Universal problems during residency: abuse and harassment

Overall Description and Predictors of Disruptive Behavior Toward Nurses in the Perioperative Arena

PURPOSE

To investigate the prevalence, characteristics, causes, consequences, and predictors of and responses to disruptive behavior toward nurses in the perioperative arena.

DESIGN

A cross-sectional design using a network questionnaire platform.

METHODS

Nurses in the perioperative arena were recruited online in March 2020. Data on disruptive behavior toward nurses in the past 6 months and nurses' sociodemographic and environmental factors were collected.

FINDINGS

Nurses (N = 496) responded validly to the survey. In total, 82.1% of participants experienced disruptive behavior. Assignment of overwhelming workloads and verbal aggression were the most common behaviors, and surgeons were the major perpetrators. Perpetrators' intrapersonal issues were the most commonly perceived causes. A positive strategy was the most common strategy adopted by participants. Further, 80.8% of participants recounted their negative experiences, and more than half of respondents (59.9%) talked with their nursing colleagues. Nearly half of respondents (45.9%) did not report disruptive behavior. Negative emotions as an immediate effect were reported by 53.1% of the participants, and the most common long-term impact was decreased passion for work. Middle age, job position, practice environment, and system help were risk factors for experiencing disruptive behavior.

CONCLUSIONS

The prevalence of disruptive behavior toward nurses in the perioperative arena is high, and its ramifications should not be ignored. Health care institutions should urgently implement intervention strategies to reduce disruptive behavior toward nurses.

An obscured obstacle-Prevalence and nature of micro aggressions amongst healthcare professionals

INTRODUCTION

Microaggressions create negative consequences on the mental health of individuals who experience them, such as feelings of alienation, frustration and low self-esteem. Physicians worldwide are negatively impacted by the detrimental effects of microaggressions and implicit bias. It is imperative to establish the prevalence specificity of the problem hence the aim of this study is to determine the prevalence, nature and determinants of microaggressions amongst healthcare professionals.

METHOD

The study used an online anonymous survey to collect data including demographics, awareness of the term, experience of microaggression, acts and response. The research findings were analyzed using univariate and multivariate analyses using Chi-square test and binary logistic regression respectively.

RESULT

A total of 443 participants (40.9% males, 59.1% females) included 403 physicians (91%), 21 dentists (4.7%), 15 nurses (3.4%) and 4 pharmacists (0.9%). More than half of the participants (59.8%) were aware of the term micro-aggression. The percentage was significantly higher among respondents from the western region of Saudi Arabia than the Gulf/Middle Eastern countries. Approximately 38.1% of the participants experienced microaggression and more than half (55.62%) did not report experiencing microaggression. The most common form of microaggression was passive-aggressive behavior (80.5%) followed by invalidation of an opinion (73.4%). Among those who experienced microaggression, (12.9%) reported anger as the most predominant emotional response.

CONCLUSION

Microaggression is a universal phenomenon. Further research is necessary to determine its prevalence in other countries to establish a comprehensive understanding of its cultural context.

Unveiling the obstacles encountered by women doctors in the Pakistani healthcare system: A qualitative investigation

In Pakistan, women outnumber men in medical colleges with 80 percent enrollment, yet many fail to practice medicine following graduation. Pakistan Medical Council (PMC) states 50 percent of graduated women doctors either did not practice or left employment in a short period. Thus, the non-servicing women doctors are assumed as the one of the major causes for the overall doctors' shortage in the country. Addressing this enduring matter, this study aims to explore and understand the factors that discourage women doctors from practicing medicine in Pakistani hospitals. The study employed qualitative exploratory inquiry with an interpretive paradigm to attain a deeper understanding of the problem. 59-semi structured interviews were conducted by non-working women doctors across the entirety of Pakistan. The narratives were then analyzed by thematic analysis using ATLAS.ti 22. The findings have resulted in the three major themes, i.e., workplace challenges, socio-cultural obstructions, and familial restrictions that possibly obstruct women from practicing medicine in hospitals. The findings suggested that accepting traditional cultural values, including entrenched gender roles in society, deters women from practicing medicine. The prevailing patriarchal societal system includes stereotypes against working women; early marriages hinder women from practicing medicine. The prevailing societal system upholds the influence of in-laws and a husband for women doctor professional employment. As a result, severe work-life conflict was reported where most women doctors ended up in their profession in the middle of struggling between socially rooted gender roles as homemakers and their professional careers-furthermore, the study found various workplace issues that posit an additional burden on already struggling women doctors. Issues include poor recruitment and selection process, transfer constraints, excessive workload with inadequate salary, harassment, gender discrimination, unsafe work environment, and little support from the administration highly contribute to the shortage of women doctors in Pakistan.

Workplace bullying and sexual harassment among general surgery residents in Colombia

INTRODUCTION

Workplace bullying and sexual harassment are concerns among general surgery residents in Colombia.

OBJETIVE

To explore the prevalence and impact of workplace bullying and sexual harassment incidents among general surgery residents in Colombia.

MATERIALS AND METHODS

This nationwide study was conducted in 2020. Residents selfrated their exposure to workplace bullying and to sexual harassment in the forms of gender harassment, unwanted sexual attention, and sexual coercion. We analyzed demographic variables, perpetrator’s characteristics, and differences between victims and non-victims.

RESULTS

The study included 302 residents. It found that 49% of general surgery residents in Colombia suffered from workplace bullying and 14.9% experienced sexual harassment. The main forms of sexual harassment were gender harassment (47%) and unwanted sexual attention (47%). Women reported significantly higher rates of being sexually harassed. Surgeons were the main perpetrators of sexual harassment.

CONCLUSIONS

Workplace bullying and sexual harassment are frequent events in general surgery residency in Colombia. These findings suggest the need for interventions to improve the educational culture of surgical departments and decrease the prevalence of these behaviors.

National Comparison of Program Director Perceptions vs. Resident Reports of the Learning Environment and Well-Being

OBJECTIVE

Our research objectives were to (1) assess the correlation between PD perceptions and their residents' reported experiences and (2) identify PD and program characteristics associated with alignment between PD perceptions and their residents' reports.

DESIGN, SETTING, PARTICIPANTS

A survey was administered to US general surgery residents following the 2019 American Board of Surgery In-Training Examination (ABSITE) to study wellness (burnout, thoughts of attrition, and suicidality) and mistreatment (gender discrimination, sexual harassment, racial/ethnic/religious discrimination, bullying). General surgery program directors (PDs) were surveyed about the degree to which they perceived mistreatment and wellness within their programs. Concordance between PDs' perceptions and their residents' reports was assessed using Spearman correlations. Multivariable logistic regression models examined factors associated with alignment between PDs and residents.

RESULTS

Of 6,126 residents training at SECOND Trial-enrolled programs, 5,240 (85.5%) responded to the ABSITE survey. All 212 PDs of programs enrolled in the SECOND Trial (100%) responded to the PD survey. Nationally, the proportion of PDs perceiving wellness issues was similar to the proportion of residents reporting them (e.g., 54.9% of PDs perceive that burnout is a problem vs. 40.1% of residents experience at least one burnout symptom weekly); however, the proportion of PDs perceiving mistreatment vastly underestimated the proportion of residents reporting it (e.g., 9.3% of all PDs perceive vs. 65.9% of all residents report bullying). Correlations between PDs' perceptions of problems within their program and their residents' reports were weak for racial/ethnic/religious discrimination (r = 0.176, p = 0.019), sexual harassment (r = 0.180, p = 0.019), burnout (r = 0.198, p = 0.007), and thoughts of attrition (r = 0.193, p = 0.007), and non-existent for gender discrimination, bullying, or suicidality. Multivariable regression models did not identify any program or PD characteristics that were consistently associated with improved resident-program director alignment.

CONCLUSIONS

Resident and PD perceptions were generally disparate regarding mistreatment, burnout, thoughts of attrition, and suicidality. Reconciling this discrepancy is critical to enacting meaningful change to improve the learning environment and resident well-being.

Prevalence and Impact of Academic Violence in Medical Education

Situations of mistreatment in the academic environment are prevalent worldwide, but research in this area is scarce in middle-low-income countries. This study aimed to estimate the prevalence of mistreatment inflicted against Brazilian medical students. In addition, characterize these situations and analyze their consequences. Cross-sectional study conducted with 831 medical students from public and private institutions. Absolute and relative frequencies of the analyzed variables and possible associations were determined through univariate and multivariate logistic regression. Chi-square test of association with second-order Rao-Scott adjustment was also used. The response rate was 56%. Public institution pointed to a higher prevalence of mistreatment when compared to private (59% versus 43%). Female students were the most affected. Verbal and psychological aggression was more prevalent. The aggressor usually was a faculty member. Mistreatment incidence increased over the years of training, with higher rates in the internship. About 94% of the students felt affected in anyway, with 77% feeling diminished and depressed. More than 50% reported impaired academic performance. Almost 30% sought help from experts. The reporting rate was extremely low. Adequate identification of the situations by the victims, safe reporting mechanisms and, an educational system capable of maintaining an appropriate learning environment are essential to break this destructive cycle.

Influence of Psychological Safety and Organizational Support on the Impact of Humiliation on Trainee Well-Being

OBJECTIVES

To develop physicians who can practice safely, we need better understanding of how the clinical learning environment affects trainee well-being. Two psychosocial constructs may help us understand the context: psychological safety (belief one can speak up without concerns) and perceived organizational support (degree to which members feel that their organization cares for them and values their contributions). The objective of this study is to test a moderated mediation model to determine how humiliation (X) impacts trainees' well-being (Y) while taking into account psychological safety (mediator) and organizational support (moderator).

METHODS

Between May and June 2018, a single health system recruited resident physicians across 19 programs to complete an anonymous electronic survey to assess facets of the clinical learning environment, well-being, and experiences of humiliation. In a moderated mediation analysis, mediation helps explain how a predictor variable (X) impacts an outcome variable (Y) through a mediating variable, whereas moderation helps explain under what conditions such a relationship exists.

RESULTS

Of 428 residents, 303 responded (71%) to the survey across 19 training programs. The effects of humiliation on well-being were mitigated by psychological safety, which varied depending on the levels of perceived organizational support. Environments rated 1 SD below the mean on perceived organization support by residents had a stronger negative impact of public humiliation on psychological safety.

CONCLUSIONS

The findings suggest that humiliation is associated with well-being through the effects of psychological safety and influenced by organizational support. Further work might explore the relationship by investing resources (e.g., faculty development, mentorship) to increase psychological safety and reduce humiliation during training, especially within environments prone to be perceived as unsupportive of trainees.

Workplace bullying in surgical environments in Saudi Arabia: A multiregional cross-sectional study

BACKGROUND

Workplace bullying (WPB) is any sort of repeated and unjustified verbal, sexual, or physical intimidation that a person is exposed to by a group or another person in the workplace. In healthcare environments, practitioners are occasionally victims of WPB incidents. Bullying in surgical environments is an important issue that needs attention as it could affect patient care either directly or indirectly. The objective of this study was to assess the prevalence of bullying in surgical environments in multiple regions in Saudi Arabia.

MATERIALS AND METHODS

This cross-sectional study was conducted among surgeons, trainees, interns, nurses, and students in surgical specialties in multiple Saudi regions. The survey was designed by Survey Monkey and posted online. The data were analyzed through SPSS Version-21 by computing descriptive statistics as frequency and percentages with graph construction.

RESULTS

About two-thirds (65.2%) of the 788 study participants were male and were between the age of 20 and 29 years (67.8%). Consultants came first as perpetrators of bullying in the past 12 months (44.3%) and residents and interns were the major victims. The NAQ-R score ranged from 22.00 to 110.00, with a mean score of 42.47 (SD=17.9). Statistically significant association was found between mean NAQ-R score and age (P = 0.007), specialty (P = 0.002), and position (P < 0.001).

CONCLUSION

WPB is a pervasive problem in surgical environments in multiple regions of Saudi Arabia. Consultants and specialists are the primary offenders in bullying, which makes the hospital an environment for bullying behaviors.

Experiences of LGBTQ+ Residents in US General Surgery Training Programs

Importance

Previous studies have shown high rates of mistreatment among US general surgery residents, leading to poor well-being. Lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) residents represent a high-risk group for mistreatment; however, their experience in general surgery programs is largely unexplored.

Objective

To determine the national prevalence of mistreatment and poor well-being for LGBTQ+ surgery residents compared with their non-LGBTQ+ peers.

Design, Setting, and Participants

A voluntary, anonymous survey adapting validated survey instruments was administered to all clinically active general surgery residents training in Accreditation Council for Graduate Medical Education-accredited general surgery programs following the 2019 American Board of Surgery In-Training Examination.

Main Outcomes and Measures

Self-reported mistreatment, sources of mistreatment, perceptions of learning environment, career satisfaction, burnout, thoughts of attrition, and suicidality. The associations between LGBTQ+ status and (1) mistreatment, (2) burnout, (3) thoughts of attrition, and (4) suicidality were examined using multivariable regression models, accounting for interactions between gender and LGBTQ+ identity.

Results

A total of 6956 clinically active residents completed the survey (85.6% response rate). Of 6381 respondents included in this analysis, 305 respondents (4.8%) identified as LGBTQ+ and 6076 (95.2%) as non-LGBTQ+. Discrimination was reported among 161 LGBTQ+ respondents (59.2%) vs 2187 non-LGBTQ+ respondents (42.3%; P < .001); sexual harassment, 131 (47.5%) vs 1551 (29.3%; P < .001); and bullying, 220 (74.8%) vs 3730 (66.9%; P = .005); attending surgeons were the most common overall source. Compared with non-LGBTQ+ men, LGBTQ+ residents were more likely to report discrimination (men: odds ratio [OR], 2.57; 95% CI, 1.78-3.72; women: OR, 25.30; 95% CI, 16.51-38.79), sexual harassment (men: OR, 2.04; 95% CI, 1.39-2.99; women: OR, 5.72; 95% CI, 4.09-8.01), and bullying (men: OR, 1.51; 95% CI, 1.07-2.12; women: OR, 2.00; 95% CI, 1.37-2.91). LGBTQ+ residents reported similar perceptions of the learning environment, career satisfaction, and burnout (OR, 1.22; 95% CI, 0.97-1.52) but had more frequent considerations of leaving their program (OR, 2.04; 95% CI, 1.52-2.74) and suicide (OR, 1.95; 95% CI, 1.26-3.04). This increased risk of suicidality was eliminated after adjusting for mistreatment (OR, 1.47; 95% CI, 0.90-2.39).

Conclusions and Relevance

Mistreatment is a common experience for LGBTQ+ surgery residents, with attending surgeons being the most common overall source. Increased suicidality among LGBTQ+ surgery residents is associated with this mistreatment. Multifaceted interventions are necessary to develop safer and more inclusive learning environments.

Perception of Harrasment or Discrimination during Urology Residency in Colombia

Purpose Workplace bullying (harassment, abuse, or discrimination), practiced persistently against an individual, can generate a hostile workplace environment, consequently leading to exhaustion, with poor psychological outcomes, and the onset of symptoms such as loss of confidence, fatigue, depressive thoughts, desertion, and suicidal thoughts. There are no publications regarding this issue in Colombia.

Our objective is to describe the residents' perception of gender and workplace discrimination and verbal/sexual harassment during their urological training.

Methods Observational, descriptive, cross-sectional study with anonymous surveys. We evaluated the demographic characteristics and the residents' perception of harassment, the type of harassment, how it affected their performance during residency, and from whom it was perceived.

Results We were able to obtain answers from 82/115 residents (71.3%), most of them men (45 [56%]). In total, 66% (54) reported workplace harassment; and 35.4% (29) felt gender discrimination, most of them women (17; 58.6%). Verbal abuse was reported by 64.6% (53), and it affected the work of 92.5%. The parception of workplace harassment was similar among both men and women (32 [69.5%] men and 21 [61.1%] women). A total of 7(19%) women reported sexual abuse. Regarding the source of the abuse, 39 (65.8%) was by professors, 26 (45%), by other residents, and 17 (35.4%), by patients.

Conclusion The perception of harassment during urology residency in Colombia is real, and it affects the work of residents. This abuse is greater on the part of men, and is mainly perpetrated by professors. We consider our work the starting point to continue researching a topic of national and international importance.

Percepción de acoso o discriminación durante la residencia de urología en Colombia

Objetivos El maltrato laboral (acoso, abuso o discriminación) ejercido de manera persistente contra un individuo genera un ambiente de trabajo hostil y lleva a agotamiento, con un impacto psicológico importante y la posibilidad de aparición de síntomas depresivos. En Colombia, no contamos con publicaciones al respecto.

El objetivo de nuestro trabajo es conocer la percepción de los residentes de urología en cuanto a discriminación de género y acoso laboral, verbal y sexual durante su formación.

Metodos Estudio observacional, descriptivo, de corte transversal, por medio de encuestas anónimas. Evaluamos las características demográficas, la percepción de acoso, el tipo de acoso, si éste afectó el rendimiento laboral del residente, y por parte de quién lo percibió.

Resultados Obtuvimos respuestas de 82/115 (71,3%) residentes, en su mayoría hombres (45 [56%]). En total, 66% (54) reportaron haber experimentado acoso laboral; y 35,4% (29) reportaron haber experimentado discriminación de género, siendo más frecuente en las mujeres (17; 58,6%). El acoso verbal fue reportado por un 64,6% (53), y afectó el trabajo de un 92,5%. La percepción de acoso laboral fue similar entre hombres y mujeres (32 [69.5%] hombres y 21 [61.1%] de mujeres). En total, 7 (19%) mujeres reportaron acoso sexual. Con respecto a la fuente de acoso, 39 (65,8%) fue por profesores, 26 (45%), por otros residentes, y 17 (35.4%), por pacientes.

Conclusión La percepción de acoso durante la residencia de urología en Colombia es real, y afecta el trabajo de los residentes. Este acoso es mayor por parte de los hombres, y es principalmente generado por profesores. Consideramos nuestro trabajo el punto de partida para continuar investigando un tema de importancia a nivel nacional y internacional.

Experiences of Gender Discrimination and Sexual Harassment Among Residents in General Surgery Programs Across the US

Importance

Mistreatment is a common experience among surgical residents and is associated with burnout. Women have been found to experience mistreatment at higher rates than men. Further characterization of surgical residents' experiences with gender discrimination and sexual harassment may inform solutions.

Objective

To describe the types, sources, and factors associated with (1) discrimination based on gender, gender identity, or sexual orientation and (2) sexual harassment experienced by residents in general surgery programs across the US.

Design, Setting, and Participants

This cross-sectional national survey study was conducted after the 2019 American Board of Surgery In-Training Examination (ABSITE). The survey asked respondents about their experiences with gender discrimination and sexual harassment during the academic year starting July 1, 2018, through the testing date in January 2019. All clinical residents enrolled in general surgery programs accredited by the Accreditation Council for Graduate Medical Education were eligible.

Exposures

Specific types, sources, and factors associated with gender-based discrimination and sexual harassment.

Main Outcomes and Measures

Primary outcome was the prevalence of gender discrimination and sexual harassment. Secondary outcomes included sources of discrimination and harassment and associated individual- and program-level factors using gender-stratified multivariable logistic regression models.

Results

The survey was administered to 8129 eligible residents; 6956 responded (85.6% response rate)from 301 general surgery programs. Of those, 6764 residents had gender data available (3968 [58.7%] were male and 2796 [41.3%] were female individuals). In total, 1878 of 2352 female residents (79.8%) vs 562 of 3288 male residents (17.1%) reported experiencing gender discrimination (P < .001), and 1026 of 2415 female residents (42.5%) vs 721 of 3360 male residents (21.5%) reported experiencing sexual harassment (P < .001). The most common type of gender discrimination was being mistaken for a nonphysician (1943 of 5640 residents [34.5%] overall; 1813 of 2352 female residents [77.1%]; 130 of 3288 male residents [4.0%]), with patients and/or families as the most frequent source. The most common form of sexual harassment was crude, demeaning, or explicit comments (1557 of 5775 residents [27.0%] overall; 901 of 2415 female residents [37.3%]; 656 of 3360 male residents [19.5%]); among female residents, the most common source of this harassment was patients and/or families, and among male residents, the most common source was coresidents and/or fellows. Among female residents, gender discrimination was associated with pregnancy (odds ratio [OR], 1.93; 95% CI, 1.03-3.62) and higher ABSITE scores (highest vs lowest quartile: OR, 1.67; 95% CI, 1.14-2.43); among male residents, gender discrimination was associated with parenthood (OR, 1.72; 95% CI, 1.31-2.27) and lower ABSITE scores (highest vs lowest quartile: OR, 0.57; 95% CI, 0.43-0.76). Senior residents were more likely to report experiencing sexual harassment than interns (postgraduate years 4 and 5 vs postgraduate year 1: OR, 1.77 [95% CI, 1.40-2.24] among female residents; 1.31 [95% CI, 1.01-1.70] among male residents).

Conclusions and Relevance

In this study, gender discrimination and sexual harassment were common experiences among surgical residents and were frequently reported by women. These phenomena warrant multifaceted context-specific strategies for improvement.

Systematic review of academic bullying in medical settings: dynamics and consequences

PURPOSE

To characterise the dynamics and consequences of bullying in academic medical settings, report factors that promote academic bullying and describe potential interventions.

DESIGN

Systematic review.

DATA SOURCES

We searched EMBASE and PsycINFO for articles published between 1 January 1999 and 7 February 2021.

STUDY SELECTION

We included studies conducted in academic medical settings in which victims were consultants or trainees. Studies had to describe bullying behaviours; the perpetrators or victims; barriers or facilitators; impact or interventions. Data were assessed independently by two reviewers.

RESULTS

We included 68 studies representing 82 349 respondents. Studies described academic bullying as the abuse of authority that impeded the education or career of the victim through punishing behaviours that included overwork, destabilisation and isolation in academic settings. Among 35 779 individuals who responded about bullying patterns in 28 studies, the most commonly described (38.2% respondents) was overwork. Among 24 894 individuals in 33 studies who reported the impact, the most common was psychological distress (39.1% respondents). Consultants were the most common bullies identified (53.6% of 15 868 respondents in 31 studies). Among demographic groups, men were identified as the most common perpetrators (67.2% of 4722 respondents in 5 studies) and women the most common victims (56.2% of 15 246 respondents in 27 studies). Only a minority of victims (28.9% of 9410 victims in 25 studies) reported the bullying, and most (57.5%) did not perceive a positive outcome. Facilitators of bullying included lack of enforcement of institutional policies (reported in 13 studies), hierarchical power structures (7 studies) and normalisation of bullying (10 studies). Studies testing the effectiveness of anti-bullying interventions had a high risk of bias.

CONCLUSIONS

Academic bullying commonly involved overwork, had a negative impact on well-being and was not typically reported. Perpetrators were most commonly consultants and men across career stages, and victims were commonly women. Methodologically robust trials of anti-bullying interventions are needed.

LIMITATIONS

Most studies (40 of 68) had at least a moderate risk of bias. All interventions were tested in uncontrolled before-after studies.

Comprehensive Characterization of the General Surgery Residency Learning Environment and the Association With Resident Burnout

OBJECTIVES

To characterize the learning environment (ie, workload, program efficiency, social support, organizational culture, meaning in work, and mistreatment) and evaluate associations with burnout in general surgery residents.

BACKGROUND SUMMARY DATA

Burnout remains high among general surgery residents and has been linked to workplace exposures such as workload, discrimination, abuse, and harassment. Associations between other measures of the learning environment are poorly understood.

METHODS

Following the 2019 American Board of Surgery In-Training Examination, a cross-sectional survey was administered to all US general surgery residents. The learning environment was characterized using an adapted Areas of Worklife survey instrument, and burnout was measured using an abbreviated Maslach Burnout Inventory. Associations between burnout and measures of the learning environment were assessed using multivariable logistic regression.

RESULTS

Analysis included 5277 general surgery residents at 301 programs (85.6% response rate). Residents reported dissatisfaction with workload (n = 784, 14.9%), program efficiency and resources (n = 1392, 26.4%), social support and community (n = 1250, 23.7%), organizational culture and values (n = 853, 16.2%), meaning in work (n = 1253, 23.7%), and workplace mistreatment (n = 2661, 50.4%). The overall burnout rate was 43.0%, and residents were more likely to report burnout if they also identified problems with residency workload [adjusted odds ratio (aOR) 1.60, 95% confidence interval (CI) 1.31-1.94], efficiency (aOR 1.74; 95% CI 1.49-2.03), social support (aOR 1.37, 95% CI 1.15-1.64), organizational culture (aOR 1.64; 95% CI 1.39-1.93), meaning in work (aOR 1.87; 95% CI 1.56-2.25), or experienced workplace mistreatment (aOR 2.49; 95% CI 2.13-2.90). Substantial program-level variation was observed for all measures of the learning environment.

CONCLUSIONS

Resident burnout is independently associated with multiple aspects of the learning environment, including workload, social support, meaning in work, and mistreatment. Efforts to help programs identify and address weaknesses in a targeted fashion may improve trainee burnout.

Workplace Bullying Among Junior Doctors in Malaysia: A Multicentre Cross-Sectional Study

Background

Research suggests that junior doctors often experience workplace bullying, which may have adverse impacts on medical training and delivery of quality healthcare. However, evidence among local population has not been established. The present study aims to examine the prevalence of workplace bullying among Malaysian junior doctors and explore its associated sociodemographic and employment factors.

Methods

A multicentre cross-sectional study was conducted in 12 government hospitals accredited for housemanship training within the central zone of Malaysia. The study included a total of 1,074 house officers who had been working for at least 6 months in various housemanship rotations. The Negative Acts Questionnaire-Revised (NAQ-R) was used to examine workplace bullying.

Results

The 6-month prevalence of workplace bullying among study participants was 13%. Work-related bullying such as ‘being ordered to do work below your level of competence’, person-related bullying such as ‘being humiliated or ridiculed in connection with your work’, and physically intimidating bullying such as ‘being shouted at or being the target of spontaneous anger’ were commonly reported by study participants. Medical officers were reported to be the commonest perpetrators of negative actions at the workplace. Study participants who graduated from Eastern European medical schools (adjusted odds ratio [AOR] 2.27; 95% confidence interval [CI]: 1.27, 4.07) and worked in surgical-based rotation (AOR 1.83; 95% CI: 1.13, 2.97) had higher odds of bullying compared to those who graduated from local medical schools and worked in medical-based rotation, whereas study participants with good English proficiency (AOR 0.14; 95% CI: 0.02, 0.94) had lower odds of bullying compared to those with poor English proficiency.

Conclusion

The present study shows that workplace bullying is prevalent among Malaysian junior doctors. Considering the gravity of its consequences, impactful strategies should be developed and implemented promptly in order to tackle this serious occupational hazard.

Intimidation, harassment, and discrimination during family medicine residency training: a mixed methods study

BACKGROUND

The importance of wellbeing of family medicine residents is recognized in accreditation requirements which call for a supportive and respectful learning environment; however, concerns exist about learner mistreatment in the medical environment. The purpose of this study was to to describe family medicine graduates' perceived experience with intimidation, harassment and discrimination (IHD) during residency training.

METHODS

A mixed-methods study was conducted on a cohort of family medicine graduates who completed residency training during 2006-2011. Phase 1, the quantitative component, consisted of a retrospective survey of 651 graduates. Phase 2, the qualitative component, was comprised of 11 qualitative interviews. Both the survey and the interviews addressed graduates' experience with IHD with respect to frequency and type, setting, perpetrator, perceived basis for IHD, and the effect of the IHD.

RESULTS

The response rate to the survey was 47.2%, with 44.7% of respondents indicating that they experienced some form of mistreatment/IHD during residency training, and 69.9% noting that it occurred more than once. The primary sources of IHD were specialist physicians (75.7%), hospital nurses (47.8%), and family physicians (33.8%). Inappropriate verbal comments were the most frequent type of IHD (86.8%). Graduates perceived the basis of the IHD to be abuse of power (69.1%), personality conflict (36.8%), and family medicine as a career choice (30.1%), which interview participants also described. A significantly greater proportion IMGs than CMGs perceived the basis of IHD to be culture/ethnicity (47.2% vs 10.5%, respectively). The vast majority (77.3%) of graduates reported that the IHD experience had a negative effect on them, consisting of decreased self-esteem and confidence, increased anxiety, and sleep problems. As trainees, they felt angry, threatened, demoralized, discouraged, manipulated, and powerless. Some developed depression or burnout, took medication, or underwent counselling.

CONCLUSIONS

IHD continued to be prevalent during family medicine residency training, with it occurring most frequently in the hospital setting and specialty rotations. Educational institutions must work with hospital administrators to address issues of mistreatment in the workplace. Residency training programs and the medical establishment need to be cognizant that the effects of IHD are far-reaching and must continuously work to eradicate it.

Inadequate treatment in internships: a comparison between medical and other students

Aims: Inadequate treatment is one of the factors interfering with a successful social and working life. Among students, it can impair their health and learning progress. In the field of medicine the problem of inadequate treatment seems widespread. This study examines wether inadequate treatment in internships differs between medicine and other academic disciplines. Method: Using a questionnaire, the frequency, forms and severity of inadequate treatment among students were compared between the disciplines of medicine, civil engineering and teaching. Results: 69,3% of medical students reported inadequate treatment during their internships, about twice as many as students of other disciplines. The ratios of verbal, non-verbal and organisational inadequate treatment were similar between the different academic disciplines. However, medical students executed tasks without receiving sufficient safety precautions or training significantly more often (sevenfold) than students of other disciplines. In total however, the experienced incidents of inadequate treatment were seen as similarly severe across the different academic fields. Conclusion: Inadequate treatment of students during internships is a larger problem in medicine than in civil engineering or teaching, particularly concerning the performance of unsafe tasks. With regard to the health of students and patients, inadequate treatment in the medical education should be tackled. Previous studies suggest that this goal can be achieved only through longtime extensive measures on the level of students, lecturers, faculty and teaching hospitals.

Mistreatment, discrimination and burn-out in Neurosurgery

OBJECTIVE

Issues concerning harassment, bullying and discrimination are not unknown to medical specialties and are likely to be present in neurosurgery as well. The aim of this study was to estimate the extent to which neurosurgeons are faced with issues pertaining to this mistreatment.

METHODS

A survey consisting of fourteen questions was distributed among members of the Congress of Neurological Surgeons (CNS). The survey consisted of three parts: 1) demographics; 2) exposure to mistreatment; 3) experienced burnout symptoms.

RESULTS

In total 503 out of the 5665 approached CNS members filled in a survey (response rate 8.9 %). Respondents consisted for 85.9 % out of neurosurgeons and for 13.9 % out of residents. Overall, 61.4 % of the respondents was a victim of form of abusive behavior, while 47.9 % was a victim of at least one form of discrimination. Most reported sources of these mistreatments were other neurosurgeons or (family of) patients. Overall, 49.9 % of the respondents experienced burnout symptoms. Multivariable logistic regression analysis showed that female respondents had higher odds of being a victim of abuse (OR 2.5, 95 % CI 1.4-4.6). Female respondents (OR 19.8, 95 % CI 8.9-43.9) and ethnic minorities (OR 3.8, 95 % CI 2.3-6.2) had higher odds of being a victim of discrimination. Furthermore, victims of abuse were at higher odds (OR 1.7, 95 % CI 1.1-2.6) of having burnout symptoms.

CONCLUSIONS

Mistreatment and experiencing burnout symptoms frequently occurs among neurosurgeons and residents.

Career aspirations among specialty residents in France: a cross-sectional gender-based comparison

BACKGROUND

Most studies evaluating career aspirations among gender are performed in Anglo-Saxon countries. Two recent French studies looked at the career choice of residents in obstetrics & gynecology. It seemed useful to us to broaden this questioning to other specialties, by proposing a study to all residents in the same Faculty. The objective of our study was to describe residents' career aspirations and possible barriers according to gender.

METHODS

Declarative cross-sectional survey, using questionnaires sent by email to the specialty residents of the Faculty of Medicine of Lille (France). An analysis by specialty group (i.e., medicine, surgery, obstetrics & gynecology, and anesthesia & resuscitation) and a comparison of the results according to gender were performed.

RESULTS

Of the 1384 specialty residents currently in training, 462 answered the questionnaire (33.38%), among whom 289 women and 173 men (average age = 27.08 ± 0.091 years). Seventeen women (5.9%) were currently considering a university hospital career versus 37 men (21.4%) (p = 0.001). Gender analysis made it possible to identify obstacles to engaging in a university career: lacking a female model, more frequent doubting the ability to undertake this type of career among women (61.6%) than men (35.3%) (p < 0.001), and gender discrimination felt in the workplace for 51.6% of women (versus 7.5% of men, p < 0.001). Subgroup analysis showed specificities related to each specialty.

CONCLUSIONS

Few residents plan to embark upon a university hospital career, let alone female residents. There are considerations specific to each specialty and marked gender differences regarding career aspirations. Many features have been identified as obstacles to access to university hospital positions for women. It is important to develop strategies to remove these barriers and enable women to pursue such university careers.

TRIAL REGISTRATION

Not applicable (no intervention).

Nevertheless, They Persisted: How Women Experience Gender-Based Discrimination During Postgraduate Surgical Training

OBJECTIVE

More women than ever are pursuing surgical specialties despite historical dominance by men. The objective of this study was to examine how surgical residents experience gender-based discrimination during their residency training, including the common sources, settings, and implications of these experiences.

DESIGN

A sequential explanatory mixed methods design was used to combine results from an initial quantitative survey of surgical residents of all genders at the University of Calgary with qualitative data derived from interviews with surgical residents who identified as women.

PARTICIPANTS

Thirty-seven surgical residents of all genders completed a survey. Fourteen women completed a one-to-one, semistructured interview.

RESULTS

Women reported significantly more frequent experiences of gender-based discrimination than men, particularly regarding lack of respect from others, inappropriate jokes or comments, and hostile or humiliating behaviors. Nursing staff and patients were reported as prominent sources of discrimination, and the emergency and operating rooms were the most common settings. The qualitative findings highlighted the additional challenges for women during surgical residency, including navigating the relationships with nursing, having to work "twice as hard" to receive respect from patients and nurses, reports of persistent harassment and bullying, becoming desensitized to mistreatment and discrimination, and the influence of their gender on the quality of their education as well as their well-being.

CONCLUSIONS

Despite the increasing number of women entering surgical specialties, women surgical residents report frequent and severe experiences of gender-based discrimination during their training, even at an academic institution where over half of residents are women.

Sexual Harassment Among Medical Students: Prevalence, Prediction, and Correlated Outcomes

BACKGROUND

Few studies are dedicated to understanding the extent and impact of sexual harassment among medical students. The aim of this study was to use behaviorally specific measures to examine prevalence of sexual harassment toward medical students. Associated mental health and academic impacts were also studied.

METHODS

A multisite survey was conducted at four medical schools. Sexual harassment was measured using the Sexual Experiences Questionnaire (SEQ), a valid and reliable instrument. Students were also surveyed about depressive and post-traumatic stress disorder (PTSD) symptoms and their level of academic engagement. We also assessed their perceptions of institutional response and whether they felt safe at their institution.

FINDINGS

The final sample included 524 medical students (response rate = 13%). Findings revealed that 36.6% reported sexual harassment by a faculty/staff member and 38.5% reported harassment by a fellow student. The odds of harassment by faculty/staff, as well as peers, were significantly higher for women with an adjusted odds ratio (AOR) = 9.83, 95% confidence interval (CI) = [3.74, 25.80] and multiracial students with an AOR: 2.93, 95% CI: [1.16, 7.39]. Those who experienced sexual harassment were more likely to report academic disengagement and symptoms of depression and PTSD.

CONCLUSION/APPLICATION TO PRACTICE

Sexual harassment in medical schools can potentially limit a student's academic success and negatively impact their mental health. Supportive services and efforts to address peer and professional cultures that promote harassment are needed. Experiences of harassment require swift and competent responses by medical school leadership in collaboration with occupational and/or student health services to mitigate detrimental impacts and support medical students throughout their training.

How pregnancy and childbirth affect the working conditions and careers of women surgeons in Japan: findings of a nationwide survey conducted by the Japan Surgical Society

PURPOSE

To identify the conflicts between a career as a surgeon and pregnancy and childbirth for women in Japan.

METHODS

The Japan Surgical Society conducted a nationwide survey on pregnancy and childbirth among its members who are women. The questionnaire included items regarding demography, working styles, and pregnancy and childbirth, including adverse events and harassment.

RESULTS

The response rate was 29.9% (1068 responses, median age, 37 years). Among the responders, 61% were married and 47% had children (average number of children, 1.7). Half of the respondents reported having experienced sexual harassment and 62% reported having received unwelcome comments about pregnancy. About 20% had undergone fertility treatment. In total, 51% had pregnancies, with miscarriages in 33% of these. The top answer for the best timing for pregnancy and childbirth was after becoming board-certified. Nearly one-third of first-time mothers experienced adverse events during pregnancy and delivery, and 28% quit or changed their job because of their pregnancy and the birth of their first child.

CONCLUSIONS

Japanese women who choose a career as a surgeon face obstacles during pregnancy and childbirth. It is vital to share the findings of this study and understand the issues associated with pregnancy and childbirth regardless of gender. Interventions are essential to ensure that every pregnant surgeon has a safe working environment to allow unobstructed development of her career.

Sexual-orientation based discrimination is associated with anxiety and depression in young physicians. A national study

INTRODUCTION

The professional risk factors for depression and anxiety are underexplored in young physicians. While there has been increasing research on the mental health and well-being of lesbian, gay and bisexual patients, few studies have examined the mental health and well-being of lesbian, gay and bisexual young physicians.

OBJECTIVE

The objective of the present study was to determine the prevalence of Sexual Orientation-Based Discrimination (SOBD) in French young physicians and if SOBD was associated with increased anxiety and depression in this population.

METHOD

This national study is a cross-sectional observational epidemiological national study. The participants were recruited between April 1^st 2019 and June 31^st 2019. One question with binary answer was asked on SOBD. Mental health was assessed by Hamilton Anxiety & Depression scales.

RESULTS

On the 2003 participants, 148 (7%) reported SOBD exposure, 647 (32%) current anxiety disorders and 174 (9%) a current major depressive disorder according to their HAD score. SOBD was almost twice more frequently reported in participants with anxiety disorder and major depression (respectively 10%,vs 6% and 12% vs. 7%, p<0.05). In the first model of multivariate analyses, current anxiety disorder was significantly associated with being woman (adjusted odds ratio aOR=1.688, 95%CI 1.350-2.110, p<0.001) and SOBD (aOR=1.729, 95%CI 1.226-2.440, p=0.002). In the second model of multivariate analyses, current major depression was significantly associated with only SOBD (aOR=1.748, 95%CI 1.057-2.888, p=0.029).

CONCLUSION

SOBD has been associated with increased rates of anxiety disorder and major depression in young physicians and should be targeted in mental health prevention programs.

Female victims and female perpetrators: medical students' narratives of gender dynamics and professionalism dilemmas

Medicine is a gendered discipline, in which women, both as patients and practitioners, have often held subordinate positions. The reproduction of dominant gender biases in the medical setting can negatively impact the professional development of medical students and the wellbeing of patients. In this analysis of medical students' narratives of professionalism dilemmas, we explore students' experiences of gender bias in hospital settings. Seventy-one students participated in 12 group interviews, where they discussed witnessing or participating in various activities that they thought were professionalism lapses. Within the dataset, 21 narratives had a distinctly gendered component broadly pertaining to patient dignity and safety dilemmas, informed consent issues, and female student abuse. Interestingly, perpetrators of such acts were commonly female healthcare professionals and educators. Although students recognized such acts as professionalism lapses and often expressed concern for patient wellbeing, students did not intervene or report such acts due to hierarchical cultural contexts, and at times even reproduced the discriminatory behavior they were criticizing. This raises concerns about medical students' professionalism development and the extent to which gender bias is ingrained within particular medical systems. The normalization of disrespectful and abusive treatment of female patients poses immediate and future consequences to the wellbeing and safety of women. Furthermore, the same socio-cultural values that sustain these acts may account for perpetrators often being women themselves as they strive to overcome their subordinate position within medicine.

More Than Aligning Perception: Impact of an Educational Intervention on Medical Student Mistreatment Reporting

BACKGROUND

Despite decades of reporting, rates of medical student mistreatment on the surgical clerkship remains a national issue. To understand whether misaligned perceptions about what constitutes mistreatment were leading to the high rates of reported mistreatment at our institution, we implemented an intervention designed to educate students about the unique challenges of the surgical environment and to build consensus around the definition of mistreatment.

STUDY DESIGN

Medical students were recruited from the surgery clerkship to participate in a video vignette-based curriculum accompanied by a facilitated discussion. Participants completed a survey before and after the educational intervention to assess their understanding of mistreatment and their perceptions of the surgical learning environment. At the end of each clerkship block students who participated in the intervention, as well as students who did not participate, were asked to complete a questionnaire about their experiences during the clerkship.

RESULTS

During 6 clerkship blocks, 53 students participated in the intervention (51% of the third-year student cohort). Students who participated in the intervention were more likely to report experiencing mistreatment or witnessing mistreatment during the clerkship. Students who participated in the intervention also reported experiencing neglect more frequently than students who did not participate.

CONCLUSIONS

We found that using an educational intervention designed to align perceptions of what constitutes mistreatment in the surgical learning environment did not decrease rates of mistreatment reporting on the surgical clerkship at our institution. Students who participated in the intervention reported increased confidence in their ability to define and recognize mistreatment after the intervention, as well as increased comfort reporting mistreatment and turning to faculty with concerns about mistreatment.

Comparison of professionalism between emergency medicine resident physicians and faculty physicians: A multicenter cross-sectional study

Professionalism is a critical competency for emergency medicine (EM) physicians, and professional behavior affects patient satisfaction. However, the findings of various studies indicate that there are differences in the interpretation of professionalism among EM resident physicians and faculty physicians. Using a cross-sectional survey, we aimed to analyze common challenges to medical professionalism for Japanese EM physicians and survey the extent of professionalism coursework completed during undergraduate medical education. We conducted a multicenter cross-sectional survey of EM resident physicians and faculty physicians at academic conferences and eight teaching hospitals in Japan using the questionnaire by Barry and colleagues. We analyzed the frequency of providing either the best or second-best answers to each scenario as the main outcome measure and compared the frequencies between EM resident physicians and EM faculty physicians. Fisher's exact test and the Wilcoxon rank sum test were used to analyze data. A total of 176 physicians (86 EM resident physicians and 90 EM faculty physicians) completed the survey. The response rate was 92.6%. The most challenging scenario presented to participants dealt with sexual harassment, and only 44.5% chose the best or second-best answers, followed by poor responses to the confidentiality scenario (69.9%). The frequency of either the best or second-best responses to the confidentiality scenario was significantly greater for EM resident physicians than for EM faculty physicians (77.1% versus 62.9%, p = 0.048). More participants in the EM resident physician group completed formal courses in medical professionalism than those in the EM faculty physician group (25.8% versus 5.5%, p < 0.01). Further, EM faculty physicians were less likely than EM resident physicians to provide acceptable responses in terms of confidentiality, and few of both had received professionalism training through school curricula. Continuous professionalism education focused on the prevention of sexual harassment and gender gap is needed for both EM resident physicians and faculty physicians in Japan.

An Empirical National Assessment of the Learning Environment and Factors Associated With Program Culture

OBJECTIVES

To empirically describe surgical residency program culture and assess program characteristics associated with program culture.

SUMMARY BACKGROUND DATA

Despite concerns about the impact of the learning environment on trainees, empirical data have not been available to examine and compare program-level differences in residency culture.

METHODS

Following the 2018 American Board of Surgery In-Training Examination, a cross-sectional survey was administered to all US general surgery residents. Survey items were analyzed using principal component analysis to derive composite measures of program culture. Associations between program characteristics and composite measures of culture were assessed.

RESULTS

Analysis included 7387 residents at 260 training programs (99.3% response rate). Principal component analysis suggested that program culture may be described by 2 components: Wellness and Negative Exposures. Twenty-six programs (10.0%) were in the worst quartile for both Wellness and Negative Exposure components. These programs had significantly higher rates of duty hour violations (23.3% vs 11.1%), verbal/physical abuse (41.6% vs 28.6%), gender discrimination (78.7% vs 64.5%), sexual harassment (30.8% vs 16.7%), burnout (54.9% vs 35.0%), and thoughts of attrition (21.6% vs 10.8%; all P < 0.001). Being in the worst quartile of both components was associated with percentage of female residents in the program (P = 0.011), but not program location, academic affiliation, size, or faculty demographics.

CONCLUSIONS

Residency culture was characterized by poor resident wellness and frequent negative exposures and was generally not associated with structural program characteristics. Additional qualitative and quantitative studies are needed to explore unmeasured local social dynamics that may underlie measured differences in program culture.

Exploration of Mistreatment and Burnout Among Resident Physicians: a Cross-Specialty Observational Study

PURPOSE

Resident physician mistreatment and burnout are widespread issues in medical training, but the association between the two remains unclear. This study examines the prevalence and types of mistreatment among resident physicians in core specialties and its association with burnout syndrome as well as feelings of depression/anxiety.

METHODS

A cross-sectional, survey-based observational study of medical residents was conducted at the University of California, Davis Medical Center in 2014. Current residents (PGY2 or higher) in the internal medicine, family medicine, obstetrics/gynecology, surgery, and pediatrics programs completed anonymous questionnaires addressing topics such as workplace mistreatment, feelings of depression/anxiety, and stress management. Burnout was measured using the Maslach Burnout Inventory.

RESULTS

Forty-four out of 105 residents (41.9%) witnessed mistreatment of their co-residents while 26 residents (24.8%) disclosed personal accounts of mistreatment. Seventy-one percent of residents met the criteria for burnout. Residents who had been personally mistreated were almost eight times more likely to report burnout (OR 7.6, 95% CI = 1.7-34.4) and almost four times more likely to report symptoms of anxiety and depression (OR 3.8, 95% CI = 1.6-9.1). Public belittlement or humiliation was the most common type of mistreatment.

CONCLUSION

Encountering mistreatment was associated with higher rates of burnout, as well as depression/anxiety. While it is uncertain if mistreatment in the workplace has a causative impact on burnout syndrome, the findings reveal the need to address work-related environmental factors that may contribute to both resident physician mistreatment and burnout.

Medical students' experiences with sexual discrimination and perceptions of equal opportunity: a pilot study in Germany

BACKGROUND

Data is available on sexual discrimination and subjective perceptions of equal opportunity in medical education for many countries. Surveys focussing on sexual harassment have not yet been conducted at German medical schools.

METHODS

A student initiative surveyed all medical students at the Hannover Medical School (MHH) using an anonymous online questionnaire on equal opportunity and sexual discrimination to identify potential problems in education.

RESULTS

A total of 343 students (15%) participated in the survey. Over 50% reported having either witnessed sexual harassment or experienced it themselves. Female students indicated having experienced sexual harassment three times more often than their male peers; verbal forms of sexual discrimination predominate. These observations and experiences of sexual harassment demonstrated significant influences on many perceptions regarding equal opportunity and equal treatment in the MHH undergraduate medical education at MHH.

CONCLUSION

This blind spot in medical education in the German-speaking countries should be scrutinized more closely. The experience of sexism in the context of undergraduate medical education, which has negative effects on students, should no longer be ignored in empirical education research.

Gender-based Harassment of Emergency Medicine Trainees: What Faculty Educators Need to Know

There is increased interest in workplace harassment as reports of improper workplace conduct have surfaced among multiple industries and governments. Accounts of sexual misconduct in academic medical centers also highlight the need for further education and training for faculty educators. The purpose of this paper is to provide faculty educators with the tools to recognize and respond to gender-based harassment of medical trainees. More specifically, we will review existing literature, the definition of gender-based harassment, federal laws, institutional reporting protocols, and retaliation toward reporters of harassing behavior.

Intimidation and Sexual Harassment during Plastic Surgery Training in the United States

Background

Attending physicians, peers, other providers, and patients are sources of intellectual growth, but may also be a source of abuse and harassment. Published international studies have found that harassment within residency training is widespread but there is little data regarding plastic surgery training. The authors sought to explore the incidence of harassment experienced by plastic surgery residents currently enrolled in US integrated and independent programs.

Methods

After an IRB-approved exemption was obtained, an anonymous internet-based survey was distributed via email to all plastic and reconstructive surgery residency programs. The survey was comprised of 23 questions that focused on personal experience or knowledge of other colleagues who had encountered abuse and harassment during their training. Responses were collected during a 60-day period. The response rate was 16%.

Results

A total of 173 individuals completed the survey. Regarding harassment experienced by the respondents, 39.2% reported verbal abuse, 19.9% experienced sexual harassment, and 3.6% reported being physically abused during their training. Of those individuals who were sexually harassed, 72.7% were females. In many of the cases (64.5%), the instigator was a supervising physician. Most respondents did not feel comfortable reporting the abuse (74.19%).

Conclusions

Abuse and sexual harassment rates among active plastic and reconstructive surgery residents in the United States are high and attention should be brought to this important issue. Further studies should be conducted to assess the extent of abuse so that it can lead to implementation of programs that provide accountability, improved support, counseling strategies, and foster appropriate professional development.

Exploring Action Items to Address Resident Mistreatment through an Educational Workshop

Mistreatment of trainees is common in the clinical learning environment. Resident mistreatment is less frequently tracked than medical student mistreatment, but data suggest mistreatment remains prevalent at the resident level. To address resident mistreatment, the authors developed an Educational Advance to engage emergency medicine residents and faculty in understanding and improving their learning environment. The authors designed a small-group session with the following goals: 1) Develop a shared understanding of mistreatment and its magnitude; 2) Recognize the prevalence of resident mistreatment data and identify the most common types of mistreatment; 3) Relate study findings to personal or institutional experiences; and 4) Generate strategies for combating mistreatment and strengthening the clinical learning environment at their home institutions. Design was a combination of presentation, small group discussion, and facilitated discussion. Results were presented to participants from a previously administered survey of resident mistreatment. Public humiliation and sexist remarks were the most commonly reported forms. Faculty were the most frequent perpetrators, followed by residents and nurses. A majority of respondents who experienced mistreatment did not report the incident. Session participants were then asked to brainstorm strategies to combat mistreatment. Participants rated the session as effective in raising awareness about resident mistreatment and helping departments develop methods to improve the learning environment. Action items proposed by the group included coaching residents about how to respond to mistreatment, displaying signage in support of a positive learning environment, zero tolerance for mistreatment, clear instructions for reporting, and intentionality training to improve behavior.

"Yes, I'm the Doctor": One Department's Approach to Assessing and Addressing Gender-Based Discrimination in the Modern Medical Training Era

While gender-based bias and discrimination (GBD) is known to exist in medical training, there is limited guidance for training programs on how to understand and combat this issue locally. The Massachusetts General Hospital Department of Surgery established the Gender Equity Task Force (GETF) to address GBD in the local training environment. In 2017, members of the GETF surveyed residents in surgery, anesthesia, and internal medicine at 2 academic hospitals to better understand perceived sources, frequency, forms, and effects of GBD. Overall, 371 residents completed the survey (60% response rate, 197 women). Women trainees were more likely to endorse personal experience of GBD and sexual harassment than men (P < .0001), with no effect of specialty on rates of GBD or sexual harassment. Patients and nursing staff were the most frequently identified groups as sources of GBD. While an overwhelming majority of both men (86%) and women (96%) respondents either experienced or observed GBD in the training environment, less than 5% of respondents formally reported such experiences, most frequently citing a belief that nothing would happen. Survey results served as the basis for a variety of interventions addressing nursing staff and patients as sources of GBD, low confidence in formal reporting mechanisms, and the pervasiveness of GBD, including sexual harassment, across specialties. These results reproduce other studies' findings that GBD and sexual harassment disproportionately affect women trainees while demonstrating how individual training programs can incorporate local GBD data when planning interventions to address GBD.

Psyche Meets the Gatekeepers: Creating a More Humane Culture for Women in Medicine

In the Greek myth of Psyche and Eros, Psyche must fulfill four seemingly impossible tasks to achieve full consciousness before she can be reunited with her bridegroom, Eros. From early childhood, girls and women can encounter gender stereotyping, sexual harassment and assault, and other gender-related challenges. Although both men and women can face mistreatment in medical school, female students experience sexual harassment and sexual assault at higher rates than male students. In medical training and career advancement, women often face additional obstacles unrelated to the formal education of physicians, such as salary and promotional disparities, and lack of mentorship, sponsorship, or role models. The suicide rate for male physicians is nearly 1.5 times higher than the general population; for female physicians, it is more than twice as high. Parenthood can pose additional challenges for mothers and fathers early in their academic careers, and women are vastly underrepresented as they try to move past the "gatekeepers" into leadership roles. Using the framework of the Psyche and Eros myth to examine the trajectory of a female physician's career, this article provides insights into these challenges, as well as strategies to address some of these inequities, such as programs to support female promotion and leadership, expanded mentorship and mentor models, sponsorship opportunities, leadership accountability, implicit bias training, and others. The authors call for the participation of both men and women as essential in ventures to create a more humane environment for the training and practice of medicine.

Organisational antecedents of workplace victimisation: The role of organisational climate, culture, leadership, support, and justice in predicting junior doctors' exposure to bullying at work

Workplace bullying is a pervasive phenomenon among junior doctors that may negatively impact their training and abilities to deliver quality healthcare, yet evidence on the factors of bullying among them remains lacking. This study examined the role of organisational climate, culture, leadership, support, and justice in junior doctors' exposure to workplace bullying on the basis of the work environment hypothesis, which suggests that workplace psychosocial factors are the main antecedents of bullying at work. Multilevel analysis of a universal sample (n = 1074) of junior doctors working in the central zone of Malaysia, using mixed effects logistic regression, was conducted. Analysis indicates that junior doctors working in departments with neutral and positive organisational climate, moderate and high degree of clan culture, moderate and high degree of adhocracy culture, moderate degree of hierarchy culture, moderate degree of production and achievement-oriented leadership style, moderate and high degree of organisational support, moderate degree of procedural justice, moderate and high degree of interactional justice, and high degree of distributive justice have lower odds of bullying compared with their counterparts. The results present evidence that all aspects of the organisation influence junior doctors' exposure to bullying and should be considered when developing antibullying initiatives targeted at them.

Missed opportunities in the way medical schools evaluate the ethical domain in clerkship rotations

Background

Several lines of evidence indicate that medical schools have been failing to adequately nurture empathy and the ethical dimension in their graduates, the lack of which may play a central role in the genesis of medical errors, itself a major source of avoidable deaths, incapacity and wasted resources. It has been widely proposed that medical schools should adopt evaluation strategies as a means to promote a culture of respectful relationships. However, it is not clear if evaluation strategies in medical schools have addressed key domains related to that aim, such as ethics, through the perspective of their students. Hence, we conducted a national survey of instruments used by Brazilian medical schools to assess clerkship rotations from the perspective of students, with a main focus on the ethical domain.

Methods

The authors invited 121 randomly selected institutions to participate in the study. Key informants answered a questionnaire about clerkship rotations and sent copies of any instrument used to assess the quality of clerkship rotations according to the students’ perspectives.

Results

Twenty-six (53%) of 49 participating schools used an instrument to assess the quality of clerkship rotations according to the perspective of students. Just 13 (27%) schools had instruments containing at least one question encompassing the ethical domain. Only 2 (4%) schools asked students specifically about the occurrence of any negative experience concerning the ethical domain during rotations. Merely 1 (2%) school asked students about having witnessed patient mistreatment and none asked about mistreatment against students themselves.

Conclusions

There are several missed opportunities in the way medical schools assess the quality of clerkship rotations regarding the ethical domain. Closing the gap between usual institutional discourses regarding ethics and how that dimension is assessed within clerkship rotations might represent an important step towards the improvement of medical education and healthcare systems.

Screening for Harassment, Abuse, and Discrimination among Surgery Residents: An EAST Multicenter Trial

Estimating the prevalence of harassment, verbal abuse, and discrimination among residents is difficult as events are often under-reported. The purpose of this study was to determine the prevalence of discrimination and abuse among surgical residents using the HITS (Hurt, Insulted, Threatened with harm or Screamed at) screening tool. A multicenter, cross-sectional, survey-based study was conducted at five academic teaching hospitals. Of 310 residents, 76 (24.5%) completed the survey. The HITS screening tool was positive in 3.9 per cent. The most common forms of abuse included sexual harassment (28.9%), discrimination based on gender (15.7%), and discrimination based on ethnicity (7.9%). There was a positive correlation between individuals who reported gender discrimination and racial discrimination (r = 0.778, n = 13, P = 0.002). Individuals who experienced insults were more likely to experience physical threats (r = 0.437, n = 79, P < 0.001) or verbal abuse (r = 0.690, n = 79, P < 0.001). Discrimination and harassment among surgical residents in academic teaching hospitals across the United States is not uncommon. Further research is needed to determine the impact of these findings on resident attrition.

The Shame-Blame Game: Is It Still Necessary? A National Survey of Shame-based Teaching Practice in Canadian Plastic Surgery Programs

Background:

As understanding of poor physician mental health and burnout strengthens, it is becoming important to identify factors that detract from wellbeing. Shame-based learning (SBL) is detrimental to psychological health and can contribute to burnout, substance abuse and suicide. This study endeavoured to quantify the unknown prevalence and effects of SBL in Canadian plastic surgery programs.

Methods:

An electronic survey was sent to all attending surgeons and trainee (residents and fellows) members of the Canadian Society of Plastic Surgeons. SBL was assessed using a validated questionnaire. Data was analyzed using descriptive statistics and thematic analysis.

Results:

98 responses (14.7%) comprising of 63 attending surgeons and 36 trainees were received. The majority of attending surgeons (78 percent) and trainees (67%) have been shamed. Fourteen percent of trainees and 9% of attending surgeons felt that SBL is necessary. The most common event provoking shaming for trainees was wrong answers (56%) and for attending surgeons was disagreement in clinical care (21%). For both groups, shamers were in positions of authority. The most common effect of SBL in trainees was a loss of self-confidence (53%), compared to no negative effect in attending surgeons (49 percent). Thirty-nine percent of trainees dealt with shaming events with support from fellow trainees (39 percent), while attending surgeons kept it to themselves (40 percent).

Conclusion:

SBL is present in Canadian plastic surgery residency programs and has numerous detrimental effects. To foster better mental health, residency programs should identify ongoing SBL and make efforts to transition to healthier feedback strategies.

Residents' Experiences of Abuse and Harassment in Emergency Departments

The widespread epidemic of emerging abuse in Emergency Departments (ED) toward residents generates negative effects on the residents' health and welfare. The purpose of this study was to determine and highlight the high prevalence of abuse and harassment toward Emergency residents. In 2011, a multi-institutional, cross-sectional study was conducted at seven Emergency Residencies of central hospitals in Iran. Residents were asked about their age, marital status, postgraduate year (PGY) levels, and work experiences before residency. Prevalence of abuse in four categories was evaluated: verbal abuse; verbal and physical threat; physical assault and sexual harassment; and by whom. The data were analyzed by SPSS version 17.0 (SPSS, Inc., Chicago, IL, USA). Two hundred fifteen of the 296 residents (73%) completed the survey. The prevalence of any type of abuse experienced was 89%; 43% of residents experienced verbal and physical threats, 10% physical assault, and 31% sexual harassment. Verbal abuse and verbal and physical threats without the use of weapons were higher in men in comparison with women ( p< .04). Women were more likely than men to encounter sexual harassment (31% vs. 7%, p< .01). Among the sexual harassment categories, sexual jokes (51%) were the most prevalent between residents. Junior residents (PGY-1) were more likely to experience abuse than senior residents (PGY-2 and PGY-3; p< .01). Patients and their companions were the main agents of abusive behaviors. Abuse and harassment during residency in ED are highly prevalent. Educational programs and effective preventive measures against this mistreatment are urgently required.

Inappropriate behaviours experienced by doctors while undertaking specialty training

Purpose

To explore inappropriate behaviours experienced during specialty training in Australia and their implications for doctors’ training experiences and outcomes. This is a subset of data from a larger study exploring experiences of doctors in Australian specialty training—a qualitative study of enablers, stressors and supports.

Methods

In this qualitative study, registrars in specialist training programmes in Australia were invited and interviewed between August 2015 and August 2016. Semistructured open-ended questions were used to explore topics of relevance to their workplace, training, support service use and personal lives. Interviews were transcribed verbatim, de-identified and content and thematic analysis undertaken. Recruitment was ceased when data saturation was reached and no new themes emerged. Key themes related to inappropriate behaviours experienced during specialty training are reported in this study.

Results

17 participants were recruited (including one Indigenous and one international medical graduate). A total of six specialty training programmes across multiple states at various locations across Australia were represented in this cohort. Almost all participants reported confronting (personally experienced or witnessed) inappropriate behaviours during their training, perpetrated most commonly by senior doctors. Key themes of inappropriate behaviour that emerged were belittling and humiliation, sexually inappropriate behaviour, inappropriate behaviour as part of the ‘culture’ of medicine, reluctance to raise concerns due to fear of recrimination, and impacts of inappropriate behaviour.

Conclusion

Varying inappropriate behaviours were experienced by doctors in specialty training, having implications for their psychological well-being. A multidimensional and multisystem approach is required in the management of this serious issue.

Workplace violence by specialty among Peruvian medical residents

OBJECTIVE

To determine the prevalence of workplace violence among Peruvian medical residents and to evaluate the association between medical specialty and workplace violence per type of aggressor.

METHODS

This was a cross-sectional secondary analysis that used data from the Peruvian Medical Residents National Survey 2016 (ENMERE-2016). The outcome of interest was workplace violence, including physical and verbal violence, which were categorized according to the perpetrator of violence (patients/relatives and worker-to-worker). Primary exposure was the medical specialty, categorized as clinical, surgical, and other specialties. To evaluate the associations of interest, we estimated adjusted prevalence ratios (PR) with their respective 95% confidence intervals (95% CI) using Poisson regression models with robust variances.

RESULTS

A total of 1054 Peruvian medical residents were evaluated. The mean age was 32.6 years and 42.3% were female. Overall 73.4% reported having suffered of workplace violence sometime during the residency, 34.4% reported violence from patients/relatives, and 61.1% reported worker-to-worker violence. Compared with clinical residents, surgical residents had a lower prevalence of violence from patients/relatives (PR: 0.71; 95% CI: 0.59-0.87), but a higher prevalence of worker-to-worker violence (PR: 1.11, 95% CI: 1.01-1.23).

CONCLUSION

Nearly three quarters of medical residents reported having suffered workplace violence sometime during their residency. Compared with clinical residents, surgical residents had lower rates of violence from patients/relatives, but higher rates of worker-to-worker violence; while residents from non-clinical and non-surgical specialties had a lower prevalence of both types of violence.

Systematic review of the prevalence, impact and mitigating strategies for bullying, undermining behaviour and harassment in the surgical workplace

Background

Bullying, undermining behaviour and harassment (BUBH) have been reported in entertainment, politics and sport. Such behaviours may also be common in surgery, and are frequently associated with poor patient care and inferior outcomes. The aim was to define the prevalence and impact of this behaviour in the international surgical workplace, and to explore counterstrategies.

Methods

A systematic review was conducted by searching EMBASE, Medline, PsycINFO and the Cochrane Database of Systematic Reviews in August 2017. Original research studies (Oxford Centre for Evidence-based Medicine levels 1–4) investigating the prevalence and impact of BUBH in surgery, and/or counterstrategies, were eligible for inclusion. The review was conducted in accordance with PRISMA guidelines.

Results

Of 2692 papers, 32 were eligible for inclusion. Twenty-two reported the prevalence of BUBH in surgery, 11 studied the impact of this behaviour and six investigated counterstrategies. Prevalence data showed that BUBH are common in the surgical workplace. Their impact can be profound, compromising mental health, reducing job satisfaction, and inducing suicidal ideation. Formal reporting systems were perceived as ineffective and even potentially harmful to victims.

Conclusion

Bullying, undermining behaviour and harassment are highly prevalent within surgery, and extremely damaging to victims. There is little high-quality research into counterstrategies, although professionalism training using simulated scenarios may be useful.

Violence against doctors, a serious concern for healthcare organizations to ponder about

Background

Aggression and Violence against primary care physicians is reportedly common in Pakistan but there is no any documented study to-date on this burning issue.

Methods

A formed written questionnaire was distributed among 769 primary care physicians aged 31 ± 7.68 years. Apart from the demographic data, the questionnaire included questions regarding the level of safety that primary care physicians felt during their work setups and on-call duties, along with the experience of aggression against them by the perpetrators & the support provided by the hospital management in such cases.

Result

Response rate was 68% i.e. 524 physicians agreed to participate in the study. It was found that majority (85%) of the physicians has faced mild events, 62% have faced moderate events and roughly 38% were subjected to severe violence. Some physicians revealed more than one form of aggression being faced by them in 12 months preceding months which makes the collective percentage greater than 100%. Verbal abuse is the most frequent type of mistreatment faced by the doctors from the patients or their attendants.

Conclusion

A considerable number of physicians participated have faced mild violence in which verbal abuse was commonest; followed by moderate and severe events.

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Aggression and violence against doctors is reportedly high.

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Quantification of the sense of safety felt by male and female primary care physicians.

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Determining the proportion of doctors who experienced aggression and violence.

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Determining the type of aggression or violence.

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Needing the necessary subject be made a part of the medical education and (CME).

Gender differences and similarities in medical students' experiences of mistreatment by various groups of perpetrators

BACKGROUND

Mistreatment of medical students during medical education is a widespread concern. Studies have shown that medical students report the most mistreatment compared to students of other study programs and that the prevalence of mistreatment peaks during clinical training. For this reason, a study was conducted to assess prevalence of mistreatment among medical students committed by various groups of people. The focus was to identify whether gender was associated with the experience of mistreatment. Additionally, students' perception of university climate for reporting sexual harassment was assessed.

METHOD

In the study 88 medical students (45 women, 43 men) participated. A modified version of the Questionnaire on Student Abuse was used to assess students' experience of various types of mistreatment and associated distress during medical education. To explore factors that could be associated with this experience the organizational climate for reporting sexual harassment was assessed with the Psychological Climate for Sexual Harassment.

RESULT

The most often cited perpetrators of mistreatment were strangers (79.5%), friends (75.0%) and university staff (68.2%). Strangers mostly committed psychological mistreatment and sexual harassment, whereas friends additionally engaged in physical mistreatment of medical students. The most common form of mistreatment conducted by university staff was humiliation of students. These kinds of psychological mistreatment were reported to be distressing (43%). Gender differences were found in the prevalence of mistreatment. Women experienced more sexual harassment and humiliation than did men. On the other hand, men experienced more physical mistreatment than did women. Women reported experiencing more distress from mistreatment experiences than did men and also more often reported being mistreated by university staff than did men. Women perceived a greater risk in reporting sexual harassment to the organization than did men.

CONCLUSION

Mistreatment of female and male students should be focused on using a gender perspective because types of mistreatment can differ by gender. Additionally, interventions should include the societal level as there was a high prevalence of mistreatment perpetrated by strangers. Also the issue of trust in the university needs to be addressed and the organization is called on to visibly demonstrate that it represents and protects its students as well as its staff.