A Northwestern Medicine study found that nearly one in five surgical residents have experienced frequent bullying and that women and racial or ethnic minorities were more likely to report frequent bullying in surgical residency programs, according to survey results published in JAMA.
“Bullying is a repetitive issue where people are seeing patterns of mistreatment and abuse, and this assessment shows that when we use even the most stringent definitions of bullying, it’s a common problem for surgery residents,” said Lindsey Zhang, MD, MS, postdoctoral fellow in the Department of Surgery and first author of the study.
Bullying during surgical training, defined as persistent negative and aggressive behaviors that result in humiliation, intimidation or punishment, has been found in previous studies to be associated with stress, depression and burnout.
For the current study, a confidential questionnaire was completed by more than 6,900 surgical residents from 301 accredited residency programs in the United States. The survey measured how often residents experienced nine specific behaviors of frequent bullying within the academic year: repeated reminders of mistakes, being shouted at, withholding important information, persistent criticism, hostility, being the subject of gossip, exclusion, offensive remarks and unwanted jokes.
Residents were also asked to report if they had experienced symptoms of burnout, including emotional exhaustion and depersonalization, or if they had thoughts of program attrition or suicide over the course of the academic year.
Of the residents surveyed, 44 percent reported what was considered to be occasional bullying, and 18 percent reported frequent bullying. Residents who were frequently bullied also had higher rates of burnout, thoughts of suicide, and thoughts of dropping out of their program.
Residents who were most likely to report frequent bullying were women, identify as racial or ethnic minorities, those who were divorced or widowed, and residents who trained in the Northeast region of the U.S. or in community programs.
“When it comes to women and racial or ethnic minorities, we weren’t surprised by the findings. It was disheartening, but also validating,” said Yue-Yung Hu, MD, MPH, assistant professor of Surgery in the Division of Pediatric Surgery and senior author of the study.
For residents who reported any bullying behavior, 42 percent reported repeated reminders of mistakes, 39 percent reported being shouted at, 32 percent reported the withholding of important information, 30 percent reported persistent criticism and 24 percent reported hostility. These behaviors were most commonly displayed by attending physicians; the remaining behaviors were most commonly attributed to co-residents.
Reasons for why bullying is so prevalent in surgical residencies may be partially attributed to the hierarchical nature of the field itself, high stakes within the operating room and long-standing cultural norms, according to the authors.
“Hierarchy is a risk for mistreatment; the power differential means you can’t speak up when you see it happening or when it happens to you,” Hu said, and noted that although the power structure can be potentially harmful, it also has the simultaneous benefit of of clarifying roles which may be helpful in crisis situations.
The authors noted that the results also showed variability from program to program: some programs didn’t have any residents who reported bullying; in others, a majority of the residents reported bullying. As part of the SECOND trial, a national cluster-randomized trial focused on surgical resident wellness, the team is currently evaluating the structure and function of surgical residency programs across the U.S. to determine what factors may facilitate frequent bullying towards residents.
According to Zhang, the findings suggest there is a way to train surgical residents in a way that respects hierarchy and authority but also respects residents as individuals. Nonetheless, a culture change will take time.
“It’s really important that we continue to highlight that surgery is a very rewarding field and is also now becoming a field that is very much willing to recognize its flaws,” Zhang said. “The fact that we are talking about this, that we continue to talk about it on social media, that surgeons themselves are willing to recognize and discuss these issues is really, I think, the step that needs to be taken for the culture of surgery to continue to change.”
This work was supported by the Accreditation Council for Graduate Medical Education, the American College of Surgeons, the American Board of Surgery and the John A. Hartford Foundation.
