respect and dignified communication can lead to reduced academic participation, decreased performance, psychological distress, and weakened professional ethics.
Data were collected from medical sciences students and faculty members through semi-structured interviews and field observations and analyzed using a thematic approach. Three main dimensions of dignity-based interactions emerged:
Interpersonal and Communicative Respect – respectful speech, active listening, constructive feedback Educational and Clinical Respect – safe learning climate, acceptance of errors, educational justice Structural and Institutional Respect – organizational support, ethical policies, behavioral oversight
Respectful educational interactions were found to enhance learning motivation, academic engagement, psychological safety, and professional ethics.
Three main themes and multiple subthemes were identified: interpersonal/communicational respect (politeness, active listening, feedback culture), academic/clinical respect (constructive evaluation, safe learning space, error acceptance), and institutional respect (supportive policies, ethical climate, justice in assessment). Respect positively influenced motivation, engagement, academic performance, and professional formation.
Dignity in medical education is not merely a human virtue but a critical policy element for improving educational outcomes, mental health, and professional development. Institutionalizing respectful communication and adopting supportive policies can sustain this culture and significantly enhance the quality of medical training.
Medical students routinely face stressors including heavy workload, clinical pressures, hierarchical structures, and exposure to humiliating behaviors. Such experiences undermine confidence, motivation, and professional ethics. Surveys, including one of 94,153 Chinese medical graduates, show 84% reported at least one episode of mistreatment, linked to burnout, reduced empathy, and career regret. Failure to institutionalize respect risks losing competent, ethical future clinicians and negatively impacts patient care.
A qualitative thematic analysis explored perceptions of “respect” among students and faculty:
Respect is a structural driver of learning quality and professional growth (
Enhances motivation, participation, cognitive engagement, and dialogue
Acts as a protective factor against emotional exhaustion (
Students exposed to respectful environments demonstrate humane patient care Fosters responsibility, fairness, and ethical integrity Faculty serve as role models for respectful communication Thus, respect is foundational to cultivating ethical physicians and nurses.
| Dimension | Characteristics |
|---|---|
|
|
Respectful tone, avoidance of humiliation, active listening, reciprocal courtesy |
|
|
Opportunities for inquiry, constructive feedback, acceptance of mistakes, educational justice |
|
|
Supportive policies, fair evaluation, workload management, and clear regulations |
| Positive outcomes | Consequences of disrespect |
|---|---|
| Higher self-worth | Lower self-confidence |
| Reduced stress/anxiety | Psychological pressure & burnout |
| Psychological safety | Fear of error, performance anxiety |
| Academic enthusiasm | Demotivation, disengagement |
| Option | Description |
|---|---|
|
|
A mandatory institutional policy defining disrespect (verbal, discriminatory, humiliating), clarifying consequences, and applicable to all faculty, clinicians, and staff. |
|
|
Regular workshops for faculty/clinical staff on communication, constructive feedback, and student dignity. |
|
|
A secure online/paper mechanism with an independent review committee ensuring confidentiality and non-retaliation. |
|
|
Fair distribution of clinical opportunities, acceptance of errors as learning moments, and recognition of students as team members. |
|
|
Annual surveys, psychological safety indicators, and monitoring of mistreatment/discrimination to inform corrective action. |
Establish multidisciplinary taskforce Develop official mistreatment policy Build confidential reporting system Prepare training modules
Launch reporting mechanism and awareness campaign Deliver training to selected faculty/staff Conduct baseline learning-environment survey
Mandatory training for all faculty/clinical units Integrate professionalism metrics into staff evaluation Annual surveys on learning climate, mental health, and respect
Mandate communication skills and professionalism training for all students and faculty. Adopt and publicly display a “Code of Respect” across classrooms and clinical sites. Implement a protected and confidential reporting system for both misconduct and exemplary behavior. Provide psychological support and workload management to reduce stress and prevent burnout. Establish recognition mechanisms for faculty and students who model respectful behavior. Monitor the educational environment regularly using validated tools with transparent feedback loops.
Respect in medical education is not merely an interpersonal courtesy but a policy-driven and structural element essential to educational quality. Integrating respect into institutional policies, training frameworks, monitoring systems, and organizational culture enhances learning outcomes, safeguards mental health, strengthens professional ethics, and supports the formation of humane and responsible healthcare providers.
From a policy standpoint, nurturing a culture of respect represents a strategic investment in the resilience, competence, and ethical integrity of the future healthcare workforce—and, ultimately, in the quality of patient care.
This study was approved by the Ethics Committee of Kermanshah University of Medical Sciences (IR.KUMS.REC.1404.394). All methods were carried out in accordance with relevant guidelines and regulations. Written informed consent was obtained from all participants prior to inclusion in the study.
Not applicable.
The datasets generated and/or analyzed during this study are not publicly available due to ethical restrictions related to participant confidentiality. The Ethics Committee of Kermanshah University of Medical Sciences reviewed and approved the data management plan to ensure privacy. De-identified data may be made available from the corresponding author upon reasonable request for research purposes, subject to Ethics Committee approval and compliance with institutional regulations. Requests for access should be addressed to the corresponding author:
we sincerely thank all participants for generously sharing their experiences and insights, which made this study possible.
Abstract
This policy brief addresses the urgent issue of dignity and respect in medical education environments. Using qualitative thematic analysis, the authors identify three core dimensions of respectful interaction: (1) Interpersonal and Communicative Respect, (2) Educational and Clinical Respect, and (3) Structural and Institutional Respect. The paper presents five policy options and a three-phase implementation roadmap, concluding that dignity must be institutionalized as a structural policy element rather than treated merely as a personal virtue. The paper draws on a large-scale study reporting that 84% of Chinese medical graduates experienced at least one episode of mistreatment, underscoring the global relevance of the problem.
Comments
The paper presents a clear, logically organized structure that a general reader can follow. The abstract effectively communicates the core problem, methodology, and conclusions. The three-dimensional conceptualization of respect (interpersonal, educational/clinical, structural) is intuitively accessible and is clearly presented. Concise descriptions of five actionable instruments offer the policy options. The three-phase implementation roadmap, while brief, provides a temporal framework that readers from outside academia can understand. The policy implications are logically connected to the findings. The paper correctly identifies that disrespect leads to burnout, reduced empathy, and career regret. The connection between respectful environments and professional identity formation is conceptually sound and consistent with established theory in medical education. The six final policy recommendations are clearly written, specific, and actionable. They follow logically from the three-dimensional conceptual framework established earlier in the paper. The three-phase implementation roadmap provides temporal specificity, measurable indicators, and a realistic progression that policymakers could plausibly adopt.
Issues for revision
-The paper does not sufficiently situate the reader within the specific cultural, institutional, or healthcare system context. Commonly, medical education operates within a hierarchical structure shaped by specific cultural norms around authority and deference. A general international reader cannot fully assess the transferability of the proposed policy framework to other settings.
-The paper states that data were collected via "semi-structured interviews until saturation" and analyzed with a "thematic approach", but provides no information on the number of participants, the duration of fieldwork, or specific thematic categories that emerged.
-No breakdown of participant characteristics (year of study, specialty, gender, academic rank of faculty) is provided.
-The paper does not reference existing dignity or anti-harassment frameworks implemented in peer institutions internationally, which would have enriched the contextual framing considerably.
-The paper cites only 7 references. Key references are entirely absent, like Hafferty (Hidden curriculum theory), Edmondson (Psychological safety), Deci & Ryan (Self-Determination Theory), and Dyrbye (Burnout in medical trainees).
-As a policy brief, the paper would be significantly strengthened by citing systematic reviews or meta-analyses on mistreatment interventions in medical education.
-The six recommendations are presented as a flat, undifferentiated list. Without prioritization, institutional decision-makers face ambiguity about where to begin, particularly in resource-constrained settings.
-The recommendations do not acknowledge the specific challenges of implementing them within the particular medical education system — including administrative hierarchies, resource constraints, or potential faculty resistance. A policy brief gains credibility precisely when it addresses implementation barriers honestly.
-The recommendation to implement a confidential reporting system is sound, but the paper acknowledges that underreporting is a risk "if confidentiality is not guaranteed." It does not, however, offer concrete strategies for ensuring that confidentiality — a critical gap given the hierarchical power dynamics identified in the research itself.
-The suggestion to recognize faculty who model respectful behavior is valuable but entirely unsupported by evidence or examples. What forms should recognition take? What perverse incentives might arise? These questions are left unaddressed.
-All recommendations are directed at institutions or faculty. Students are framed exclusively as recipients of respectful treatment, with no recommendation addressing their agency in co-creating respectful environments, a significant oversight from a participatory or rights-based policy perspective.
-Beyond annual surveys, there is no discussion of how the recommended culture change would be sustained across faculty turnover, budget cycles, or institutional leadership changes. All critical vulnerabilities for long-term policy effectiveness.
Does the paper provide a comprehensive overview of the policy and the context of its implementation in a way which is accessible to a general reader?
Partly
Is the discussion on the implications clearly and accurately presented and does it cite the current literature?
Partly
Are the recommendations made clear, balanced, and justified on the basis of the presented arguments?
Partly
Reviewer Expertise:
Health psychology, Promotion and Prevention, Public Health
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.