As a resident physician, Anees Bahji, MD, and colleagues experienced various forms of intimidation, harassment, and discrimination. They set out to learn more about the true extent of the problem.

“We undertook a meta-analysis in order to capture as much data from as many residents as possible,” says Bahji, the study’s lead author and an addiction psychiatry fellow at University of Calgary.

The researchers analyzed 52 studies to establish how often resident physicians reported intimidation, harassment, and discrimination.1 Most (64.1%) reported it had happened to them at one time or another. The biggest surprise was just how common it was. “Prevalence was incredibly high — over 90% for some forms of harassment and intimidation,” Bahji reports.

The most common perpetrators were relatives or friends of patients, nurses, and patients. “It is also concerning from a prevention perspective. The data indicate prevalence is on the rise despite implementation of anti-harassment programming,” Bahji observes.

It is hard to say if the problem is worse, or if residents are just reporting it more. “We could not tease this out specifically with the methods available to us, as most of the data came from surveys,” Bahji explains.

Regardless, this is a longstanding problem, as another survey of 87 healthcare students about intimidation, harassment, and discrimination while in their clinical training revealed.2 “We started hearing more and more about patients who were not treating our student learners well,” says Patricia A. Findley, DrPH, MSW, the study’s lead author and an associate professor of social work at Rutgers.

Physicians were listed as the leading cause, followed by nurses and fellow trainees. “We were surprised by the number of students who reported ‘fat shaming’ or comments related to their bodies,” Findley says.

Few effective solutions or prevention tactics have been implemented. “Part of it is a combination of negative traditions. Learners are at the bottom of the academic hierarchy,” Bahji says.

Residents and other medical trainees rely on their superiors for evaluations and promotions to the next stages of their training. While women were more likely to experience harassment, male residents also experienced significant levels of intimidation, harassment, and discrimination. “This suggests that all residents, regardless of sex, gender, ethnicity, training level, country of origin, [or] program of training, are vulnerable,” Bahji says.

The authors of some studies included in the review by Bahji and a colleague also examined the effect of abuse in residency. “Quite often, residents reported symptoms of psychiatric illness: anxiety, depression, suicidal thoughts, substance use, burnout, and demoralization,” Bahji says.

This carries important ethical implications, considering the increasing recognition of the problem of physician burnout. “It is possible that burnout begins in residency if trainees are mistreated,” Bahji offers.

In recent years, awareness of medical student mistreatment has “grown tremendously,” according to Janet Malek, PhD, an associate professor at the Baylor College of Medicine Center for Medical Ethics and Health Policy.

This is mainly due to information made available from the Association of American Medical Colleges’ Medical School Graduation Questionnaire, which asks specific questions about mistreatment.3 “Responding to these incidents requires a response on the institutional level because they are often the result of an organization’s culture,” Malek says.

Medical school administrators should develop reporting mechanisms (electronic or in-person, anonymous or not) and ensure students and others are aware of these mechanisms. It also is important to develop clear policies against retaliation and to institute faculty development initiatives to change a toxic culture.

Ethicists who work in medical schools can team with administrators to develop good policies. They also can encourage people to report issues. At times, ethicists become aware of an ongoing problem with an individual because a student describes it, or because the ethicist observes it directly. “We have a duty to raise the concern with those individuals’ supervisors when it is possible to do so in a way that protects the confidentiality of the students who have experienced the behaviors,” Malek says.

One reason medical student mistreatment persists is because an evaluation from a single person can determine a student’s whole future career, says Rosalind Ekman Ladd, PhD, a visiting scholar in philosophy at Brown University. This motivates students to stay on the good side of their supervisors.

Unfortunately, this may mean no one reports mistreatment. Instead, students may simply put up with racist and sexist insults. “Mistreatment and how to report it certainly could be a topic of discussion in orientation sessions for new med students,” Ladd suggests.

Select hospital policies offer a safe reporting system and explicit statements of ethical standards, but those are no guarantee. “It is also necessary to get buy-in from the students themselves in order to change the culture and make it acceptable to report mistreatment,” Ladd adds.

REFERENCES

  1. Bahji A, Altomare J. Prevalence of intimidation, harassment, and discrimination among resident physicians: A systematic review and meta-analysis. Can Med Educ J 2020;11:e97-e123.
  2. Findley PA, Harris CE. Interdisciplinary healthcare students’ experiences of intimidation, harassment, and discrimination during training. J Allied Health 2020;49:e39-e42.
  3. Mavis B, Sousa A, Lipscomb W, Rappley MD. Learning about medical student mistreatment from responses to the medical school graduation questionnaire. Acad Med 2014;89:705-711.