Intimidation and harassment in residency: a review of the literature and results of the 2012 Canadian Association of Interns and Residents National Survey.

BACKGROUND
Intimidation and harassment (I&H) have been longstanding problems in residency training. These behaviours continue to be prevalent, as evidenced by the 2012 Canadian Association of Interns and Residents (CAIR) National Resident Survey. More than seven in ten (72.9%) residents reported behaviour from others that made them feel diminished during their residency. We conducted a literature review to identify other surveys to determine the prevalence, key themes, and solutions to I&H across residency programs.


METHOD
PubMed and MEDLINE searches were performed using the key words "intimidation," "harassment," "inappropriate behaviour," "abuse," "mistreatment," "discrimination," and "residency." The search was limited to English language articles published between 1996 and 2013, and to papers where ten or more residents were surveyed or interviewed.


RESULTS
A total of ten articles were reviewed. Our findings showed that I&H continue to be highly prevalent with 45-93% of residents reporting this behaviour on at least one occasion. Verbal abuse was the most predominant form; staff physicians and nurses tended to be the dominant source. Residents reported that I&H caused significant emotional impact; however, very few incidents of inappropriate behaviour were reported. Very few solutions to I&H were proposed.


CONCLUSIONS
I&H in residency education continue to be common problems that are under-reported and under-discussed. The opportunity exists to improve efforts in this area. Definitions of what incorporates I&H should be revisited and various educational and structural initiatives should be implemented.


Introduction
Intimidation and harassment (I&H) have been longstanding problems in residency training. Intimidation in medical education includes any behaviour, educational process, or tradition that induces fear or anxiety in the resident physician which generally has a detrimental effect on the learning environment. 1 Furthermore, the Ontario Human Rights Code defines abuse and harassment as engaging in vexatious comments or conduct that is known or ought to be known to be unwelcome. Intimidation occurs when these words or actions disparage or humiliate the resident physician or cause the resident physician to undertake a course of action against his/her will, or refrain from undertaking an activity that, except for abuse or harassment, would be undertaken. 2 Clearly, this is serious and potentially damaging.
The Canadian Association of Interns and Residents (CAIR) has been concerned with addressing intimidation and harassment issues in post-graduate medical education for a number of years. In 1996, CAIR published a position paper on intimidation and harassment. 1 Since then, several efforts have been made to address I&H at the residency level. Many provincial resident organizations have published policies on this issue including a list of resources available to report I&H. At a national level, the Royal College of Physicians and Surgeons as well as the College of Family Physicians of Canada have included an I&H policy as part of their accreditation standards for residency programs.
Despite these efforts, I&H continue to be major issues for residents across Canada. In the 2012 CAIR National Resident Survey, more than seven in ten (72.9%) residents said they had experienced inappropriate behaviour from others that made them feel diminished during their residency. Half of all respondents (50.5%) said they had experienced this behaviour from either staff physicians or nursing staff. Over one quarter of respondents reported that they experienced yelling/shaming/condescension by colleagues (26.6%). Nearly four in ten (37.8%) cited their program director as a resource to help deal with inappropriate behaviour, and just over half (54.9%) said that the resources available to them were effective or somewhat effective. 3 In order to better understand and address I&H, CAIR conducted a literature review to identify the prevalence, key themes and proposed solutions to I&H across residency programs.

Methods
PubMed and MEDLINE searches were performed using the key words "intimidation," "harassment," "inappropriate behaviour," "abuse," "mistreatment," "discrimination," and "residency." These search terms were used based on input from the 2012-2013 CAIR board of directors. The search was limited to English language articles published between 1996 and 2013. It was also limited to papers where ten or more residents were surveyed or interviewed.
Two individuals from the 2012-2013 CAIR Member Outreach Committee reviewed each article for inclusion. A total of ten articles met the above criteria and were agreed upon by both reviewers. The majority of the articles were based on surveys from residents in programs across the United States or Canada. Two articles were surveys of residents outside North America, namely from Japan and Nigeria. One article was based on a survey of graduates from family medicine residency programs.
Appendix 1 provides a summary of the articles reviewed in this document.

Results
Eight major themes were discovered as part of the literature review, based on input from the two reviewers. These are listed below:

1) High prevalence of inappropriate behaviour
Resident intimidation, harassment and abuse continue to affect a significant number of residents. Eight of the ten studies reported that between 45-93% of residents had experienced some form of inappropriate behaviour during their residency training on at least one occasion.
3,4,6,8-12 There did not seem to be significant variation in rates of intimidation and harassment between the North American and international residents.

2) Verbal abuse as the predominant form
In all the studies reviewed, verbal abuse was the most common form of intimidation and harassment e52 experienced by residents. This was mostly in the form of inappropriate verbal comments and nonphysical verbal threats.
Sexual harassment and gender discrimination were also noted as common forms of I&H in four studies. 4,6,8,11 Sexual harassment was experienced by between 25-60% of residents, while one study from 1996 reported that 93% of residents surveyed had experienced some form of sexual harassment on at least one occasion. 11 Female residents more commonly reported gender discrimination. 4

3) Sources of abuse -physicians and nurses
All ten studies identified attending/staff physicians as a source of abuse. The next most common source was nursing staff, as identified in seven studies.

3,4,8-12
Six studies also identified residents at higher levels as well as patients and their families as sources of abuse. 6,8-12

4) Variation among rotations/specialties
Two studies looked at rates of I&H between various rotations or specialties. They both found that I&H were most common during a surgical rotation or in surgical specialties compared to non-surgical specialties. 6,8 Of specific interest is the study by Musselman et al. (2005) that surveyed only surgical residents and faculty. This survey showed that many residents felt that "surgical culture" enabled them to accept behaviours that might otherwise be labeled as inappropriate. In surgical specialties I&H was rationalized: residents were more likely to classify behaviours as legitimate if they had a positive effect on their education. 5

5) Cause of I&H -generation gaps and engrained culture
Two studies commented on the root cause of I&H in residency training. The Japanese study by Nagata-Kobayashi et al (2007) stated that negative traditions within the medical culture were the main cause of mistreatment. 6 The 2006 American Medical Association survey concluded that "generation gaps in medicine create conflict that lends itself to behaviours of intimidation and harassment." 7

6) Negative Emotional Impact
Four studies discussed the emotional/workplace impact of I&H. These studies concluded that I&H generally had a negative impact on the residents' work, that they experienced a decreased level of satisfaction with residency, and that anger and decreased eagerness to work were the most common emotional reactions to I&H. 6,8-10

7) Awareness of reporting structures for I&H/reasons to avoid reporting
Five studies addressed the question of whether residents were aware of how to report I&H. 3,6,7,9,11 These showed that between 50-75% of residents knew of the resources available to them to report inappropriate behaviours. However, only between 12-25% of incidents were actually reported. One study showed that of those residents that had reported I&H, 91% had experienced this behaviour on more than one occasion. 10 In another survey, 50% of residents stated they did not feel comfortable reporting these behaviours to their residency program. 7 Other reasons stated for not reporting the behaviours included that the individual did not think it was a problem, that they did not think that it was worthwhile, or that they did not believe that it would accomplish anything. 11

8) Solutions to intimidation and harassment
Unfortunately, very few articles proposed specific solutions to dealing with I&H. Most studies proposed that residency programs should be charged with addressing these issues through prevention, education, identification and enforcement. 3,5,7,11,12 The study by Cook et al. (1996) suggested several solutions via educational, behavioural and structural means. Incorporation of abuse and harassment topics in formal and informal curriculums as well as incorporating humanistic qualities in supervisor evaluations was suggested. Behavioural initiatives included labeling and addressing discriminatory and abusive events as well as issuing corporate policies in this regard. Structural solutions involved appointing a residency program ombudsperson, and establishing an institutional office to deal with problems of sexual harassment.

Discussion
The 2012 CAIR National Resident Survey and this literature review suggest that I&H in residency education continue to be common problems.
Despite the implementation of several policies and resources to deal with inappropriate behaviour, e53 residents often do not feel comfortable reporting these behaviours, believing that such actions would not lead to a favourable outcome or a change in behaviour. The problem, therefore, is not one of knowing that resources exist, but rather the lack of confidence in the effectiveness of these resources. This may be in part due to the fact that one of the major resources residents have identified is their program director. This may create an inherent conflict of interest, thereby deterring the resident from reporting inappropriate behaviours.
There are certain limitations to this paper. First, the review was limited to those papers that reported results of surveys of ten or more residents. Major themes: high prevalence of inappropriate behaviour, verbal abuse, sources of abuse, cause of I+H, awareness of reporting structures, solutions to I+H 44.7% of graduates experiences IHD while a resident -34% only once, 62% more than once. Inappropriate verbal comments most common form of IHD (94%), followed by work as punishment (28%). Main sources of IHD were from specialty physicians (77%), hospital nurses (54%), specialty residents (45%) and patients (35%). Primary basis of IHD was perceived to be gender (27%), ethnicity (16) and culture (10%). 54% of respondents knew about the process to address IHD during residency.
Perceptions of IHD are prevalent amongst family medicine graduates from Alberta. Residency programs should recognize and address any IHD concerns while actively promoting prevention.

Daugherty, Baldwin, Rowley (1998)
Random sample of all 2nd year residents listed in the American Medical Association medical research and information database Cross-sectional survey of 1277 2nd year residents across the United States Response rate: 72% Major themes: high prevalence of inappropriate behaviour, verbal abuse, sources of abuse, variation amongst rotations/ specialties, negative emotional impact 93% of respondents noted at least 1 episode of perceived mistreatment during their internship year -most commonly in the form of humiliation or belittlement. 63% reported that mistreatment took place on 3 or more occasions. Attending faculty, residents at higher levels, patients and nurses were the most sited source of mistreatment. Sexual harassment or discrimination was reported to occur on at least 1 occasion by 30% of residents. Female residents experienced this behaviour more commonly than men. The main forms of sexual harassment or discrimination came in the form of sexual slurs or comments, followed by favouritism and sexual advances. The highest prevalence was in the surgical specialties (80%). Being humiliated or belittled had a high negative correlation with overall satisfaction with the first-year residency experience.
Residents report significant mistreatment during first year residency. Mistreatment was highly negatively correlated to overall satisfaction with first-year residency.

Musselman et al. (2005)
Surgical residents and faculty in 2 university departments of surgery Major themes: high prevalence of inappropriate behaviour, verbal abuse, sources of abuse, negative emotional impact. 78% of residents reported experiencing intimidation and harassment through the course of the residency training. The source of I&H was from administration staff (58%), chief executive of the hospital (41%), patients families (40%) and from the nursing staff (33%). I&H were mainly in the form of inappropriate verbal comments (67%). Of those residents who had reported I&H, 91% had experienced I&H more than once.
Intimidation and harassment occurs among many residents. A number of residents are prone to emotional and mental health concerns during their training.

Internal medicine residents in Canada
Cross-sectional survey of 543 residents across 13 programs Frequency of experienced and witnessed different types of abuse based on a 7-pt Likert scale How often they experienced psychological abuse, Major themes: high prevalence of inappropriate behaviour, sources of abuse Psychological abuse -Approximately equal frequency was attributed to attending physicians and nurses/ other healthcare professionals (68-79%). Gender discrimination -Mostly experienced by females from their patients (47%), nurses/ health care workers (36%) or by attending physicians (25%). Sexual harassment -Predominantly experienced by females from attending physicians, peers and patients. Equal rates of sexual Residency programs should start addressing prevention and management of bias, discrimination abuse by attending physicians and peers.
Recommended curricular time to learn how to deal with abusive patients. These types of teachings should be incorporated into programs that already address resident stress e57 gender discrimination and sexual harassment How often they witnessed racial discrimination and homophobic remarks. Response rate: 84% harassment between males and females from nurses/ healthcare workers. Physical assault -Almost exclusively from patients. Racial discrimination was commonly witnessed from patients (67%), peers (50%) and attending physicians (49%). Homophobic remarks were witnessed from all groups (53-61%).