Bullies in the hospital

When you picture bullying, playgrounds probably come to mind before hospital wards. But the problem of bullies in school extends all the way through medical training, according to a recent study.

Almost half of residents and fellows reported that they had been bullied at some point in training, according to the national survey, conducted in June 2015 and published in PLOS ONE in March. The almost 2,000 trainees who took the survey reported attendings as the most common source of bullying, followed by nurses. They cited belittling and undermining of their work and unjustified criticism and monitoring, as well as destructive innuendo and sarcasm, and attempts to humiliate.

For more details on the problem of bullying in academic medicine, ACP Hospitalist recently spoke to lead study author Amar R. Chadaga, MD, FACP, clinical assistant professor at the University of Illinois College of Medicine in Chicago.

Q: What led you to study this issue?

A: I saw mistreatment when I was a medical student. During residency I didn't experience too much, but I saw a lot of it during my short-lived cardiology fellowship. After I left that, I thought, “Hmm, I think this is more pervasive than just me.”

Q: How did the results of the study compare to your expectations?

A: They were in line with what I expected... [and] what people had seen not only in the late 1990s in America but also what they had found in the United Kingdom and other places. While I was definitely not surprised, I was still saddened.

Q: Do you think the prevalence of bullying in medical training has changed over time?

A: I think it's stayed the same and I think it's just more subtle.

Q: Do you think the people involved in the incidents cited by the survey respondents think they're bullying?

A: No, no, not at all. My coauthor and I would say the line between bullying and tough love is very, very gray in graduate medical education. So somebody's tough love is somebody else's bullying. [We didn't study the issue from the opposite perspective] because studies have shown that even just feeling bullied in itself can lead to the learner having health issues and things like that and so if it's in that gray area, it really shouldn't be done.

Q: Can you tell from the survey how often this happens?

A: To us it didn't really matter. If their answers were even a few times, rarely, or frequently, we put them as a yes. Even just 1 time can have a profound impact. There's no way for us to really quantify it. We feel like 1 time is 1 too many. That's why we dichotomized that that way. It was also for ease of statistical analysis.

Q: Patients were reported as the source of the bullying in 23% of the cases. What are your thoughts on that?

A: I added [patients as an answer] because I felt intimidated by patients before. With the age of the Internet, having more areas where they can find out about their disease or just taking a firmer stance on their health—which is all fine, I'm all for that—sometimes as trainees, we're caught in the middle between attendings and patients about whether to order stuff or not order stuff if the patient wants it. Trying to explain that to patients is hard for the learner and they're maybe potentially caught in the middle of it all.

Q: What would you like to see happen in response to your findings?

A: The big thing is that we want this included in the [Accreditation Council for Graduate Medical Education (ACGME)] annual survey. We don't believe it's on there, because what we get back doesn't really portray anything about bullying or mistreatment. That's number 1 because these results need to be validated with a cohort that's more in line with what's in the graduate medical training environment.

We should have a place where people can openly let people know without fear of retaliation. Historically, 90% of bullying incidents in GME went unreported, in my research on the topic. ACGME needs to set expected standards of behavior. The gray area gets a little less gray if you have the accrediting body for most of the residencies put the standard there and then we make procedures for [dealing with bullying].

The annual survey should be completely public, because a lot of Medicare dollars go into trainees' education. Add it to the ACGME survey, create procedures, and thirdly make this survey publicly available so [residency applicants] can make informed decisions about where they want to go. That's what will really make change. [Programs] will really want to change because they don't want a bullying score really high.

Q: Do you think the rate of bullying differs by facility?

A: I think. There could be an argument that says that in university settings, there's more bullying, because it's hierarchical, but there could be an argument made that says community places have it because there's not as much oversight. [If the ACGME reported on bullying], you can really use the data and say, “We've found that in this specific program that it's the women who are really at risk.”

Q: Your survey found that female trainees were more likely to bullied, along with those who were nonwhite or had a height below 5′8″ or a body mass index of 25 [kg/m2] or more. What are your thoughts on that?

A: The nonwhite, the shorter, the heavier, I was not so surprised. The female [bullying]—I thought we had made more progress than that. We're actually delving into some of the data even deeper, doing regression analysis right now, and we're finding that the women have the most propensity to be bullied. We're still crunching the numbers.

Q: What response have you gotten to your study?

A: I got an e-mail from a surgeon who told me that I was completely wasting time: “Sometimes this ‘bullying’ actually helps them and you can't [prove] causation.” I think there are going to be some people saying we do coddle them too much and they won't be receptive.

I think, though, most people will be receptive as you show them this data and you show them the data that getting bullied leads to people leaving the field. If you could show them that it affects people's health, that they're not satisfied, take more sick time. If you could tie it to patient outcomes, I think that would potentially be the holy grail.