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Table 1.  
Consequences of Perceived Bullying as Described by Residents Who Experienced It Since the Start of Their Residency Training
Consequences of Perceived Bullying as Described by Residents Who Experienced It Since the Start of Their Residency Training
Table 2.  
Logistic Regression of Resident and Program Characteristics Associated With the Perception of Having Been Bullied Among Internal Medicine Residentsa
Logistic Regression of Resident and Program Characteristics Associated With the Perception of Having Been Bullied Among Internal Medicine Residentsa
1.
Loerbroks  A, Weigl  M, Li  J, Glaser  J, Degen  C, Angerer  P.  Workplace bullying and depressive symptoms: a prospective study among junior physicians in Germany.  J Psychosom Res. 2015;78(2):168-172. doi:10.1016/j.jpsychores.2014.10.008PubMedGoogle ScholarCrossref
2.
Leisy  HB, Ahmad  M.  Altering workplace attitudes for resident education (A.W.A.R.E.): discovering solutions for medical resident bullying through literature review.  BMC Med Educ. 2016;16(1):127. doi:10.1186/s12909-016-0639-8PubMedGoogle ScholarCrossref
3.
Chadaga  AR, Villines  D, Krikorian  A.  Bullying in the American graduate medical education system: a national cross-sectional survey.  PLoS One. 2016;11(3):e0150246. doi:10.1371/journal.pone.0150246PubMedGoogle ScholarCrossref
4.
Paice  E, Smith  D.  Bullying of trainee doctors is a patient safety issue.  Clin Teach. 2009;6(1):13-17. doi:10.1111/j.1743-498X.2008.00251.xGoogle ScholarCrossref
5.
Ayyala  MS, Chaudhry  S, Windish  D, Dupras  D, Reddy  ST, Wright  SM.  Awareness of bullying in residency: results of a national survey of internal medicine program directors.  J Grad Med Educ. 2018;10(2):209-213. doi:10.4300/JGME-D-17-00386.1PubMedGoogle ScholarCrossref
6.
Olweus  D.  Bullying at School: What We Know and What We Can Do. Malden, MA: Blackwell Publishing; 1993.
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Research Letter
August 13, 2019

Perceived Bullying Among Internal Medicine Residents

Author Affiliations
  • 1Department of Medicine, Rutgers New Jersey Medical School, Newark
  • 2Department of Family Medicine, Georgetown University School of Medicine, Washington, DC
  • 3Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
JAMA. 2019;322(6):576-578. doi:10.1001/jama.2019.8616

Bullying during medical education can have negative consequences that range from the well-being of the trainees to compromised patient care.1,2 The rates at which medical trainees report bullying has fluctuated widely (10%-48%) in prior studies,2-4 and differs by level of training and country.

A recent study of internal medicine residency training program directors reported that only 31% were aware of any bullying of their trainees during the previous year.5 We characterized the proportion of residents who perceived to have been bullied during their residency training.

Methods

This study was deemed exempt by the Johns Hopkins University institutional review board. The Internal Medicine In-Training Examination (IM-ITE) is a self-assessment examination administered by the American College of Physicians every year to internal medicine residents; a brief survey is attached to the end of the examination and its completion is voluntary. The 2016 IM-ITE supplementary survey focused on bullying during residency training.

Bullying was defined as “harassment that occurs repeatedly (>once) by an individual in a position of greater power”1,2,6 and residents were asked “During your time at your residency program, were you ever bullied?” Those perceiving to have been bullied were asked to characterize the type of harassment (verbal, physical, sexual, or other), the consequences of the bullying (from a list of 8 options plus none of the above; Table 1), and whether they sought help.

We used descriptive statistics to summarize trainee and program characteristics and Pearson χ2 tests for bivariable analysis of characteristics associated with perceived bullying. Multivariable logistic regression models were used to examine the odds of perceived bullying by trainee and program characteristics. Because the probability of experiencing bullying during training could only increase with each postgraduate year, we entered postgraduate year level into the model and used postgraduate year 3 as the reference category. The χ2 goodness-of-fit statistic was used to evaluate the fit of successive logistic regression models. A 2-sided P < .05 defined statistical significance, except for the final model, for which a Bonferroni correction was used to adjust the threshold to P < .004. All analyses were performed using SPSS Statistics version 24.0 (IBM Corp).

Results

Of the 26 021 internal medicine trainees who took the 2016 examination, 24 104 (93%) completed the survey and 21 212 (88%) allowed their data to be used for research purposes. Of these, 13.6% (n = 2876) reported experiencing bullying since the beginning of residency training. Among the residents who perceived being bullied, verbal harassment was the most common (80%), followed by other (25%), physical harassment (5.3%), and sexual harassment (3.6%). Of those who felt bullied, 31% sought help to deal with it. The most commonly described consequences of bullying were feeling burned out (57%), worsened performance as a resident (39%), and depression (27%) (Table 1).

The following resident characteristics were significantly associated with reported bullying: speaking a native language other than English, higher postgraduate year level, being an international medical graduate, and lower IM-ITE tertile (Table 2). Only 1 program variable was significantly associated with bullying. Compared with US residency programs, trainees at international residency programs had significantly greater odds of experiencing bullying.

Discussion

This survey of internal medicine residents found that 14% perceived being bullied since starting residency training. Although the results suggest that bullying during residency was associated with certain characteristics (eg, international medical graduates and those who perform lower on the IM-ITE), a better understanding of how residents experience bullying and the learning contexts in which it occurs is needed.

The definition of bullying may have been interpreted differently by distinct individuals; however, the bullying estimates in this study most likely represent an underestimate of mistreatment because less consequential hassling or microaggressions by superiors and harassment by those of equal or less power would not have been counted. Other limitations include a lack of data on frequency or severity of bullying, the absence of detail about the perpetrators, and the limited trainee and program characteristics available.

Taking steps to eliminate bullying is essential to ensure supportive learning environments that will promote the professional development of all medical trainees.

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

Accepted for Publication: May 30, 2019.

Corresponding Author: Scott M. Wright, MD, Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, 5200 Eastern Ave, Baltimore, MD 21224 (swright@jhmi.edu).

Author Contributions: Dr Rios had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Ayyala, Wright.

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

Statistical analysis: Rios, Wright.

Supervision: Ayyala.

Conflict of Interest Disclosures: None reported.

Funding/Support: Dr Wright receives support as the Anne Gaines and G. Thomas Miller Professor of Medicine through the Johns Hopkins Center for Innovative Medicine.

Role of the Funder/Sponsor: The Johns Hopkins Center for Innovative Medicine 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; and decision to submit the manuscript for publication.

Meeting Presentations: Presented in part at the Society of General Internal Medicine Annual Meeting; April 12, 2018; Denver, Colorado; and at the International Conference on Physician Health; October 11, 2018; Toronto, Ontario, Canada.

Additional Contributions: We acknowledge the American College of Physicians IM-ITE survey team for their assistance with this project.

References
1.
Loerbroks  A, Weigl  M, Li  J, Glaser  J, Degen  C, Angerer  P.  Workplace bullying and depressive symptoms: a prospective study among junior physicians in Germany.  J Psychosom Res. 2015;78(2):168-172. doi:10.1016/j.jpsychores.2014.10.008PubMedGoogle ScholarCrossref
2.
Leisy  HB, Ahmad  M.  Altering workplace attitudes for resident education (A.W.A.R.E.): discovering solutions for medical resident bullying through literature review.  BMC Med Educ. 2016;16(1):127. doi:10.1186/s12909-016-0639-8PubMedGoogle ScholarCrossref
3.
Chadaga  AR, Villines  D, Krikorian  A.  Bullying in the American graduate medical education system: a national cross-sectional survey.  PLoS One. 2016;11(3):e0150246. doi:10.1371/journal.pone.0150246PubMedGoogle ScholarCrossref
4.
Paice  E, Smith  D.  Bullying of trainee doctors is a patient safety issue.  Clin Teach. 2009;6(1):13-17. doi:10.1111/j.1743-498X.2008.00251.xGoogle ScholarCrossref
5.
Ayyala  MS, Chaudhry  S, Windish  D, Dupras  D, Reddy  ST, Wright  SM.  Awareness of bullying in residency: results of a national survey of internal medicine program directors.  J Grad Med Educ. 2018;10(2):209-213. doi:10.4300/JGME-D-17-00386.1PubMedGoogle ScholarCrossref
6.
Olweus  D.  Bullying at School: What We Know and What We Can Do. Malden, MA: Blackwell Publishing; 1993.
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