Bullying in medicine
- This article primarily concerns bullying involving doctors. For bullying involving nurses, see Bullying in nursing.
Bullying in the medical profession is common, particularly of student or trainee doctors. It is thought that this is at least in part an outcome of conservative traditional hierarchical structures and teaching methods in the medical profession which may result in a bullying cycle. The rampant problem of medical student mistreatment and bullying was systematically studied and reported in a 1990 JAMA study by pediatrician Henry K. Silver which found that 46.4 percent of students at one medical school had been abused at some point during medical school; by the time they were seniors, that number was 80.6 percent.
While the stereotype of a “victim” as a weak inadequate person who somehow deserves to be bullied is salient, there is growing evidence that bullies, who are often driven by jealousy and envy, pick on the highest performing and most skilled staff or students, whose mere presence is sufficient to make the bully feel insecure. Threats (of exposure of inadequacy) must be ruthlessly controlled and subjugated. Psychological models such as transference and projection have been proposed to explain such behaviors, wherein the bully's sense of personal inadequacy is projected or transferred to a victim; through making others feel inadequate and subordinate, the bully thus vindicates their own sense of inferiority.
Displacement is another defense mechanism that can explain the propensity of many medical educators to bully students, and may operate subconsciously. Displacement entails the redirection of an impulse (usually aggression) onto a powerless substitute target. The target can be a person or an object that can serve as a symbolic substitute. Displacement can operate in chain-reactions, wherein people unwittingly become at once victims and perpetrators of displacement. For example, a resident physician may be undergoing stress with her patients or at home, but cannot express these feelings toward patients or toward her family members, so she channels these negative emotions toward vulnerable students in the form of intimidation, control or subjugation. The student then acts brashly toward a patient, channeling reactive emotions which cannot be directed back to the resident physician onto more vulnerable subjects.
Beyond its ramifications for victims, disrespect and bullying in medicine is a threat to patient safety because it inhibits collegiality and cooperation essential to teamwork, cuts off communication, undermines morale, and inhibits compliance with and implementation of new practices.
Bullying can significantly decrease job satisfaction and increase job-induced stress; it also leads to low self confidence, depression, anxiety and a desire to leave employment. Bullying contributes to high rates of staff turnover, high rates of sickness absence, impaired performance, lower productivity, poor team spirit and loss of trained staff. This has implications for the recruitment and retention of medical staff.
Chronic and current bullying are associated with substantially worse health, according to research by Laura M. Bogart, associate professor of pediatrics at Harvard Medical School.
Studies have consistently shown that physicians have had the highest suicide rate compared to people in any other line of work—40% higher for male doctors and a 130% higher for female doctors. Research has traced the beginning of this difference to the years spent in medical school. Students enter medical school with mental health profiles similar to those of their peers but end up experiencing depression, burnout, suicidal ideation and other mental illnesses at much higher rates. Despite better access to health care, they are more likely to cope by resorting to dysfunctional and self-injurious behaviors, and are less likely to receive the right care or even recognize that they need some kind of intervention.
Exposure to bullying and intimidation during formative years of medical training has been found to contribute to these consequences. Fear of stigmatisation among medical students was the subject of a study in JAMA by Thomas Schwenk and colleagues at the University of Michigan's Department of Family Medicine, MI, USA. 53% of medical students who reported high levels of depressive symptoms were worried that revealing their illness would be risky for their careers and 62% said asking for help would mean their coping skills were inadequate, according to the study published in September 2010. "Medical students are under extraordinary demands. They feel they are making life and death decisions and that they can never be wrong. There is such tremendous pressure to be perfect that any sense of falling short makes them very anxious", says Schwenk.
Bullying of medical students
Medical students, perhaps being vulnerable because of their relatively low status in health care settings, may experience verbal abuse, humiliation and harassment (nonsexual or sexual). Discrimination based on gender and race are less common.
In one study, around 35% of medical students reported having been bullied. Around one in four of the 1,000 students questioned said they had been bullied by a doctor, while one in six had been bullied by a nurse. Furthermore, bullying has been known to occur among medical students. Manifestations of bullying include:
- being humiliated by teachers in front of patients or peers
- been victimised for not having come from a "medical family" (often people who enter medicine have an older sibling pursuing the same degree or share ties with other individuals in the profession with whom familial relationship confers some degree of protectsia or special influence - especially within academic settings.) Such practices extend to admissions procedures, which are regularly influenced by factors far afield of candidates' intrinsic merits, such as being related to faculty members or well-known medical luminaries.
- being put under pressure to carry out a procedure without supervision.
- being ostracized by other medical students for asking questions (due to the medical content being confusing for some students) through social media networks (Facebook bullying), phone, or in person.
One study showed that the medical faculty was the faculty in which students were most commonly mistreated.
Bullying of junior (trainee) doctors
In a UK study, 37% of junior doctors reported being bullied in the previous year and 84% had experienced at least one bullying behaviour. Black and Asian physicians were more likely to be bullied than other physicians. Women were more likely to be bullied than men.
Trainee doctors who feel threatened in the clinical workplace develop less effectively and are less likely to ask for advice or help when they need it. Persistent destructive criticism, sarcastic comments and humiliation in front of colleagues will cause all but the most resilient of trainees to lose confidence in themselves.
Bullying of doctors and consultants is rampant in the UK NHS - for example, eight documented cases of victimized NHS staff five doctors and three consultants. The farewell interview from Sir Ian Kennedy (Chair of the HealthcareCommission) caused significant media interest following his statement that bullying is a ‘corrosive’ problem that the NHS must address.
Medical training usually takes place in institutions that have a highly structured hierarchical system, and has traditionally involved teaching by intimidation and humiliation. Such practices may foster a culture of bullying and the setting up of a cycle of bullying, analogous to other cycles of abuse in which those who experience it go on to abuse others when they become more senior. Doctors are increasingly reporting to the British Medical Association that they are being bullied, often by older and more senior colleagues, many of whom were badly treated themselves when more junior.
Physician Jonathan Belsey relates in an emblematic narrative published in AMA Virtual Mentor entitled Teaching By Humiliation that "however well you presented the case, somewhere along the line you would trip up and give the predatory professor his opportunity to expose your inadequacies. Sometimes it would be your lack of medical knowledge; sometimes the question that you failed to ask the patient that would have revealed the root of the problem, or sometimes your ineptitude at eliciting the required clinical signs. On one memorable occasion, when I had appeared to cover all the bases clinically, the professor turned to me and berated me for attending his ward round wearing a plaid shirt that was clearly inappropriate for an aspiring doctor."
Bullying in psychiatry
Psychiatric trainees experience rates of bullying at least as high as other medical students. In a survey of psychiatric trainees in the West Midlands, 47% had experienced bullying within the last year with even higher percentages amongst ethnic minorities and females. Qualified psychiatrists are not themselves required to be psychiatrically assessed.
Doctors bullying/abusing patients and nurses
|This section requires expansion. (April 2011)|
Speaking of many doctor's predilection of bullying nurses, Teresa Brown writes:
...the most damaging bullying is not flagrant and does not fit the stereotype of a surgeon having a tantrum in the operating room. It is passive, like not answering pages or phone calls, and tends toward the subtle: condescension rather than outright abuse, and aggressive or sarcastic remarks rather than straightforward insults.
Bullying in nursing
Nurses experience bullying quite frequently. It is thought that relational aggression (psychological aspects of bullying such as gossipping and intimidation) are commonplace. Relational aggression has been studied among girls but not so much among adult women.
In popular culture
Sir Lancelot Spratt, a character played by actor James Robertson Justice in the film series Doctor in the House, is often referenced as the archetypal arrogant bullying doctor ruling by fear. The film series also demonstrates bullying of student doctors by other doctors and the nursing matron.
In the American sitcom Scrubs, Dr. Cox uses intimidation and sarcasm as methods of tormenting the interns and expressing his dislike towards them and their company.
- Field, T. (2002). "Bullying in medicine". BMJ 324 (7340): 786. doi:10.1136/bmj.324.7340.786/a.
- Björkqvist, K (2001). "Social defeat as a stressor in humans". Physiology & Behavior 73 (3): 435–42. doi:10.1016/S0031-9384(01)00490-5. PMID 11438372.
- Coverdale, J. H.; Balon, R.; Roberts, L. W. (2009). "Mistreatment of Trainees: Verbal Abuse and Other Bullying Behaviors". Academic Psychiatry 33 (4): 269–73. doi:10.1176/appi.ap.33.4.269. PMID 19690101.
- Curtis P Medical students complain of bullying The Guardian 4 May 2005
- Rautio, Arja; Sunnari, Vappu; Nuutinen, Matti; Laitala, Marja (2005). "Mistreatment of university students most common during medical studies". BMC Medical Education 5: 36. doi:10.1186/1472-6920-5-36. PMC 1285362. PMID 16232310.
- Stebbing, J; Mandalia, S; Portsmouth, S; Leonard, P; Crane, J; Bower, M; Earl, H; Quine, L (2004). "A questionnaire survey of stress and bullying in doctors undertaking research". Postgraduate Medical Journal 80 (940): 93–6. doi:10.1136/pmj.2003.009001. PMC 1742926. PMID 14970297.
- Bairy, KL; Thirumalaikolundusubramanian, P; Sivagnanam, G; Saraswathi, S; Sachidananda, A; Shalini, A (2007). "Bullying among trainee doctors in Southern India: A questionnaire study". Journal of Postgraduate Medicine 53 (2): 87–90. doi:10.4103/0022-3859.32206. PMID 17495372.
- Quine, L. (2002). "Workplace bullying in junior doctors: Questionnaire survey". BMJ 324 (7342): 878–9. doi:10.1136/bmj.324.7342.878. PMC 101400. PMID 11950736.
- Israël, E; Louwette, R; Lambotte, C (1975). "Two familial cases of congenital erythroderma ichthyosiforme". Revue médicale de Liège 30 (13): 439–44. PMID 1096266.
- Paice E, Smith D. Bullying of trainee doctors is a patient safety issue. The Clinical Teacher 2009; 6:13-7.
- Bullying Report by Central London Community NHS Trust
- Williams K (1998) Stress linked to bullying. BMA News Review, April 18
- Hoosen, I. A. (2004). "A survey of workplace bullying of psychiatric trainees in the West Midlands". Psychiatric Bulletin 28 (6): 225–7. doi:10.1192/pb.28.6.225.
- Gadit AA Bullying in psychiatry must stop - Clinical Psychiatry News, May, 2007
- Doctor faces court-martial in patient abuse case Stars and Stripes January 16, 2010
- 'Groping' surgeon found guilty BBC News 28 July 2002
- title="Physician Heel Thyself"|url='http://www.nytimes.com/2011/05/08/opinion/08Brown.html'
- Hutchinson, M; Wilkes, L; Vickers, M; Jackson, D (2008). "The development and validation of a bullying inventory for the nursing workplace". Nurse researcher 15 (2): 19–29. doi:10.7748/nr2008.01.15.2.19.c6326. PMID 18283759.
- Porter-O'grady, T (2008). "Transforming work environments. Interview by Diane E Scott and Amanda Rosenkranz". The American nurse 40 (2): 7. PMID 18494401.
- Richards A, Edwards SL A Nurse's Survival Guide to the Ward (2008)[page needed]
- Dellasega, Cheryl A. (2009). "Bullying among nurses". The American journal of nursing 109 (1): 52–8. doi:10.1097/01.NAJ.0000344039.11651.08. PMID 19112267.
- Ahmer, Syed; Yousafzai, Abdul Wahab; Bhutto, Naila; Alam, Sumira; Sarangzai, Amanullah Khan; Iqbal, Arshad (2008). Syed, Ehsan, ed. "Bullying of Medical Students in Pakistan: A Cross-Sectional Questionnaire Survey". PLoS ONE 3 (12): e3889. doi:10.1371/journal.pone.0003889. PMC 2586648. PMID 19060948.
- Faruqui, R. A.; Ikkos, G. (2007). "Poorly performing supervisors and trainers of trainee doctors". Psychiatric Bulletin 31 (4): 148–52. doi:10.1192/pb.bp.105.008730.
- Frank, E. (2006). "Experiences of belittlement and harassment and their correlates among medical students in the United States: Longitudinal survey". BMJ 333 (7570): 682–0. doi:10.1136/bmj.38924.722037.7C.
- Gadit, A A M; Mugford, G (2008). "A pilot study of bullying and harassment among medical professionals in Pakistan, focussing on psychiatry: Need for a medical ombudsman". Journal of Medical Ethics 34 (6): 463–6. doi:10.1136/jme.2007.021832. PMID 18511621.
- Imran, N; Jawaid, M; Haider, II; Masood, Z (2010). "Bullying of junior doctors in Pakistan: A cross-sectional survey". Singapore medical journal 51 (7): 592–5. PMID 20730401.
- Maida, Ana Margarita; Vásquez, Alicia; Herskovic, Viviana; Calderón, José Luis; Jacard, Marcela; Pereira, Ana; Widdel, Lars (2003). "A report on student abuse during medical training". Medical Teacher 25 (5): 497–501. doi:10.1080/01421590310001606317. PMID 14522671.
- Mukhtar, F; Daud, S; Manzoor, I; Amjad, I; Saeed, K; Naeem, M; Javed, M (2010). "Bullying of medical students". Journal of the College of Physicians and Surgeons--Pakistan : JCPSP 20 (12): 814–8. PMID 21205548.
- Paice, E.; Aitken, M; Houghton, A; Firth-Cozens, J (2004). "Bullying among doctors in training: Cross sectional questionnaire survey". BMJ 329 (7467): 658–9. doi:10.1136/bmj.38133.502569.AE. PMC 517643. PMID 15256417.
- Mistry M and Latoo J Bullying: a growing workplace menace BJMP Mar 2009 Volume 2 Number 1
- Paice, E; Firth-Cozens, J (2003). "Who's a bully then?". BMJ (Clinical research ed.) 326 (7393): S127. doi:10.1136/bmj.326.7393.S127. PMID 12689995.
- Quine, Lyn (1999). "Workplace bullying in NHS community trust: Staff questionnaire survey". BMJ (Clinical research ed.) 318 (7178): 228–32. doi:10.1136/bmj.318.7178.228. PMC 27703. PMID 9915730.
- Vanderstar ES Workplace Bullying in the Healthcare Professions 2004 8 Employee Rights and Employment Policy Journal 455
- Wood, D. F (2006). "Bullying and harassment in medical schools". BMJ 333 (7570): 664–5. doi:10.1136/bmj.38954.568148.BE. PMC 1584336. PMID 17008645.
- Wood DF Bullying in medical schools Student BMJ October 2006
- Bullying and harassment British Medical Association 8 May 2007
- Guidance for medical students on harassment, intimidation, victimisation and bullying British Medical Association 21 December 2007
- Bullying and harassment of doctors in the workplace Report British Medical Association Health Policy & Economic Research Unit May 2006
- The cost of bullying to the NHS
- The Bullying Culture of Medical School
- News stories
- Bullying on the NHS BBC News January 22, 1999
- Bullying 'ruining NHS workers' lives' BBC News 6 December 2000
- Many junior doctors bullied BBC News 11 April 2002
- One in four junior doctors bullied BBC News 26 September 2002
- Dunne R 'My fellow doctors bullied me' BBC News 9 June 2003
- NHS anti-bullying culture ordered BBC News 12 January 2006
- Targets' triggering NHS bullying BBC News 18 May 2006
- Surgery team 'unsafe' - and at times 'dangerous' Staffordshire Newsletter 10 March 2011