The quality of education that medical trainees, including medical students and residents, receive is influenced by their interactions with patients and their families, supervisors, nurses, peers, and other health care providers. These individuals can be a source of mentorship and encouragement and have a significant impact on trainees’ career paths. However, sometimes these same individuals also can be a source of discomfort, stress, abuse, harassment, or discrimination.
In 1982, Silver1 brought attention to this issue when he compared medical students’ attitudes before and after enrolling in medical school. He observed that some students went from being “alert, enthusiastic, and excited” to “cynical, dejected, frightened or depressed, and filled with frustration” over the course of their medical training.1 Furthermore, Silver1 suggested that the issue of abuse might be pervasive in medical training and perhaps that it was a necessary part of becoming a physician.
Recently, several studies have addressed this issue and found that medical trainee harassment and discrimination is a widespread phenomenon and not a problem limited to certain countries or particular training programs. In some studies, the prevalence of abuse was strikingly high, with up to 95% of trainees reporting that they had experienced at least one form of harassment or discrimination during their medical training.2–4 According to responses to the Association of American Medical Colleges Graduation Questionnaire in 2011, approximately one in six U.S. medical students reported that they had experienced some form of harassment or discrimination by the end of their fourth year.5 In addition, different studies have reported variable forms of abuse, including verbal, physical, sexual, and academic harassment, and gender and racial discrimination.2
Such abuse during training creates hostile work environments and induces stress and discomfort, which may impair performance.6 Sheehan and colleagues6 found that trainees who were frequently harassed were less likely to complete assignments or provide optimal patient care. In addition, trainees who were harassed had more emotional health problems and family life and social responsibility disruptions compared with nonharassed trainees.6 Other studies found that harassed trainees were more likely to have depression, anxiety, insomnia, and appetite loss and were more likely to drink alcohol for escape than nonharassed trainees.7–11
A synthesis of the prevalence and risk factors of harassment and discrimination is needed to understand the significance of such mistreatment and to explore potential preventative strategies. Although some training programs have implemented several measures to eradicate the mistreatment of medical trainees, a time trend analysis on the prevalence of harassment and discrimination is needed to provide insight into the extent of the problem and whether these measures have been effective. Furthermore, common risk factors that are identified in such an analysis could be used by educators and program directors to develop, implement, and evaluate prevention interventions. The objective of our study was to examine the prevalence, risk factors, and sources of harassment and discrimination, as well as time trends, through a systematic review.
To guide our review, we used a systematic review protocol based on the PRISMA Statement.12 We assembled and circulated a draft protocol to systematic review methodologists and clinicians and revised it as necessary.
Studies eligible for inclusion were cohort studies, cross-sectional studies, and case series written in English. We included studies reporting information on the following: prevalence of harassment and discrimination (for a complete taxonomy of the relevant terms, see Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A197) among medical trainees (including medical students, interns, and residents in all residency levels and all training programs). When a study reported data on fellows or senior doctors, we abstracted only those data related to the trainees who fit our definition. We included the following sources of harassment and discrimination: consultants (also known as staff or attending physicians), fellows, residents, students, patients and patients’ families, nurses, and other health care providers, and the following risk factors: gender, ethnicity, shift time, and type of rotation.
An experienced information specialist (L.P.) conducted all of the literature searches in consultation with the research team. We used Medical Subject Headings and text words related to the harassment and discrimination of medical trainees to search MEDLINE (OVID Interface, 1948 to July 2, 2011) and EMBASE (OVID Interface, 1980 to July 2, 2011). For our main electronic search strategy (MEDLINE), see Supplemental Digital Appendix 2 at http://links.lww.com/ACADMED/A197. We modified it as necessary for EMBASE (available on request from the authors). We did not limit the search by study design or date of dissemination. We identified additional articles through scanning the reference lists of included studies and e-mailing authors who published more than one article in this area of research.
Two reviewers (two of N.F., C.S., M.T.) independently screened the search results for inclusion using a predefined inclusion criteria form. We obtained the full text of potentially relevant articles and assessed them in a similar manner. We resolved discrepancies by discussion or the involvement of a third reviewer (A.C.T.).
Data collection process
We developed a draft data extraction form, then piloted and modified it as necessary. Two reviewers (two of N.F., C.S., E.L., L.P.) independently extracted all of the data using the standardized data extraction form. We resolved discrepancies by discussion or the involvement of a third reviewer (A.C.T.). When multiple study publications reported data from the same population (i.e., companion reports), we considered the study reporting the largest sample size or longest duration of follow-up as the major publication, and we used the other report(s) for supplementary data only.
The extracted data included study characteristics (e.g., study design, sample size, type of harassment and discrimination examined, setting), participant characteristics (e.g., type of trainees, mean age, gender), and results for the prevalence, risk factors, and sources of harassment and discrimination.
We assessed the methodological quality in individual studies using the Newcastle–Ottawa Scale (NOS).13 The NOS consists of eight items pertaining to selection (representativeness of the exposed cohort, selection of the nonexposed cohort, ascertainment of exposure, demonstration that outcome of interest was not present at start of study), comparability (comparability of cohorts on the basis of the design or analysis), and outcome (assessment of outcome, sufficient duration of follow-up, adequacy of follow-up). For cross-sectional studies and case series, we modified the NOS to include the following five items: representativeness of the trainee population, ascertainment of exposure, comparability of cohorts on the basis of the design or analysis, assessment of outcome, and adequacy of response rate. Two reviewers (two of N.F., C.S., E.L., L.P.) assessed study quality independently, and we resolved discrepancies by discussion or the involvement of a third reviewer (A.C.T.).
Synthesis of results
We described the results narratively and conducted a meta-analysis, as appropriate. For the meta-analysis, we derived pooled prevalence estimates using a random-effects model and 95% confidence intervals (CIs) based on a normal distribution.14 We reported the mean, standard deviation, and range for continuous outcomes and the frequency and percentage for binary outcomes. We assessed statistical heterogeneity using the I2 statistic14 and depicted the studies in a forest plot to examine heterogeneity visually. We conducted all analyses in SAS 9.2 software (SAS Institute Inc., Cary, North Carolina).
The literature search yielded 2,160 citations (see Figure 1). From these, we excluded 1,983 because they did not include medical trainees (n = 1,451), did not report harassment or discrimination of medical trainees (n = 443), did not provide primary data (n = 68), were not published in English (n = 13), were not eligible study designs (n = 7), or did not report prevalence or risk factors for harassment or discrimination (n = 1). We retrieved and examined the remaining 177 articles for relevance. Reasons for exclusion at the full-text review included that the study did not provide primary data (n = 38), did not report harassment or discrimination of medical trainees (n = 28), did not report prevalence or risk factors of harassment or discrimination (n = 23), was not an eligible study design (n = 16), did not include medical trainees (n = 7), or was not written in English (n = 3). A total of 62 studies fulfilled the inclusion criteria: 57 cross-section al2–4,6,11,15–55,57–67 and 2 cohort studies8,56 as well as 3 companion reports,68–70 which we used for supplemental data only.
Study and trainee characteristics
The majority of studies were conducted in the United States, Canada, Pakistan, the United Kingdom, Israel, and Japan. All studies were conducted between 1987 and 2011, and the number of trainees ranged from 6 to 13,168 (see Appendix 1). The types of harassment reported included verbal, physical, sexual, and academic harassment. Discrimination was categorized according to gender or race.
The population of trainees varied across the included studies (see Appendix 2). Medical students were included in 32 studies, residents in 23 studies, and interns (unspecified) in 3 studies. One of the included studies provided data for students and residents together.21
Sources of harassment and discrimination
Thirty-two studies reported an average of four sources of harassment and discrimination (range: 1–8). The most common sources were consultants (cited by 34.4% of respondents), followed by patients or patients’ families (21.9%), nurses (15.6%), fellows/residents (15.6%), and others (faculty, interns, and students, 3.1%).
Risk factors for harassment and discrimination
Sixteen studies observed a higher prevalence of harassment (mainly sexual) and gender discrimination amongst female trainees compared with male trainees, which was statistically significant (P < .05) in 12 studies,4,8,19,25,31,33,38,41,42,52,63,70 yet not in the remaining 4 studies.2,16,20,56 Regarding ethnicity, 1 study found that residents from the Middle East experienced a higher level of discrimination in training programs conducted in the United States.22 Furthermore, 5 studies noted a higher prevalence of racial and cultural discrimination among nonwhite trainees (P < .00001).3,11,36–38 Four other studies found that residents in surgical training programs reported a higher incidence of harassment and discrimination compared with those in other training programs,43,46,63,70 which was statistically significant in one study (P < .001).43
Among the 57 cross-sectional studies (see Supplemental Digital Appendix 3 at http://links.lww.com/ACADMED/A197), 17 studies used a sample that was truly representative of the average trainee (e.g., random sample), 19 studies used a sample that was somewhat representative of the average trainee, and 20 studies used a selected group of trainees (e.g., volunteers). We scored only 1 study as not providing a description of the derivation of the trainee population.48 For the ascertainment of exposure item, only 1 study used a structured interview,46 and the remaining 56 studies used written self-report. For the comparability of cohorts on the basis of the design or analysis item, 1 study controlled for the most important factors (e.g., age, gender),41 and the remaining 56 studies did not control for anything. For the assessment of outcome criterion, 31 studies used a record linkage/questionnaire and 26 studies used self-report. Lastly, 3 studies accounted for all eligible trainees who participated in the study,16,23,26 13 studies accounted for 80% to 90% of eligible trainees, 36 studies accounted for <80% of eligible trainees, and 5 studies provided no statement about eligible trainees or participants for the adequacy of response rate criterion.42,48,54,64,66 For the results of the quality assessment for the 2 cohort studies, see Supplemental Digital Appendix 4 at http://links.lww.com/ACADMED/A197.
Harassment and discrimination prevalence for all trainees.
The pooled prevalence for harassment and discrimination during medical training was 59.4% (n = 51 studies, 38,353 trainees, 95% CI: 52.0%–66.7%; see Table 1). The most common type of abuse experienced by the trainees was verbal harassment (n = 28 studies, 27,258 trainees, prevalence: 63.0%, 95% CI: 54.8%–71.2%), whereas the least common type was physical harassment (n = 24 studies, 23,776 trainees, prevalence: 15.3%, 95% CI: 12.1%–18.6%). We found statistical heterogeneity across studies (see Supplemental Digital Appendix 5 at http://links.lww.com/ACADMED/A197) but no time or regional trends.
Harassment and discrimination prevalence for medical students.
The pooled prevalence for harassment and discrimination during undergraduate medical training and clerkship was 59.6% (n = 30 studies, 26,579 medical students, 95% CI: 49.2%–68.0%). Verbal harassment was the most common type of abuse (n = 16 studies, 18,865 medical students, prevalence: 68.8%, 95% CI: 56.6%–80.9%), whereas the least common type was physical harassment (n = 15 studies, 18,790 medical students, prevalence: 9.0%, 95% CI: 7.0%–11.1%). As expected, we again found statistical heterogeneity across studies (see Table 2 and Supplemental Digital Appendix 6 at http://links.lww.com/ACADMED/A197).
Harassment and discrimination prevalence for residents.
The pooled prevalence for harassment and discrimination during residency training was 63.4% (n = 19 studies, 11,193 residents, 95% CI: 53.6%–73.2%). Residents cited gender discrimination as the most common form of abuse (n = 3 studies, 1,315 residents, prevalence: 66.6%, 95% CI: 58.7%–74.5%), followed by verbal harassment (n = 12 studies, 9,867 residents, prevalence: 58.2%, 95% CI: 45.5%–70.9%). The least common type was racial discrimination (n = 3 studies, 3,261 trainees, prevalence: 26.3%, 95% CI: 24.2%–28.3%). Heterogeneity was significant across these studies (see Table 2 and Supplemental Digital Appendix 7 at http://links.lww.com/ACADMED/A197).
Post hoc subgroup analyses.
We conducted a series of post hoc subgroup analyses using our data to identify trends in the prevalence of harassment and discrimination. For the 37 studies that were conducted in North America (United States and Canada), the pooled prevalence for harassment and discrimination was 63.6% (33,736 trainees, 95% CI: 55.7%–71.4%; see Supplemental Digital Appendix 8 at http://links.lww.com/ACADMED/A197).
We also conducted a subgroup analysis on the year of training and did not identify wide variation in the prevalence of harassment. For example, 16 studies, which included all years of training and data from 6,468 students, indicated that the pooled prevalence of harassment was 68.7% (95% CI: 58.2%–79.2%). Four studies, which included 4,269 junior medical trainees (students/residents), indicated that the pooled prevalence of harassment was 57.8% (95% CI: 25.6%–89.7%). Nineteen studies, which included 19,297 senior medical trainees (students/residents), indicated that the pooled prevalence of harassment was 60.5% (95% CI: 48.6%–71.5%).
We also conducted a subgroup analysis by primary language of the country (English versus non-English) and did not identify any differences (non-English: 12 studies, 4,164 trainees, pooled prevalence 60.1% [95% CI: 49.2%–71.0%] versus English: 43 studies, 36,212 trainees, pooled prevalence 62.7% [95% CI: 55.7%–69.7%]). Finally, we classified the studies using the World Bank’s classification of country economies.71 A higher pooled prevalence of harassment was reported in high-income countries (50 studies, 24,197 trainees, pooled prevalence 63.5% [95% CI: 57.4%–69.5%]) versus lower/upper-middle-income countries (6 studies, 2,877 trainees, pooled prevalence 48.7% [95% CI: 24.7%–72.6%]).
We believe that our study provides the first systematic review and meta-analysis on the prevalence of harassment and discrimination among medical trainees. Our findings emphasize how common this problem is in medical training programs around the world. Moreover, many of the studies we included in our review were completed recently, highlighting that harassment continues to be a common problem in medical education. This finding suggests that more needs to be done at the individual and organizational levels to understand the complexity of the problem.
We included 51 studies in the meta-analysis, which confirmed Silver’s earlier observations that a majority of trainees experience at least one type of harassment or discrimination during their medical training. The most commonly reported form of harassment included verbal and academic, with a prevalence ranging from 3% to 28%, whereas the most commonly reported forms of discrimination were due to race and gender, ranging from 4% to 19%. Medical trainees also reported having experienced other abusive behaviors, such as sexual and physical harassment. Although we included discrimination due to sexual orientation, we found that only 1 study reported this form of discrimination (and only 10 residents experienced it).2 We did not find any significant trends in the prevalence of harassment and discrimination in our post hoc analyses, except that lower/upper-middle-income countries seemed to report less harassment and discrimination versus high-income countries. However, this finding might be spurious, as only 6 included studies were conducted in lower/upper-middle-income countries.44,55,58,59,64,69 This relationship is an area worthy of further examination in future research.
More than two-thirds of the included studies reported sexual harassment. Female trainees were more likely to have experienced such behaviors than their male counterparts.16,19,24,25,30,38,41,52 This finding is consistent with previous reports on sexual harassment from different professions. For example, 84% of the 13,867 sexual harassment complaints reported to the U.S. Equal Employment Opportunity Commission in 2008 were filed by women.72 According to our findings, consultants and senior doctors were cited most frequently as the sources of such behaviors. In 1989, the American Medical Association (AMA) Council on Ethical and Judicial Affairs defined sexual harassment in its report entitled “Sexual Harassment and Exploitation Between Medical Supervisors and Trainees.”73 The definition included behaviors perceived as inappropriate sexual advances, sexist jokes or slurs, the exchange of rewards for sexual favors, sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature. In 1991, the AMA published Guidelines for Establishing Sexual Harassment Prevention and Grievance Procedures, which also defined sexual harassment and outlined grievance procedures.73 Although some studies in our review used their own definitions, those definitions conformed to the definition provided by the AMA.73
Despite the AMA’s remarkable attention, sexual harassment remains the most common form of abusive behavior in U.S. training programs, suggesting that more needs to be done to address and prevent this issue. For example, we should place more emphasis on educating consultants, faculty, and all sources of abuse as to the rights of trainees. The presence of sexual harassment in medical training leads to a stressful and hostile environment that competes with the optimal aim of medical education.
Acik and colleagues58 found that 5% of the trainees included in their study were considering leaving their current specialty training program because of harassment and 39% were deeply disturbed. Another report showed that a greater proportion of women than men believed that their specialty choice and residency program rankings were influenced by gender discrimination and sexual harassment considerations, evidence of the alarming consequences of such behaviors.70 Recognition of the prevalence of harassment and discrimination and the most frequent types would help to implement preventive measures. As “a friendly working environment is a productive one,”74 we suggest that health care professionals take part in communication skills and supervision training programs in addition to training in the recognition, management, and prevention of workplace violence.74 Doing so might provide a more amenable workplace environment.
Many of the included studies did not identify the gender of the perpetrator(s), and not all of the studies reported on the gender, race, and disability of the trainees. These are important variables for researchers to consider in future work.
We cannot address this problem without a reporting structure for trainees to use. Supervisors are often the perpetrators of these behaviors and are in a superior position, which can intensify trainees’ fear of negative consequences from reporting any form of abuse.63 Thus, authorities must ensure trainees’ confidentiality when reporting harassment or discrimination. Other reasons that may lead to the underreporting of harassment and discrimination include the fear of being disbelieved, embarrassment if peers learned of the occurrence, and a lack of trust in those who are in positions of authority. Trainees also may think that these behaviors are a necessary part of becoming a physician. Therefore, education is imperative for all parties to understand what constitutes abusive and hostile behaviors. For example, in 2009, Karen Judy62 from Loyola University Medical Center suggested implementing a universal curriculum on workplace violence through the graduate medical education office and ensuring an excellent dissemination to all parties, with periodic updates regarding this curriculum. Furthermore, all training programs must have a zero-tolerance policy and a grievance procedure to report all types of harassment and discrimination.75 Thus, any complaint of harassment or discrimination should be considered and investigated thoroughly by someone trained within the organization. She or he then should recommend appropriate remedies, penalties, or other actions. Perpetrators should be subjected to several actions including a written reprimand, suspension, transfer, or even dismissal.
We recognize some limitations in the included studies. First, a majority of reports on harassment and discrimination used subjective tools, such as self-report, which often lack validity or reliability. Second, many of the studies used cross-sectional surveys to assess the respondents’ experiences of harassment and discrimination, which often is open to recall bias. Third, some important variables (e.g., perpetrators’ genders) were not identified in many of the studies. In addition, our systematic review process has a number of limitations. First, we did not conduct a comprehensive search for unpublished material. Because we only included articles written in English, our results may not be generalizable to all training programs globally. Also, we are unable to determine the link between mistreatment and professionalism, given the self-report data used in our analysis.
Our review demonstrates the surprisingly high prevalence of harassment and discrimination during medical training that has not declined over time. Furthermore, the large number of reports indicates the need for extensive revision to existing policies on harassment, discrimination, and workplace violence in medical schools and across residency training programs. However, drafting such policies is necessary but not sufficient to change behavior. We also must promote a cultural change within our academic institutions to ensure that unprofessional behaviors, such as harassment and discrimination, are not tolerated and, if they do occur, that trainees feel empowered to report them and that immediate action will be taken against the abusive individual. Highlighting the extent and significance of the problem, as we have done in this report, is the first step in addressing the issue and ultimately decreasing these inappropriate behaviors.
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