Bullying has been defined as “persistent behavior against an individual that is intimidating, degrading, offensive, or malicious and undermines the confidence and self-esteem of the recipient” (1). It has been further classified by Rayner and Hoel (2) into five categories: threat to professional status, threat to personal standing, isolation, overwork, and destabilization. Several studies have shown that workplace bullying leads to anxiety, depression, intention to leave the job, and sickness absences (3, 4). According to a U.K. estimate, workplace bullying costs employers £80 million from lost workdays and up to £2 billion in lost revenues each year. It is also responsible for 50% of stress-related workplace illnesses (5).
Health professionals, particularly junior doctors-in-training, are frequent victims of bullying (3, 6–9). In a survey of junior doctors in the United Kingdom, 37% of respondents reported having experienced bullying in the last 12 months, although 84% reported having been subjected to one or more of the bullying behaviors described on a bullying scale (6). In a study of U.S. residents, 93% of respondents reported experiencing at least one incident of perceived mistreatment, while 53% reported being belittled or humiliated during their internship year by more senior colleagues (7). Hoosen and Callaghan (9) reported that in a survey of psychiatry trainees in West Midlands, United Kingdom, 47% of trainees endorsed having experienced one or more bullying behaviors in the previous year. In a similar study of trainee doctors from Southern India, 53% of men and 48% of women reported having experienced bullying (10). Almost half of U.S. women physicians reported having experienced harassment during their careers (11).
With a population of almost 165 million, Pakistan is the sixth most populous nation in the world (12). Altogether, there are an estimated 300 to 350 psychiatrists in Pakistan, which adds up to a psychiatrist to population ratio of about 1 psychiatrist per 500,000 people (13). Keeping the above figures in mind, it seems abundantly clear that Pakistan needs to train a large number of psychiatrists to meet the mental health needs of its population. Doctors are more likely to train in any specialty if, in general, it offers a learning environment that is attractive and conducive to learning. There has been some research on stress and job satisfaction in Pakistani physicians (14, 15). There have been two recently published studies reporting data on bullying of consultant psychiatrists (16) and medical students (17) in Pakistan. However, we have not come across any research on bullying faced by postgraduate trainees in Pakistan. In this study, therefore, we have tried to assess the prevalence of bullying faced by postgraduate psychiatry trainees in Pakistan and to see if any sociodemographic variables make it more likely for someone to be bullied.
The study was granted ethical approval by the ethical review committee of the Aga Khan University in Karachi. The intended sample for this study was all the postgraduate trainees registered with the College of Physicians and Surgeons, Pakistan, for either fellowship or diploma in psychiatry. Trainees registered in other subjects were not included.
We obtained the number and names of trainees registered for fellowship or diploma in psychiatry from the College of Physicians and Surgeons registration department and the list and addresses of all the teaching hospitals approved for training in psychiatry from the College of Physicians and Surgeons web site (18). Nineteen teaching hospitals are approved for psychiatry training in Pakistan; nine are in Punjab, five in Sindh, two in the North West Frontier Province (NWFP), and one in Baluchistan. In May 2007, when we made the inquiry, 84 trainees were registered with the College of Physicians and Surgeons in psychiatry. Of these trainees, 36 were working in Punjab, 31 in Sindh, 15 in NWFP, and two in Baluchistan.
In each city except Karachi we identified a key person, in all cases a health professional, to whom we sent all the data collection forms. In Karachi, the data were collected by the authors themselves. This key person asked all the respondents to read and sign an informed consent form (containing details about the purpose and the conduct of the study and contact numbers/e-mail address of the first author), had the data forms filled, and mailed them to the authors in Karachi.
The questionnaire consisted of two parts. The first collected sociodemographic data, including age, gender, marital status, whether registered for fellowship or diploma, whether the trainee was from an urban or rural background (the place where trainees completed high school was used as a proxy measure), number of years since graduation, year of training since registration with the College of Physicians and Surgeons, and the province where the trainee was being trained.
The second part consisted of a bullying scale developed and validated by Quine (3, 6), which asked whether the respondents had experienced any of the 21 bullying behaviors in the previous 12 months. These behaviors were divided into the following categories: threat to professional status (e.g., persistent attempts to belittle, undermine, or humiliate; persistent unjustified criticism), threat to personal standing (e.g., undermining personal integrity, destructive sarcasm, threats, persistent teasing, physical violence), isolation (e.g., withholding necessary information, social exclusion, denying leave, training, promotion), overwork (e.g., undue pressure, impossible deadlines), and destabilization (e.g., shifting goals, changing responsibilities without notice). The trainees were also asked whether the perpetrator(s) had been consultants, nurses, managers, patients, or peers.
We used the chi-square test and Fisher’s exact test for analyzing nominal data and the Mann-Whitney U test for analyzing ordinal data. All statistical tests were performed with SPSS (Version 13.0).
Out of these 84 trainees, 60 participated in the survey, for a response rate of 71.4%. Fifteen refused to participate, and nine could not be reached because they were away either on vacation or external rotations. Among the refusals, 12 trainees working at one teaching hospital were unwilling to participate without the permission of the head of the department, which they did not receive. Not all trainees answered all the questions; hence, the total number of trainees is different in response to different questions.
The sociodemographic details of the participants and the proportion experiencing bullying within each group are given in Table 1.
Forty-eight participants (80%) had experienced at least one of the 21 bullying behaviors in the prior 12 months. There were no significant differences between male and female trainees (79% versus 82%), single and married trainees (77% versus 79%), trainees from urban and rural backgrounds (both 80%), trainees registered for fellowship or diploma (79% versus 75%), or between those training in different provinces, in the proportion who had experienced bullying. Similarly, there was no significant association of bullying with age, number of years since graduation, and number of years since registration with the College of Physicians and Surgeons, Pakistan.
The three bullying behaviors most frequently experienced were persistent attempts to belittle and undermine work (41.7%), persistent attempts to humiliate in front of colleagues (41.7%), and persistent and unjustified criticism and monitoring of work (38.3%). The detailed breakdown of frequency of bullying behaviors reported by trainees in descending order of frequency is given in Table 2.
The overwhelming majority of trainees reported being bullied by their consultants (73.3%), followed by peers (35.6%), managers (22.2%), patients (15.6%), and nurses (13.3%). The percentages add up to more than a hundred because a number of trainees reported being bullied by more than one person. Among the three trainees who experienced actual physical violence, one faced it at the hands of a consultant, one a peer, and one a patient.
In this first survey of bullying faced by postgraduate trainees in Pakistan, 80% of psychiatry trainees reported having experienced at least one bullying behavior in the preceding 12 months. This is almost twice as frequent compared with the 38%, 47%, and 37% reported in three surveys done in the United Kingdom (3, 9, 19) and the 50% reported in India (10); it is almost the same as the 84% reported in another survey of junior doctors across all specialties in the United Kingdom (6). In the United States, 93% of first-year residents reported having experienced at least one incident of perceived mistreatment during their internship year (7), while 42% of senior medical students reported having experienced harassment and 84% belittlement during medical school (20). This shows that the prevalence of bullying experienced by psychiatry trainees in Pakistan, while quite high, may not be unusual compared with the developed countries.
Some of the large differences in the prevalence of bullying reported may be because of differences in definition and operationalization of the concept of bullying rather than true differences in prevalence. For example, in the study of junior doctors by Quine (6), only 37% of respondents answered affirmatively to a direct question asking whether they had been subjected to bullying in the prior 12 months, while 84% reported having experienced at least one of the 21 bullying behaviors listed in the bullying scale during the same time.
The bullying behaviors reported most frequently in our study are persistent attempts to belittle and undermine work, persistent attempts to humiliate in front of colleagues, and persistent and unjustified criticism and monitoring of work. This is very similar to what was reported by junior doctors in the United Kingdom (6), where persistent attempts to belittle and undermine work and persistent unjustified criticism and monitoring of work were among the four most frequent complaints.
Interestingly, the pattern of perpetrators of bullying seems to be different in different countries. Psychiatry trainees in the United Kingdom and interns in India reported being bullied most frequently by nonmedical staff (9, 10), while in Pakistan psychiatry trainees reported that nurses were least likely to bully them. In the United Kingdom, peers were the least likely bullies, while in Pakistan peers were the group second most likely to bully. Senior medical staff, consultants, and medical personnel were the most/second most likely perpetrators of bullying in all three countries. The health care system in Pakistan is very hierarchical, with doctors considered higher in status than other professionals and doctors with a postgraduate qualification at the very top of the hierarchy. In most training institutions, the relationship between trainee and trainer is very unequal in power. Trainers can even decide whether the trainee is ready to appear in a postgraduate exam, and in most places there is no appeal process. The experience of bullying felt by trainees has to be seen within this context.
With prevalence as high as we have seen, should we accept bullying as a routine part of medical training that all doctors just have to go through? Knowing what we know about the effects of bullying on victims, such as decreased job satisfaction, increased job-induced stress, depression, anxiety, intention to leave, high rates of sickness absence, impaired performance, and lower productivity (3, 4, 8, 21), it hardly seems justifiable.
The most important step seems to be to raise awareness about what constitutes bullying and how it affects its victims. As shown by Quine (6), even people who had experienced bullying behaviors did not report being bullied in response to a direct question. Paice (22) suggests that bullies who intend to hurt to get pleasure are rare; more often, bullying accusations are linked to situations that are upsetting but an inevitable part of training (e.g., trainers telling trainees that they are not performing at the expected level). However, as Lord MacPherson (23) said in the Stephen Lawrence Inquiry report into the racist murder of a black teenager in London: “If a person feels bullied then he or she is being bullied.”
We used a well-validated questionnaire that has previously been used on junior doctors elsewhere. We tried to cover all psychiatry trainees across Pakistan and managed to get a 71% response rate. These, in our opinion, are the strengths of this study. There was no comparison group in this study, therefore, we do not know whether the high proportion of trainees experiencing bullying in this study is true across all specialties in Pakistan or is a phenomenon peculiar to psychiatry. Also, although the language of instruction in both undergraduate and postgraduate medical teaching across Pakistan is English, we did not do any pilot-testing of the questionnaire among trainees to find out how well they understood the questions. These are the weaknesses in our study.
A significant majority of psychiatry trainees surveyed (80%) reported having experienced at least one bullying behavior in the preceding 12 months. Consultants were the most likely perpetrators of bullying. However, the data need to be interpreted with caution in view of the very small number of psychiatry trainees in Pakistan and the lack of a comparison group (e.g., trainees from another specialty) in this study.
At the time of submission, the authors disclosed no competing interests.