Introduction

Students’ subjective well-being and motivation are ongoing concerns for any medical school. They are important aspects of academic life as they correlate with students’ academic performance1,2. Motivation is generally categorized into two types. First, intrinsic motivation reflects a genuine interest in an activity to learn and assimilate. Second, extrinsic motivation is derived from an expected gain or outcome. Extrinsic motivation includes external and internal rewards or punishments, self-control, personal importance, and value. Amotivation typically describes a lack of motivation3,4. A study found that motivation indirectly affects academic performance through learning engagement2. However, another study revealed that medical students’ motivation decreased as medical training progressed. Factors associated with motivation include learning environment, learning approach, time spent studying, study time, sex, stressors, sleep quality, bullying or discrimination during training, perceived social support, and determination. At the same time, depression is associated with amotivation3,5,6,7,8.

A systematic review of data across countries, including Thailand, revealed a higher prevalence of depression, anxiety, burnout, stress, and suicidal ideation in medical students compared to young people in the general population9,10,11. These mental health problems affect students personally, academically, and professionally12. The prevalence of these mental health problems was highest among fourth-year medical students13. Compared to preclinical training (first to third year in Thailand), clinical training (fourth to sixth year) can expose students to many stressful events. Studying during the clinical years also inevitably involves difficult encounters with numerous people, including patients, residents, senior faculty, and other healthcare personnel10,14. Exceedingly high expectations characterize medical training. Some individuals involved in the process may mistakenly believe that subjecting students to demanding and occasionally intimidating experiences is the optimal method to prepare them for the rigors of clinical practice. However, this approach may inadvertently contributing to the potential for mistreatment.

Mistreatment is defined as "intentional or unintentional acts occurring when behavior shows disrespect for the dignity of others and unreasonably interferes with the learning process." Mistreatment includes the use of grading and other forms of assessment in a punitive manner; discrimination or harassment based on race, religion, ethnicity, sex, or sexual orientation; humiliation; psychological or physical punishment; and sexual harassment15. Mistreatment has been reported among 35-47% of students across medical schools15,16,17. The most common form was public humiliation from clinical professors15. Previous studies in Thailand found that 63.4-74.5% of medical students experienced mistreatment during training. The most common types of mistreatment reported by Thai medical students were verbal criticism and discriminative behavior from the attending physicians6,18. Being mistreated can considerably affect students’ academic performance and well-being. Some students experience stress, burnout, anxiety, depression, and decreased motivation to continue studying as a result of mistreatment6,18,19. Experiencing recurrent and severe mistreatment is associated with students feeling overwhelmed and considering quitting medical school20.

Although mistreatment remains a challenging issue in medical education, such problems could be prevented with appropriate communication and a clear understanding between medical personnel and students15,21. Interventions to reduce mistreatment through collaboration among students, faculty, and administrative leaders have been reported. The interventions included identifying misunderstandings, challenges, and impacts of mistreatment, promoting professionalism in faculty members, prompting responses to reports of mistreatment, and providing tools to help instructors provide authentic learning environments for students. These interventions have been associated with a reduction in reported mistreatment21.

In Thailand, there are still very few studies on mistreatment among medical students, and nationwide data remain lacking6,18. Moreover, the types of academic mistreatment have not been clearly disaggregated or quantified in previous research. While earlier studies have examined factors such as year of study, GPA, burnout, and attempts to withdraw from the program, they have not explored academic motivation as a potential outcome of mistreatment. The prevalence and associated factors of mistreatment among Thai medical students are unclear. The hypothesis is that there could be some prevalence of mistreatment among Thai medical students, and mistreatment could be associated with students’ low academic motivation. This study investigates the prevalence of mistreatment and its association with academic motivation among Thai medical students in their clinical years. Additionally, the study aims to examine the existing support systems and procedures for reporting mistreatment within medical schools.

Materials and methods

This research is part of the project “Mental strength and challenges among Thai medical students in their clinical year.”

Study design and time period

This study employed a cross-sectional design among medical students currently studying and working in 23 qualified medical schools throughout Thailand (2020-2021). The study was approved by the ethics committee of the Faculty of Medicine, Chiang Mai University. Study code: FAC-MED-2563-07564 / Research ID: FAC-MED-2563-07564

Study population

The participants were medical students currently studying in their clinical years, years 4 to 6, within 23 Thai medical schools certified by the Institute of Medical Education Accreditation (IMEAc). Inclusion criteria included students having 1. an electronic device with an internet connection, such as a mobile phone, tablet, or personal computer, to submit questionnaires and 2. having passed at least one rotation in clinical training. No specific exclusion criteria were established in order to maintain inclusiveness and represent the entire population of clinical-year medical students. Students with physical or mental illnesses were not actively excluded; participation was voluntary, and it was assumed that those unable or unwilling to participate would self-select out of the study. However, responses with substantial missing or incomplete data (i.e., essential sections of the questionnaire not completed) were excluded from the final analysis to ensure data quality.

Sample size calculation

A related study conducted at a Thai medical school in the southern region indicated that the proportion of medical students experiencing mistreatment at least once during their clinical years was 63.4%18. The sample size was calculated using a single-proportion formula:

$$n=\frac{{Z}^{2 }\cdot p\cdot (1-\text{p})}{{d}^{2}}$$

In this formula, Z was set at 1.96, corresponding to a 5% type I error. The estimated proportion of mistreatment (p) was 0.634, based on findings from a previous study, and the margin of error (d) was set at 0.05. The calculation was performed using OpenEpi (version 3.01), which indicated that a minimum of 357 participants was required for this study. To reach this number efficiently during the COVID-19 pandemic, a convenience was employed, as it allowed for rapid and broad dissemination of the questionnaire through social media platforms and student networks, enhancing trust and participation rates. Due to unexpectedly high interest in the study, the online survey remained open beyond the initial target, resulting in a final sample size of 399 participants. In addition to convenience sampling, snowball sampling was employed due to the sensitive nature of the topic (mistreatment), which may discourage some students from responding through formal channels. This approach helped include participants from a broader range of backgrounds and institutions, and encouraged students who might otherwise avoid or mistrust official invitations to contribute their experiences more comfortably and anonymously.

Procedure and participant invitation

Due to COVID-19 physical distancing requirements, we developed an online questionnaire for this study. The investigators provided potential participants with a survey link or the Quick Response code (QR code). Flyers to invite students to participate in the study were placed in private areas such as medical students’ dormitories or private rooms for medical students in teaching hospitals. Social media networks such as LINE and medical student associations were used to communicate and distribute questionnaires. Communication between researchers and participants occurred through assigned university representatives and via the contact information provided by the researchers (phone and email).Payments of 200 baht (approximately 5.7 US dollars based on the October 2023 exchange rate) were offered to compensate participants for completing the questionnaires. Those who wished to receive payment were required to provide their bank account details, a valid citizen ID, or a mobile phone number linked to their bank account. This information was used solely for the payment transfer and was deleted after completion. Participants could opt out of providing this information if they did not wish to receive compensation.

The first page of the questionnaire contained information about informed consent and study details to ensure participants would understand the research purpose and voluntarily participated. No personally identifiable information, including participant names or university affiliations, was collected in the questionnaire or mentioned in any reports or publications. To maintain anonymity, researchers were unable to identify individual participants or provide direct assistance to those who experienced mistreatment. However, at the end of the questionnaire, all participants received general advice encouraging them to seek support if they had experienced mistreatment or exhibited symptoms of mental health concerns. The data were collected over a one-year period.

Measurements

The primary questionnaires included sociodemographic data, information related to participants’ status, and details about support and extracurricular activities provided by the faculty, followed by questionnaires assessing academic motivation using the Academic Motivation Scale (AMS).

The AMS measures three types of motivation based on Self-determination theory, i.e., intrinsic, extrinsic, and amotivation. It was developed by Vallerand et al.22 and adapted for use among medical students by Kusurkar et al.4. The Thai version was developed by Wongpakaran and was used with permission. The AMS has 28 items that use a 7-point Likert scale that ranges from 1 “strongly disagree” to 7 “strongly agree.” There are three subscales of intrinsic motivation: (1) obtaining knowledge, (2) accomplishment, and (3) stimulation. Extrinsic motivation also has three subscales: (1) identified regulation, (2) introjected regulation, and (3) external regulation. The score ranges from 28 to 196; the higher the score, the higher the academic motivation. The internal consistency of the Thai version of AMS was excellent (Cronbach α = 0.84)3.

Mistreatment questionnaires

The mistreatment questionnaires investigated the participants’ experiences of mistreatment or of witnessing such incidents and their reactions to mistreatment experienced by others, as assessed by a single question. The questionnaire regarding mistreatment experience was developed by collecting questions and information reported in previous studies via PubMed and Google Scholar searches. The terms “medical student,” “mistreatment,” “clinical training,” “abuse,” and “harassment” were used in articles published from 2006 to June 2020. Previous studies on the mistreatment of medical students during clinical training have been reviewed18,19,20,23. Several current medical students and faculty were also interviewed to develop this questionnaire. Each question/scenario was created to address various kinds of mistreatment. For example, in a recent bedside teaching session with a patient, a medical professor posed a question to a student regarding the diagnosis and treatment of the patient’s condition. Unfortunately, the student was unable to respond. In front of both the students and the patient, the professor bluntly remarked, "Have you read any books? You can’t even answer this simple question. You demonstrate a lack of responsibility; how do you expect to become a doctor?" Participants were asked: ‘What is your perspective on the professor’s response in this situation?’ The questionnaire consists of 38 questions to gather detailed information regarding mistreatment experiences and reporting of mistreatment incidents. The questionnaire regarding mistreatment prevalence is based on a 5-point Likert scale, ranging from ‘never’ (0 times) to 'a couple of times’ (1 to 2 times), ‘sometimes’ (3 to 5 times), ‘often’ (6 to 10 times), and ‘many times’ (over 10 times). This questionnaire has face validity assessed by the investigators, who have over 25 years of experience in mental health and psychiatry (Tinakon Wongpakaran and Nahathai Wongpakaran). The questionnaire was tested in a pilot study with 30 medical students. The content validity index is 1.00. The mistreatment questionnaire exhibited Cronbach’s alpha of 0.74.

Measurement tools of the survey

Instrument

Aim in assessing

Response format

Number of items

Recall period

Internal consistency

Composite Questionnaire of Mistreatment

Qualitative and quantitative data of mistreatment experience and mistreatment detail (Participants can select more than one choice)

5 Types of mistreatment include

1. Verbal mistreatment

2. Physical mistreatment

3. Sexual mistreatment

4. Discriminative mistreatment

5. Academic mistreatment

Mixed

13

Past to present

0.74

Academic Motivation Scale (AMS)

Level of motivation and amotivation

3 types of motivation

i.e., Motivation (intrinsic, extrinsic) and amotivation

Interpretation of the total score: 196

7

28

Past to present

0.84

  1. *Internal consistency is calculated using Cronbach’s alpha coefficient (> 0.7 considered acceptable)

Statistical analysis

Descriptive statistics were used for sociodemographic data, presented as frequencies. Percentages (%) were used for categorical variables, e.g., sex, while continuous variables, e.g., age, were presented as mean ± standard deviation or median (interquartile range). The Chi-square was used to assess differences in proportions and the Mann-Whitney U was used to compare differences for continuous variables between groups. Multiple linear regression was used to assess the relationship between mistreatment (and its subtypes) and academic motivation. Covariates included in the model were age, sex, year of study, number of clinical rotations, and underlying psychiatric conditions. Model fit was assessed by reporting the adjusted R2 and the F-statistic. Adjusted R2 quantifies the proportion of variance explained by the model, adjusted for the number of predictors. The F-statistic and its p-value test the overall model significance. Both statistics are reported to strengthen the credibility of our regression analysis. p-values < 0.05 were considered statistically significant. IBM SPSS version 22.0 was used for data cleaning and statistical analysis.

Results

Demographic

A total of 399 participants completed the questionnaire. Participants were aged between 21 and 30 years with a mean age of 23 ± 1.29 years, and 61.5% were female. The majority of students (39%) were in their 4th year. 15.3% of participants reported having psychiatric disorders (e.g., anxiety disorder, depression, and obsessive–compulsive disorder). Of the 399 participants, 323 (80.95%) reported experiencing mistreatment. Further details are presented in Table 1.

Table 1 Demographic data.
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Prevalence of mistreatment

Overall, 81% of students reported experiencing mistreatment at least once during clinical training, while 81.8% witnessed mistreatment of their peers. The prevalence of mistreatment was related to the students’ age, year, and the clinical rotations they had completed. The most common types of abuse were verbal mistreatment (74%), followed by academic mistreatment (53%). Discriminative mistreatment was reported by 37% of students, while 20% and 19% experienced sexual and physical mistreatment, respectively (Table 2).

Table 2 Type and frequency of mistreatment.
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The most common sources of mistreatment were faculty members (41%), residents (25%), and nurses (24%). Mistreatment was most frequently reported during the surgery rotation (64.5%), followed by internal medicine (21.7%) and obstetrics and gynecology (11%) (Table 3). There was no significant association between the number of clinical wards completed and the experience of mistreatment (p = 0.120).

Table 3 Mistreatment details. Participants have the option to select more than one choice.
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The most common reactions to mistreatment among students were anger (23.2%) and a decrease in motivation to learn (20.6%). Additionally, 9% of students reported having considered discontinuing their medical training due to mistreatment. Most students who experienced or witnessed mistreatment (85.8% and 88.6%) did not report these events. Most students who experienced mistreatment directly thought that the problem could not be solved (48.1%) or that it was not significant enough to be reported (21.3%). Similarly, 15.7% of students who witnessed mistreatment believed that the issue could not be addressed effectively. Some students reported uncertainty about how to support their peers who experienced mistreatment.

When asked about the perceived reasons for mistreatment, most students believed that the perpetrators did not view their actions as inappropriate or serious (28.8%). Others believed the perpetrators intended to push students toward self-improvement (19.3%) or had lost self-control (18.5%) (Table 3).

Medical school support system for students

Most participants reported that their medical schools offer student support systems, such as annual mental health screening for new students and faculty, and efforts to identify students with underlying psychiatric conditions or those considered high risk. However, most participants considered the mental health support provided by their schools to be only moderately adequate. Most students also reported that their schools provide financial support and formally recognize the achievements of both students and faculty. Participants also perceived that traditional norms and hierarchical structures are deeply embedded within their medical institutions.

Regarding a mistreatment reporting system in their medical school, most participants reported that the system’s perceived efficacy and safety were only moderate. Most systems do not clearly specify who is authorized to access the reports or address the reported issues. (Supplementary Table 1).

Mistreatment and students’ academic motivation

Multiple linear regression analyses revealed that all types of mistreatment (verbal, physical, sexual, discriminative, academic, and overall) were significantly associated with motivation for learning, after controlling for relevant covariates (all p < 0.001). The models explained between 7.3% and 10.7% of the variance in motivation for learning (adjusted R2 range: 0.073–0.107), with verbal and academic mistreatment, as well as overall mistreatment, demonstrating the highest explained variance.

Additionally, students who experienced academic mistreatment exhibited a higher amotivation score (B = 1.50, 95% CI 0.16 to 2.85, p-value = 0.029) than those who did not. Although the overall regression model was not statistically significant and explained a small proportion of variance (F(14, 377) = 1.6, p = 0.061; R2 = 0.014), academic abuse independently predicted the outcome (B = 1.50, 95% CI 0.16 to 2.85, p = 0.029). More details are presented in Table 4.

Table 4 Association between mistreatment type and academic motivation.
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Discussion

This study found that most medical students experienced mistreatment at least once during their clinical training. The prevalence is higher than in other cross-sectional studies conducted in Thailand and other Asian and Western countries6,15,18,19,20. Notably, the prevalence of mistreatment observed is comparable to findings from a national, repeated cross-sectional study in China, which reported a prevalence of 84.5%24. Compared to studies conducted in the United States and Europe, research on mistreatment among medical students in Asia remains limited. Further studies are needed to gain a deeper understanding of the prevalence and contributing factors.

Societal and cultural factors, students’ perceptions of mistreatment definition, and different research tools could influence the prevalence of mistreatment6,15,23. One key distinction between Thailand and countries such as the USA is that Thai medical education typically begins immediately after high school graduation, with students entering medical school at an average age of 1825,26. During the first three years, Thai medical students learn fundamental medical knowledge, with limited patient interaction. It is not until their clinical years that they are exposed to patient interactions and begin to develop clinical skills. This study found that mistreatment was associated with students’ age, academic year, and clinical rotations they had completed. As students advanced in their training, reports of mistreatment increased, a pattern consistent with findings from a previous study in Thai medical students, who also identified a correlation between mistreatment and academic year6. This trend may be attributed to increased exposure to potential perpetrators of mistreatment during clinical training as students advance through their education. Additionally, students’ growing maturity with age may influence their perceptions and responses to mistreatment, making them more aware of inappropriate behaviors and more likely to recognize and report such incidents.

The difference in prevalence may also be attributed to the underreporting of mistreatment. This study found similar results to previous cross-sectional research conducted in Thailand and Japan, where only 8.2–8.5% of students formally reported incidents of abuse, and few were satisfied with the reporting process6,19.The majority of students chose not to report mistreatment due to concerns about the ineffectiveness and safety of reporting systems. These figures contrast sharply with those in the United States, where 29–31% of students have reported mistreatment over the years15. This discrepancy highlights the possible influence of cultural factors on students’ willingness to report mistreatment. While most participants acknowledged that their medical schools provide some form of mental health support, institutional reporting systems remain unclear, particularly regarding the designated authorities responsible for handling reports and resolving reported issues.

Consistent with previous studies, mistreatment by faculty members is the highest, followed by residents and nurses6,15,18,27. This could be due to frequent interactions between students, faculty members, and residents, which involved intense clinical training. This highlights the need to focus on relationships and interactions between faculty members, residents, and students during training.

A previous study exploring students’ views on faculty mistreatment revealed that most attributed it to the personal characteristics of the perpetrators6. However, this study found that most students thought that a perpetrator might not be aware of mistreatment or did not consider mistreatment an inappropriate or serious act. Previous studies also raised the point that defining mistreatment is challenging , as perceptions may vary across cultures and generations15. Establishing clear communication and a mutual understanding between medical personnel and students about what constitutes mistreatment could be the first step toward prevention.

Although the self-reported underlying psychiatric disorder did not show a significant association with mistreatment, mistreatment led to students experiencing negative feelings, such as anger (23.2%) and a decrease in motivation to learn (20.6%). Notably, 9% of students even thought about quitting their training. The findings demonstrated a significant association between mistreatment and low academic motivation. This is consistent with previous cross-sectional studies conducted in Thailand, Japan, Brazil and USA that have reported the negative effects of mistreatment6,18,19,20,27. The stressful and unsafe learning environment caused by mistreatment may contribute to students’ low academic motivation. A study found that several factors related to the school environment, such as the situation in class, the teaching method, and the student–teacher relationship, could affect the academic motivation8. These findings underscore that mistreatment is a serious issue that requires greater attention within the medical education system.

Academic mistreatment was the second most reported type of mistreatment among participants and was also associated with amotivation toward studying. This finding is consistent with previous studies among Japanese medical students, which identified academic abuse such as being assigned tasks as punishment or threatened with an unjustifiably low grades as one of the most prevalent forms of mistreatment19. Despite its significance, research on academic mistreatment and its consequences remains limited. A study in a health-related field found that most students who reported being threatened with unfair grades lacked trust in the grading system28. Perceived unfairness in grading and discrimination in academic evaluation can profoundly affect students’ learning experiences, attitudes, and engagement. Given the high value placed on grades in medical education, students who experience academic mistreatment may feel vulnerable to receiving unjustified poor evaluations. Such perceived threats may lead to helplessness and, consequently, reduced motivation to improve or continue their academic efforts.

This study has some limitations. First, this study employs a cross-sectional design, which precludes the examination of any causal relationships. Nevertheless, this initial study will lay the groundwork for further and more in-depth studies. Second, a convenience and snowball sampling strategy was employed to recruit potential participants. As students’ identities and their medical institutions must be protected for their anonymity and safety, a stratified sampling strategy, which would have allowed for proportional representation across different regions of Thailand and medical schools was not feasible. Although the final sample size exceeded the minimum requirement for a cross-sectional study, it may not fully reflect the geographic and institutional diversity of the target population. Lastly, the use of self-reported questionnaires may introduce recall bias or social desirability bias.

Further research is still needed to explore the long-term effects of mistreatment. This includes follow-up studies on individuals after they become physicians, comparative analyses across different populations or settings, and qualitative studies that examine personal experiences, perceptions, and the emotional impact of mistreatment on students’ academic motivation to provide deeper insights into this issue. Future studies should aim to employ probabilistic sampling methods such as stratified sampling where feasible to enhance the generalizability of findings.

There is a need for culturally specific guidelines, policies, and interventions, as well as research evaluating the effectiveness of various strategies aimed at mitigating mistreatment. Based on our findings regarding mistreatment in medical education, we recommend the following actions: 1) Develop Comprehensive Training Programs by focusing on professional behavior, effective communication, and respectful interactions among faculty, residents, and students. This should include targeted training sessions for faculty and residents on these key areas. In addition, medical students should be equipped with skills to care for their own mental health, recognize signs of distress, and understand when and how to seek appropriate support. 2) Establish Safe Reporting Mechanisms by creating systems that allow students to report incidents of mistreatment without the fear of retaliation; 3) Increase Access to Mental Health Services by making counseling resources more readily available within the medical institution; 4) Define and Educate on Mistreatment by engaging students, faculty, and other healthcare personnel in collaboratively defining mistreatment. All stakeholders should be educated on these definitions to promote a shared understanding of what constitutes mistreatment and to foster a more respectful and positive learning environment. 5) Implement Peer Support Programs by creating peer mentorship and support networks to foster collaboration and provide students with a platform to share their experiences and seek guidance.

Conclusions

This study presents the first national-scale evidence from Thailand linking mistreatment to academic motivation among medical students. It revealed an unexpectedly high prevalence of mistreatment among Thai medical students during their clinical years, with verbal abuse by faculty being the most common. Most students believed mistreatment was not perceived as a serious matter by the perpetrators. Importantly, mistreatment was associated with lower academic motivation, yet most incidents remained unreported. Educational institutions should prioritize addressing this issue and improving reporting systems.