Bullying of medical trainees is believed to occur more frequently in medical education than once thought.
We conducted a survey to understand internal medicine program director (PD) perspectives and awareness about bullying in their residency programs.
The 2015 Association of Program Directors in Internal Medicine (APDIM) annual survey was e-mailed to 368 of 396 PDs with APDIM membership, representing 93% of internal medicine residency programs. Questions about bullying were embedded within the survey. Bivariate analyses were performed on PD and program characteristics.
Of a total of 368 PD APDIM members, 227 PDs (62%) responded to the survey. Less than one-third of respondents (71 of 227, 31%) reported being aware of bullying in their residency programs during the previous year. There were no significant differences in program or PD characteristics between respondents who reported bullying in their programs and those who did not (gender, tenure as PD, geographic location, or specialty, all P > .05). Those who acknowledged bullying in their program were more likely to agree it was a problem in graduate medical education (P < .0001), and it had a significant negative impact on the learning environment (P < .0001). The majority of reported events entailed verbal disparagements, directed toward interns and women, and involved attending physicians, other residents, and nurses.
This national survey of internal medicine PDs reveals that a minority of PDs acknowledged recent bullying in their training programs, and reportedly saw it as a problem in the learning environment.
An accepted definition of bullying by an expert on school-based bullying includes 3 components: aggressive behavior that involves unwanted negative actions, a pattern of behavior repeated over time, and a real or perceived imbalance of power.1 He notes that “a person is bullied when he or she is exposed, repeatedly and over time, to negative actions on the part of one or more other persons, and he or she has difficulty defending himself or herself.”1
Bullying in the workplace has been reported in medical specialties worldwide,2 and some claim it has reached epidemic proportions in medical education.3 The cited prevalence varies, ranging from 10% to 48% of medical trainees.4,5 Bullying in medicine has detrimental effects on the individual, the health care system, and patients,6–10 and is associated with increased medical errors and higher turnover, leading to diminished access to care.4
To better understand whether internal medicine (IM) program directors (PDs) are aware of bullying in their residency programs, we conducted a national survey to explore their perceptions about bullying.
Annually, the Association of Program Directors in Internal Medicine (APDIM) administers a nationwide survey of IM PDs. The survey methods, conducted similarly since 2008, have been previously described.11,12 For the 2015 survey, a program-specific hyperlink to a web-based questionnaire was sent electronically in August 2015 to PDs and program administrators at 368 APDIM member programs. This group represents 93% of the 396 Accreditation Council for Graduate Medical Education (ACGME)–accredited programs. Nonresponders were contacted biweekly via e-mail reminders until the survey closed in November 2015. Paper reminders were included in the registration packet of nonresponders during the October 2015 APDIM meeting. PDs were asked a standard set of demographic questions (age, gender, academic rank, specialty, and salary) and questions that characterized their programs. Survey responses were supplemented with data from publicly available sources, with programs assigned to geographic regions by US Census Bureau definitions.11 Additional descriptive data about programs were obtained from the American Medical Association Fellowship and Residency Electronic Interactive Database Access System Online, and from the ACGME.12,13
Fifteen survey questions were developed using an iterative process by the authors and were pilot tested with attending physicians active in graduate medical education. A few questions were eliminated, and others were revised to enhance clarity (provided as online supplemental material). The survey included questions about respondents' attitudes toward bullying and the learning environment, and questions about bullying in respondents' own training programs. Bullying was described as “verbal or physical harassment that occurs repeatedly over time, and involves an imbalance of power.”14 Response options included yes/no answers and 5-point Likert scales (1, strongly disagree, to 5, strongly agree).
This study was deemed exempt by the Mayo Clinic Institutional Review Board.
Prior to data analysis, program identity was blinded. We calculated descriptive statistics (PD gender, academic rank, specialty, tenure as PD [> 7 years versus ≤ 7 years], region of program, program type, and accreditation status). We used χ2 analysis (α = .05) to determine the relationship between PD characteristics, program characteristics, and reported bullying in training programs. No multiple association corrections were applied. Statistical analyses were conducted using STATA version 14 (StataCorp LP, College Station, Texas).
A total of 227 PDs (62%) completed the survey. A total of 52% (118 of 227) of PDs identified their divisional affiliation as general internal medicine. Most PDs (59%, 134 of 227) identified as male (table 1). The most common academic rank was associate professor (40%, 90 of 227).
Recognition of Bullying
Less than one-third of respondents (31%, 71 of 227) reported that they were aware of bullying in their programs during the prior year. In bivariate analyses, χ2 tests revealed no statistically significant difference between PDs who acknowledged bullying in their residency programs and any personal attributes (all P > .05; table 1). Program directors who were aware of bullying in their programs were more likely to believe that bullying is a significant problem in graduate medical education (59% [41 of 69] versus 17% [19 of 112], P < .0001), and that it has a detrimental effect on the learning environment for trainees (63% [40 of 63] versus 21% [24 of 114], P < .0001).
Details of Reported Bullying
In programs where bullying was recognized, the average number of residents reported to have been bullied in the last academic year was estimated at 6. Bullying was most frequently committed by attending physicians (69%, 48 of 70), other trainees (61%, 43 of 70), and nurses (56%, 39 of 70; table 2). Among attending physicians who were perpetrators of bullying, most were identified as male (83%, 40 of 48).
Verbal bullying was most frequently reported (87%, 61 of 70). Female trainees and interns were named the most frequent victims of bullying (79% [55 of 70] and 67% [47 of 70], respectively).
A decline in performance and depressed mood were the 2 most commonly reported consequences of bullying (23% [16 of 70] and 14% [10 of 70], respectively). However, most PDs (47%, 33 of 70) admitted to being unaware of the impact bullying had on their trainees.
This survey of IM PDs finds the majority of respondents reported no bullying of trainees occurred in their training programs during the prior year. There were no significant personal or program characteristics for PDs who acknowledged bullying in their programs, compared with those who did not. Program directors who reported bullying noted the perpetrator was most often an attending physician, and the type of bullying was verbal. Given the relatively high estimated prevalence of bullying cited in previous studies,4,6,8,15 some PDs may be underestimating the scope of this problem.
Previous studies of medical trainees have found verbal bullying to be the most common type, men more likely than women to be the bullies, and victims to be more frequently female.5,10 Our study findings are largely consistent with these findings. While it is believed that bullying negatively affects the health care environment and undermines patient safety,16 many PDs in our study described a negative impact on the learning environment. The learning environment affects the emotional development of trainees and influences their professional development.17–19 In addition to victims, observers who witness bullying can be negatively affected.20
Approximately one-third of PDs acknowledged that their trainees were bullied in the last year. This number must be taken seriously, because the well-being of trainees is low, and the burnout rate is high.21,22 Our findings may represent underestimation by PDs, and there may be far more bullying than is recognized by respondents. It is possible that victims of bullying may not relay these events to their PD.16 Barriers to reporting include the fear of retaliation, messages from the hidden curriculum that these behaviors are acceptable, and concerns that reporting may result in negative performance evaluations. If the perpetrators are senior clinicians, those who are bullied may rationalize that it is justified or part of acceptable culture.23 There also may be some element of cognitive distortion, where, as a coping strategy, emotions and events are downplayed or discounted by the victim or bystander.24
There are several limitations to this study. Respondents who denied the presence of bullying in their program may not agree with our definition, and may think behaviors they have seen did not qualify as bullying. Some PDs may not be aware of bullying because they delegate the responsibility for monitoring such behaviors to others, such as associate program directors. Although we pilot tested the survey questions, respondents may not have interpreted the questions as we intended. In addition, there may have been response bias.
In this survey of IM PDs, approximately one-third were aware of the bullying of residents in their programs in the past year, with an average of 6 residents per program affected. The majority of events were perceived to be verbal, directed toward interns and women, and involving attending physicians, other residents, and nurses.
Editor's Note: The online version of this article contains the survey questions.
Funding: Dr Wright is the Anne Gaines and G. Thomas Miller Professor of Medicine, which is supported through the Johns Hopkins Center for Innovative Medicine.
Conflict of interest: The authors declare they have no competing interests.
This abstract was presented as a poster at the Society of General Internal Medicine Annual Meeting, Washington, DC, April 19–22, 2017.
The authors would like to thank the Association of Program Directors in Internal Medicine survey team for their assistance with this project.