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Table 1.  Types and Sources of Bullying Behaviors Reported by General Surgery Residents in the 2018-2019 Academic Yeara
Types and Sources of Bullying Behaviors Reported by General Surgery Residents in the 2018-2019 Academic Yeara
Table 2.  Resident- and Program-Level Factors Associated With Frequent Bullying (N = 6264 Survey Respondents)a
Resident- and Program-Level Factors Associated With Frequent Bullying (N = 6264 Survey Respondents)a
1.
Hu  YY, Ellis  RJ, Hewitt  DB,  et al.  Discrimination, abuse, harassment, and burnout in surgical residency training.   N Engl J Med. 2019;381(18):1741-1752. doi:10.1056/NEJMsa1903759PubMedGoogle ScholarCrossref
2.
Ling  M, Young  CJ, Shepherd  HL, Mak  C, Saw  RPM.  Workplace bullying in surgery.   World J Surg. 2016;40(11):2560-2566. doi:10.1007/s00268-016-3642-7PubMedGoogle ScholarCrossref
3.
Conway  PM, Høgh  A, Nabe-Nielsen  K,  et al.  Optimal cut-off points for the Short-Negative Act Questionnaire and their association with depressive symptoms and diagnosis of depression.   Ann Work Expo Health. 2018;62(3):281-294. doi:10.1093/annweh/wxx105PubMedGoogle ScholarCrossref
4.
Paice  E, Aitken  M, Houghton  A, Firth-Cozens  J.  Bullying among doctors in training: cross sectional questionnaire survey.   BMJ. 2004;329(7467):658-659. doi:10.1136/bmj.38133.502569.AEPubMedGoogle ScholarCrossref
5.
Zhang  J, Yu  KF.  What’s the relative risk? a method of correcting the odds ratio in cohort studies of common outcomes.   JAMA. 1998;280(19):1690-1691. doi:10.1001/jama.280.19.1690PubMedGoogle ScholarCrossref
6.
Surgical Education Culture Optimization Through Targeted Interventions Based on National Comparative Data (SECOND) Trial. Accessed December 21, 2019. http://www.thesecondtrial.org
Research Letter
May 26, 2020

Prevalence, Types, and Sources of Bullying Reported by US General Surgery Residents in 2019

Author Affiliations
  • 1Surgical Outcomes and Quality Improvement Center (SOQIC), Northwestern University, Chicago, Illinois
  • 2American College of Surgeons, Chicago, Illinois
JAMA. 2020;323(20):2093-2095. doi:10.1001/jama.2020.2901

Surgical resident mistreatment is concerning.1 Bullying, one type of mistreatment, defined as persistent negative and aggressive behaviors, primarily of a psychological nature, with the effect of humiliating, intimidating, frightening, or punishing,2 has been associated with adverse outcomes such as depression.3 However, bullying during surgical training has not been well characterized, with prior evaluations limited by low survey response rates and inclusion of few institutions.2,4 We aimed to examine the prevalence, types, sources, and factors associated with bullying reported by US general surgery residents.

Methods

A voluntary, confidential survey was administered electronically to US general surgery residents following the 2019 American Board of Surgery In-Service Training Examination (ABSITE). The Short-Negative Act Questionnaire (S-NAQ), a validated workplace bullying assessment, was used to measure how often residents experienced 9 specific behaviors within that academic year (Table 1). Answers were reported using a Likert scale (never: response attributed a score of 1; now and then: 2; monthly: 3; weekly: 4; and daily: 5 [total score range, 9-45]). Occasional bullying was defined as a score of 12 to 15 and frequent bullying as a score of 16 or greater.3 For responses indicating that bullying behaviors occurred more often than never, residents were asked to identify a source from a predetermined list (Table 1).

Burnout was defined as any emotional exhaustion or depersonalization symptom (from an abbreviated Maslach Burnout Inventory) experienced at least weekly. Residents were also asked if they had thoughts of leaving their program within that academic year or of suicide within the past 12 months.1 Associations between frequent bullying and these outcomes were evaluated using χ2 tests.

A multivariable logistic regression model was constructed to identify factors associated with frequent bullying. Resident and program characteristics were obtained from the American Board of Surgery and the Accreditation Council for Graduate Medical Education (Table 2). Corrected risk ratios were calculated from logistic regression odds ratios.5 A 2-tailed P < .05 was considered statistically significant. All analyses were performed using Stata version 15.1. The Northwestern University institutional review board deemed this study exempt.

Results

There were 6956 responses to the survey (85.6% response rate) from residents in 301 accredited US programs. Of the 6264 residents who answered the S-NAQ, 4191 (66.9%) reported experiencing at least 1 bullying behavior. Occasional bullying was reported by 2744 (43.8%) residents and frequent bullying by 1133 (18.1%). The proportion of residents within a program reporting frequent bullying ranged from 0% to 66.7%.

Of residents who reported any bullying behavior, 42.3% reported repeated reminders of mistakes, 39.3% being shouted at, 31.8% withholding of important information, 30.3% persistent criticism, and 24.3% hostility. Attending surgeons were the most common source of these behaviors. Being the subject of gossip was reported by 32.7% of residents, while 31.2% reported exclusion, 23.4% offensive remarks, and 9.1% unwanted jokes. When a source was identified, these behaviors were most commonly attributed to other residents (Table 1).

Residents were more likely to report frequent bullying if they were women (20.3% vs 16.4% among men), divorced or widowed (27.1% vs 16.2% among married), racial/ethnic minorities (21.0% vs 15.9% among non-Hispanic white), training at a community program (20.9% vs 16.6% among academic), in the Northeast (21.0% vs 15.7% in the Southeast), or had low ABSITE scores (22.9% vs 14.8% with high scores) (Table 2). Residents who were frequently bullied had higher rates of burnout (61.1% vs 37.0%; P < .001), thoughts of suicide (10.4% vs 3.1%; P < .001), and thoughts of attrition (28.2% vs 7.8%; P < .001) compared with those who were not frequently bullied.

Discussion

Frequent bullying was reported by 18% of surgery residents, which often originated from surgeons (attendings and other residents), suggesting that interventions should focus on surgeon professionalism. Poor ABSITE performance and minority status were associated with frequent bullying. Women were more frequently bullied, and training in a program with more women or with departmental leaders who were women was not associated with decreased bullying. The wide variability in program-level bullying rates suggests that surgical training can occur without bullying.

Limitations include self-reporting of responses, lack of validation of the S-NAQ in educational health care settings (although the expanded questionnaire has been used in surgery previously2), and unqueried surgery-specific behaviors (such as forbidding speech in the operating room).

Bullying was a frequent experience reported in surgical training, and it was associated with burnout, thoughts of attrition, and suicidality. Training programs should focus on recognizing and addressing resident bullying to improve the surgical educational experience.6

Section Editor: Jody W. Zylke, MD, Deputy Editor.
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Article Information

Corresponding Author: Yue-Yung Hu, MD, MPH, Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, 633 N St Clair St, 20th Floor, Chicago, IL 60611 (yue-yung.hu@northwestern.edu).

Accepted for Publication: February 21, 2020.

Author Contributions: Drs Zhang and Hu had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Zhang, Ellis, Cheung, Hoyt, Bilimoria, Hu.

Acquisition, analysis, or interpretation of data: Zhang, Ellis, Ma, Bilimoria, Hu.

Drafting of the manuscript: Zhang, Ellis, Bilimoria, Hu.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Zhang, Ellis, Hu.

Obtained funding: Bilimoria.

Administrative, technical, or material support: Hu.

Supervision: Bilimoria, Hu.

Conflict of Interest Disclosures: None reported.

Funding/Support: Funding for this work was provided by the Accreditation Council for Graduate Medical Education and the American College of Surgeons. Dr Zhang was supported with funding from the John A. Hartford Foundation.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Disclaimer: The results and conclusions of this article are the authors’ own and do not represent the opinions of the Accreditation Council for Graduate Medical Education or the American College of Surgeons.

Meeting Presentation: This work was presented at the 15th Annual Academic Surgical Congress; February 2-6, 2020; Orlando, Florida.

References
1.
Hu  YY, Ellis  RJ, Hewitt  DB,  et al.  Discrimination, abuse, harassment, and burnout in surgical residency training.   N Engl J Med. 2019;381(18):1741-1752. doi:10.1056/NEJMsa1903759PubMedGoogle ScholarCrossref
2.
Ling  M, Young  CJ, Shepherd  HL, Mak  C, Saw  RPM.  Workplace bullying in surgery.   World J Surg. 2016;40(11):2560-2566. doi:10.1007/s00268-016-3642-7PubMedGoogle ScholarCrossref
3.
Conway  PM, Høgh  A, Nabe-Nielsen  K,  et al.  Optimal cut-off points for the Short-Negative Act Questionnaire and their association with depressive symptoms and diagnosis of depression.   Ann Work Expo Health. 2018;62(3):281-294. doi:10.1093/annweh/wxx105PubMedGoogle ScholarCrossref
4.
Paice  E, Aitken  M, Houghton  A, Firth-Cozens  J.  Bullying among doctors in training: cross sectional questionnaire survey.   BMJ. 2004;329(7467):658-659. doi:10.1136/bmj.38133.502569.AEPubMedGoogle ScholarCrossref
5.
Zhang  J, Yu  KF.  What’s the relative risk? a method of correcting the odds ratio in cohort studies of common outcomes.   JAMA. 1998;280(19):1690-1691. doi:10.1001/jama.280.19.1690PubMedGoogle ScholarCrossref
6.
Surgical Education Culture Optimization Through Targeted Interventions Based on National Comparative Data (SECOND) Trial. Accessed December 21, 2019. http://www.thesecondtrial.org
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