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Mistreatment of Trainees: Verbal Abuse and Other Bullying Behaviors

Received April 7, 2009; accepted April 8, 2009. Dr. Coverdale is affiliated with the Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine in Houston; Dr. Balon is affiliated with Wayne State University, Detroit; Dr. Roberts is affiliated with the Department of Psychiatry and Behavioral Medicine at the Medical College of Wisconsin in Milwaukee. Address correspondence to John H. Coverdale, M.D., Baylor College of Medicine, Department of Psychiatry and Behavioral Sciences, One Baylor Plaza BCM 350, Houston, TX 77030; jhc{at}bcm.tmc.edu (e-mail).

INTRODUCTION

TOP INTRODUCTION Conclusion REFERENCES

 
Medical school and residency training programs are intended to provide positive educational and mentorship experiences and to inculcate a culture of professionalism and collegiality. Academic psychiatrists often contribute greatly to these positive efforts, given the emphasis in their work on psychotherapeutic and interpersonal skills and their attentiveness to conflict prevention and resolution. It is very reasonable to expect, therefore, that occasions of verbal abuse or bullying of trainees would be very low in prevalence in psychiatric settings.

Is this a realistic expectation or merely a statement of what we would like to believe about our profession? In their cross-sectional survey study of 71% of all trainees in psychiatry registered with the College of Physicians and Surgeons in Pakistan, Ahmer and colleagues (1) demonstrated that disrespectful interactions may be the rule rather than the exception in psychiatric residents’ educational experience. Fully 80% of the psychiatry trainees in this study (60 respondents, response rate 71%) had been the victim of at least one bullying behavior in the preceding 12 months. The most commonly encountered behaviors were persistent attempts to belittle and undermine the work of the trainee or to humiliate the trainee in front of colleagues. The greatest source of mistreatment was from consultants (74%), as well as peers (36%), managers (22%), and nurses (13%). Interestingly, patients (16%) also were identified as engaging in verbal abuse and bullying behaviors toward psychiatric trainees.

To what degree are the findings of Ahmer et al. (1) likely similar or dissimilar to other educational settings in psychiatry and beyond? One of our goals for this editorial is to try to answer this question. We also intend to place this information on the verbal abuses or bullying of psychiatry trainees into context with relevant findings from medical students, residents in other specialties, and nurses. Finally, we will make recommendations for future research in this area. As Ahmer et al. (1) noted, the possible consequences of any attempts to belittle or undermine and humiliate residents are serious and warrant attention.

Verbal aggression, abuse, or bullying incorporates a wide range of behaviors including threats, intimidation, humiliation, excessive criticism, covert innuendo, exclusion or denial of access to opportunity, undue additions to work requirements, and shifting of responsibilities without appropriate notice (2, 3). Such occasions, especially when repeated, could take the form of psychological harassment, creating distress and dissatisfaction in the training environment. Indeed, mistreatment in professional settings unfortunately comes in many forms. These are widely varying behaviors that are not easily defined or validated as abuse or bullying; therefore, in capturing relevant information on mistreatment in psychiatry training, a key challenge was to find all the relevant articles pertaining to the verbal abuse or bullying of psychiatry residents. We used a combination of search teams including "abuse," "bullying," "harassment," "intimidation," "discrimination," "horizontal violence," "aggression," and "interpersonal conflict" and "psychiatry residents." We searched databases including PubMed, Embase, and PsycINFO. The reference lists of relevant articles were also searched for additional references. Furthermore, because articles published in Academic Psychiatry prior to 2001 were not readily located through PubMed, we searched the indexes of Academic Psychiatry for additional information. We also used the data from the latest Association of American Medical Colleges (AAMC) Graduation Questionnaire Program Evaluation Survey (4).

Psychiatry Trainees
We found five research papers concerning mistreatment and psychiatry trainees (5–9) in addition to the one published here (1). The results from these studies were mixed. Tibbo et al. (5), in their survey of psychiatric faculty, residents, and medical students in Edmonton, Alta. (92 respondents, response rate 82%), reported that perceptions of intimidation, as formally defined, were low. The study surveyed respondents’ personal experiences with intimidation and used a 7-point Likert scale (1=intimidation had never occurred; 7=intimidation occurred almost daily). The overall mean response (2.3) and standard deviation (1.5) suggested that there was little in the way of personal experiences with intimidation overall, but this did not exclude the possibility that an important minority were intimidated. The results did not distinguish between groups of faculty, residents, or medical students. Reddy and Kaplan (6) surveyed a small sample (30 respondents, response rate 61%) in the Northern Deanery (United Kingdom) and found that the majority reported having been verbally abused, although this was predominantly by patients. Only one of the respondents reported having been abused by a consultant psychiatrist.

On the other hand, Kozlowska et al. (7) examined the perceptions of a sample of Australian trainees (113 respondents, response rate 80%) and found that 41% had been severely criticized or humiliated by an attending or had observed others being severely criticized or humiliated (n=46). Several of the trainees, however, thought that criticism and humiliation were a regular or normal experience in training. Examples included being told that one was incompetent, blamed for the suicide of a patient, told to be more efficient when difficulties were perceived to be due to understaffing, shouted at in front of others, or frequently insulted. Negative consequences of such experiences included a reduction in self-confidence, feelings of uselessness, fear, and distress. Nearly one-quarter of the respondents reported that they had been the subject of malicious accusation(s) by a staff member, and a few had thought they were treated like a patient when psychotherapy was recommended for what was perceived to be a systemic or workplace problem. More prevalent concerns included a disinterest or lack of support on the part of faculty and educational or emotional neglect.

A survey of psychiatry trainees (177 respondents, response rate 76%) from the West Midlands (United Kingdom) (8) used the same set of questions that were developed by Quine (2, 3) and used by Ahmer et al. (1). In this survey, 47% of respondents, which was fewer than those in Ahmer et al.’s survey (1), had experienced one or more bullying behaviors within the preceding year. Most of those doing the bullying were nonmedical staff (28%) or senior medical staff (27%), and it was not stated how many, if any, of these senior medical staff were psychiatrists. Of note, most did not know whom to contact should they be bullied. Because foreign doctors were less likely to take any action when bullied, they were viewed as especially vulnerable (8).

Information is limited on the possible consequences of being verbally abused or bullied in psychiatric settings. No systematic study of the psychological sequelae of mistreatment of physicians-in-training can be found in the literature, although personal narratives and fiction suggest that the effects may be negative and enduring (7, 10, 11). Resident bullying and its impact on patient care has not been rigorously evaluated, although it has been speculated that disempowered groups may experience further or greater adversity, and that mistreatment of trainees might propagate adversity to patients (12). These accounts also do not inform us about the context of these occurrences, the dynamics of the bully-victim relationship, the perception of the alleged perpetrators, who was told about these behaviors, what action (if any) was taken, and how the results compared with residents in other specialty training programs at the same sites.

Sexual harassment was reported by 10% (n=14) of the women psychiatric residents in one survey (9). This survey of all Canadian psychiatric residents (314 respondents, response rate 59%) evaluated resident-educator contact and found that 7% of the residents (n=21; 19 women, 2 men) had been propositioned by an educator (9). Similarly, Kozlowska et al. (7) found that 13% (n=24) of the psychiatry trainees answered that they had been sexually harassed by a staff member or colleague, while a very small number had had a sexual relationship with a colleague. In one (now dated) survey of fourth-year psychiatric residents in the United States (548 respondents, response rate 50%), nearly 5% (n=26) had had sexual contact with psychiatry educators (13). Most of the respondents in this survey viewed sexual contact between a psychiatric resident and educator as inappropriate and harmful to an ongoing work relationship.

Other Medical Groups
Other medical groups considered here include medical students, residents in other specialties, and nurses. Medical students, perhaps being vulnerable because of their relatively low status in health care settings, commonly experienced verbal abuse or humiliation (14–20), nonsexual harassment (14, 20, 21), or sexual harassment (14, 15, 17–20, 22). Discrimination based on gender (20, 21) and race (14, 20, 21) were less common events. Of interest is the wide range of reactions to and consequences of the adversities (20), such as students’ attitudes and willingness to be recruited by the specialty of concern (20, 23). The 2008 Medical School Graduation Questionnaire (4) also provides very revealing and worrisome findings. (See also the editorial "Hard Duty" on pages 274–277 of this issue of Academic Psychiatry.) In 2008, out of 13,269 medical students who answered questions about being mistreated, 16.7% reported that they were personally mistreated during medical school. Interestingly, 22% of students (n=2,231) were not aware that their school had a mistreatment policy. Some students reported being threatened with physical harm or being physically punished (e.g., being hit, slapped, or kicked) with 6.4% reporting that this had occurred at least once, 1.5% occasionally, and 0.4% frequently (4). Students reported being required to perform favors or "personal services," such as shopping or babysitting, for senior colleagues. Fewer, but still some, students answered that they were mistreated on the basis of gender, being subjected to "offensive sexist remarks/names" directed toward the student, for example, or receiving lower evaluations solely because of gender. Another important aspect revealed in this survey is that the largest percentages of "offenders" were clinical faculty in the hospital and residents.

Bullying and mistreatment during training were also part of the experience of many early career doctors or residents in specialties other than psychiatry (3). Psychological abuse, gender discrimination, and sexual harassment were prevalent in one study (24). Nursing staff have been implicated in intimidating and harassing residents, most often by verbal comments (25), and senior residents have also been implicated (26). Some studies explicitly included psychiatric residents but did not separate them from other specialty groups (26, 27).

"Horizontal violence" denotes prolonged and frequent workplace interpersonal conflict or bullying in nursing settings (28–30). In one survey of nurses in their first year of practice, covert, inappropriate behaviors were generally more common than more direct or overt verbal statements such as rude, abusive, or humiliating comments (30). In this study (30), commonly experienced covert behaviors included being undervalued by other nurses, having learning opportunities blocked, feeling neglected, and being given too much responsibility without the appropriate level of support. Rudeness, abusive language, or aggression by nursing colleagues may create more stress in nurses than aggression that arises from other sources (31).

Conclusion

TOP INTRODUCTION Conclusion REFERENCES

 
Important numbers of psychiatric residents in the different settings studied (1, 7–9), with two exceptions (5, 6), perceived that they were intimidated, abused, harassed, or bullied by educators or staff. Regrettably, we cannot, therefore, assume that our psychiatric and psychotherapeutic skills protect us from these adversities. This body of work should be considered alongside research that has demonstrated that psychiatric residents are also vulnerable to aggressive acts by patients (32, 33).

Although individual study results are not necessarily generalizable (1, 5–9), together they indicate a cause for concern about our training environments. Further, although these studies concerning psychiatric residents are few, the results are generally consistent with those from other medical settings, including medical students, trainees in other specialties, and nurses. A key first priority for developing this area of research, therefore, is to clarify the prevalence of abuse or bullying of psychiatric residents and to evaluate the implications of these events for the trainees concerned and for training environments. Studies across the field of medicine remind us that other specialties are not spared from being abused or bullied, but in fact they commonly experience these adversities. Psychiatrists should therefore be alert to this reality and support colleagues who are victimized by working to ameliorate the associated psychologically distressing consequences.

We also know little about how verbal abuse or bullying is triggered and, more positively, how it might be prevented. Primary preventive methods include providing educational materials and communication skills training for residents, staff, and educators. Education on abuse, discrimination, and harassment in the workplace, and how these can be addressed and averted, can also be presented in formal and informal curricula (27). Such initiatives should promote inclusive language (27) and a culture of collegiality and respect for all faculty, staff, and trainees. Secondary preventive measures rely in part on clear reporting mechanisms, so that any occasion of abusive or discriminatory language or behavior can be addressed as soon as it arises. Measures such as debriefing and supportive counseling should aim to alleviate the psychologically distressing consequences of these behaviors for all recipients and observers. In the meantime, and until further data confirm or deny the concerns identified here, all training programs should be duly vigilant. The recent and universal focus on professionalism in medical education and professional behavior of physicians in practice will also help us to eradicate this unacceptable behavior.

International research such as that highlighted here (1) is important to the Journal’s mission in this era of globalization of educational research (34, 35). We thank Dr. Ahmer and colleagues (1) for drawing our attention to this important and relatively neglected topic, and we hope that their work will stimulate original research in this area. Obviously, mistreatment and bullying of trainees is a professionalism issue which occurs in many if not all cultures around the globe. As even one incident of mistreatment of bullying is too many, this behavior is a true problem in the house of medicine and psychiatry that needs to be dealt with swiftly.

ACKNOWLEDGMENTS

 
Disclosures of Academic Psychiatry editors are published in each January issue.

REFERENCES

TOP INTRODUCTION Conclusion REFERENCES

 

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				L. W. Roberts Hard Duty Acad Psychiatry, July 1, 2009; 33(4): 274 - 277. [Full Text] [PDF]

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