For more than a decade, governing medical bodies, such as The Joint Commission (previously The Joint Commission for the Accreditation of Hospitals), have warned that intimidating and disruptive behaviors among health care professionals can cause medical errors, preventable adverse outcomes, and decreased patient satisfaction. 1 One such disruptive behavior is bullying. Unlike bias, microaggressions, and discrimination, bullying is the conscious action of offenders abusing positions of authority and intentionally targeting individuals through persistent negative behaviors to impede education or career growth. 2 Bullying is a severe form of mistreatment, and given power differentials, targets have difficulty defending themselves. What makes bullying so challenging in the workplace is that “unlike harassment and discrimination, bullying does not have a specific legal definition, leaving victims without legal recourse.” 2 The American Medical Association recently adopted a new policy aimed at preventing bullying in academic medicine. 3,4 Nevertheless, bullying persists in academic medicine. 2
Although the nursing literature is rife with discussions regarding bullying, there is a relative paucity of research evaluating the extent to which bullying occurs among physicians. 5–7 Estimates of the prevalence of bullying experienced by medical trainees and faculty physicians vary from 10% to 48%, with offenders being superiors, peers, nurses, staff, and patients. 2,8–10 Moreover, among all types of physicians, women are more commonly the targets of bullying compared with men. 2,9–12 What is unknown is the prevalence of bullying among different groups of women physicians and the specific types of bullying behaviors encountered.
The consequences of bullying, particularly for women, are dire. First, being bullied can derail academic career growth, from obtaining roles to being promoted. 2,13 Second, experiencing bullying can have negative psychological effects, ranging from decreased productivity, emotional exhaustion, decreased concentration, absenteeism, anxiety, depression, and posttraumatic stress disorder. 2,14–20 This experience directly impacts the quality of patient care. Workplace stress indirectly places an undue mental health burden on the individual, which contributes to burnout. 18–20 Burnout can force individuals to change their jobs or end their careers. 20 Studies have suggested that women physicians already reduce their work to part-time or consider part-time work within 6 years of graduating residency and/or fellowship given bias, discrimination, and harassment. 21 In addition, when a physician leaves the field, the annual economic cost to an organization is approximately $7,600 per employed physician each year, 22 not including the costs to the target, such as loss of income and debt from undergraduate and medical training. These mental health and financial ramifications of being bullied greatly impact the pipeline of women into leadership positions.
We wondered whether and how successful women physician leaders in academic medicine experienced bullying during their careers given that women who pursue leadership often must engage in counterstereotypical behaviors that may increase risks of workplace harassment. 23,24 The purposes of this investigation were to estimate the prevalence of gender-based mistreatment, particularly bullying, experienced by women physicians who have become leaders in academic medicine and characterize the nature of that bullying behavior and whether the gender of the offender affected how bullying was experienced.
Method
Design, population, and sampling
We conducted a survey-based study using both quantitative and qualitative analysis methods. The population of interest was women physicians in academic medicine who had attained either associate or full-professor level and who had completed the Hedwig van Ameringen Executive Leadership in Academic Medicine (ELAM) program. 25 ELAM, established in 1995, is a program specially designed to develop senior women faculty for assuming executive leadership positions at academic health centers. 26 Just like academic medicine in general, ELAM graduates represent a diverse number of health care professionals. To control for the diversity of training environments across professions and capture bullying that occurred within the academic medical setting, we focused our study on women physicians.
We obtained a roster of ELAM alumnae (ELUMs) from the program’s leadership (N = 1,092). Because we were interested in women physicians who were likely to be still active in academic medicine, we targeted ELUMs from the classes of 2006 to 2020 (N = 747). We then selected only physician (i.e., those who held MD, DO, MBBS, or MD–PhD combination degrees) ELUMs from these years (N = 547).
Survey development and dissemination
To identify beliefs on experiences about gender-based mistreatment and given that such an instrument did not already exist, we assembled a 35-item electronic survey. 27 This survey was designed to measure the prevalence of gender-based mistreatment experienced during the careers of women physicians in academic medicine leadership positions, while profiling the nature of the mistreatment, perceptions on the potential effect on the career of the individual who experienced it, and beliefs on how to mitigate such behavior.
Our first survey item served to eliminate those who had not experienced gender-based mistreatment. Accordingly, a no response to the question, “Have you ever experienced mistreatment due to your gender?” triggered a skip to the demographic section at the end of the survey (see Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/B344). A second question was asked to determine whether the mistreatment met the threshold definition of bullying—that it is tactical and persistent. We then used the 9-item Short Negative Acts Questionnaire (S-NAQ), a well-established instrument for measuring mistreatment, particularly bullying, in the workplace. 28 We asked respondents to complete the S-NAQ twice (1 time for experiences perpetrated by men and 1 time for experiences perpetrated by women) to determine whether bullying behaviors differed by offender gender. We then asked respondents whether they had ever been bullied during their careers and details about the nature of that bullying. We defined bullying as a severe form of mistreatment that had persisted over time (not a 1-time incident), was perceived by the target individual as being on the receiving end of negative actions from 1 or more perpetrators, and placed the target in a vulnerable position that made it difficult to defend herself against the negative actions. We concluded the survey with 3 open-ended questions designed to help us understand how bullying had personally impacted the careers of these women physicians in academic medicine and to explore their ideas about what might be done to mitigate such negative behaviors. Three authors (M.S.I., D.P.W., and D.J. M.) reviewed each survey item for comprehension, retrieval, judgment, and response. 27 Then 1 author (M.S.I.) conducted informal cognitive interviewing, using a verbal probing approach, with 3 non-ELAM physician leaders. 27 Finally, we piloted this survey among other non-ELUM women physician leaders to obtain further feedback on survey content and the respondent’s understanding of questions.
We administered the survey in May to June 2021, using Dillman’s Total Design Method as a guide. 29 We gave advanced notice of the survey’s purpose via announcements in the weekly ELUMs’ newsletter, disseminated the electronic survey via email, and sent biweekly email reminders to nonresponders. 29 This process took 8 weeks. The electronic survey was distributed through Research Electronic Data Capture. 30 Participants received $30 compensation for survey completion. This study was approved as exempt by the Nationwide Children’s Hospital Institutional Review Board on June 15, 2020 (STUDY00001103), and the Drexel University Institutional Review Board on March 3, 2021 (protocol 2011008229).
S-NAQ scores
We converted our S-NAQ total scores for both the male and female offenders into bullying severity categories using the item means for each group formed by the cluster analysis of Notelaers et al. 28 We summed the item means separately for each cluster to derive a set of classification (or cut) scores for the S-NAQ, with 12 or less indicating not or infrequent bullying, 13 to 17 indicating occasional bullying, and greater than 17 indicating severe target of bullying.
Statistical analysis
We conducted bias analyses using χ2 tests of association to determine whether the respondents were representative of the total sample on key variables: region of the country, US News and World Report research ranking of the institution through which the respondents held their academic appointments, and year in which they completed the ELAM program. For bias analyses that involved region, we did not include international respondents. The Cramer φ effect sizes, an indicator of the degree to which 2 variables are associated, were computed for each χ2 test (where a 0 suggests no relationship and a +1.0 suggests a perfect relationship between 2 variables, with φ values of 0.10, 0.30, and 0.50 suggesting a small, medium, and large effect or relationship, respectively). 31,32
We used descriptive statistics to profile mistreatment and bullying experienced by the survey respondents during their professional careers. We used dependent t tests to compare the male and female S-NAQ results to determine whether mistreatment differed with regard to the gender of the offender. We also used descriptive statistics to profile the nature of bullying and compare the S-NAQ results between those respondents who said specifically that they had been bullied with those who had not. To investigate potential trends in mistreatment over time, we compared the S-NAQ scores for both male and female offenders across graduating year cohorts of the ELAM program. All statistical analyses were performed with IBM SPSS Statistics for Windows, version 28.0 (IBM Corp).
Content analysis of open-ended comments was used to describe how bullying impacted women physicians and to outline recommendations for bullying prevention and mitigation. Three study investigators (M.S.I., D.J.M., and D.P.W.) developed a codebook with coding categories based on initial review of the comments. 33 The comments were reviewed and then coded by 2 investigators (M.S.I. and D.J.M.). When there was disagreement in the coding, a third investigator (D.P.W.) arbitrated the final decisions.
Results
We surveyed all 547 ELUMs who had medical degrees (e.g., MD, DO, MBBS, MD–PhD) from a pool of 747 women who had completed the ELAM program between 2006 and 2020. Of the 547 ELUMs, 354 returned the survey, for a response rate of 64.7%. Of the 354 respondents, 302 (85.3%) answered yes to the initial screening question, “Have you ever experienced mistreatment due to your gender?” The remaining 52 respondents (14.7%) skipped the questions about mistreatment and bullying and were directed to the demographic section of the survey. Of the 302 ELUMs who screened positive for mistreatment, 291 (96.4%) completed the S-NAQ for both male and female offenders. See Supplemental Digital Appendix 2 at https://links.lww.com/ACADMED/B344 for an illustration of the sampling of this population.
Bias analysis
The ELUMs from the most recent 5 years (2016–2020) were slightly overrepresented among the respondents, whereas the middle 5 years of graduates (particularly 2012 and 2015) were slightly underrepresented (effect size = 0.17, P ≤ .001). We received the number of responses we would have expected from the graduates of 2006 to 2010. We also received slightly more surveys from individuals from academic institutions in the Central and Western regions of the country and fewer than expected from the Southern region (effect size = 0.13, P = .03). No statistically significant difference was found between respondents and nonrespondents when it came to the US News and World Report research rankings of the institution of their academic affiliation (effect size = 0.13, P = .15). In each analysis, even when χ2 tests were statistically significant, the associated effect sizes suggested the bias effects were small. 31
Demographic characteristics
Almost half of the survey respondents (168/354 [47.5%]) were between the ages of 51 and 60 years and had been practicing for 21 to 30 years (173/354 [48.9%]). Most worked in academic medical centers (308/354 [87.0%]) and identified as female. Table 1 gives the demographic characteristics of the participants. Nearly all were in positions of leadership related to educational, clinical, or research units; academic departments; medical schools; colleges or universities; or private industry. The most common leadership positions held were department chair (86/421 [20.4%]), vice chair (50/421 [11.9%]), division chief or associate chief (62/421 [14.7%]), or medical school dean (52/421 [12.4%]).
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Table 1: Demographic Characteristics of the 354 Executive Leadership in Academic Medicine Alumnae Survey Respondents
Gender-based mistreatment
A total of 302 respondents (85.3%) reported that they had experienced mistreatment at some point during their careers, specifically because they were women. Of these individuals, 172 (48.6%) believed that the mistreatment they experienced was intended to hold them back from professional advancement. The most common points in their careers in which gender-based mistreatment took place were while in practice as an attending physician (198/302 [65.6%]), during medical school (168/302 [55.6%]), during residency (136/302 [45.0%]), or during fellowship (65/302 [21.5%]).
The respondents experienced all mistreatment behaviors covered by the S-NAQ from both male and female offenders (Figure 1). The most common behavior, regardless of the offender’s gender, was being ignored or excluded in the workplace. Respondents were statistically significantly more likely to be mistreated by men than they were by women (mean [SD] S-NAQ score, 19.4 [7.3] for men bullies and 15.6 [6.2] for women bullies; effect size = 0.57; P < .001). When superimposing the cut points onto the box plot distributions of the S-NAQ scores, we found that a substantial portion (> 50%) of male mistreatment is associated with the severe bullying category, whereas the female mistreatment is associated with the occasional bullying category (Figure 2). We found no relationship between S-NAQ scores and cohort year of the respondent for both male and female offenders (R2 = 0.004).
Figure 1: Type and frequency of mistreatment by male (M) and female (F) offenders as reported by the 291 respondents who completed the Short Negative Acts Questionnaire (S-NAQ).
28 The S-NAQ was administered along with the rest of the project survey in May to June 2021. The survey asked the following question regarding the 9 behaviors noted in the S-NAQ, with responses based on the scale of never, now and then, monthly, weekly, or daily: “Think back to the time in your career when you experienced what you felt to be the most significant mistreatment. How often did you experience the following types of mistreatment from a MALE/FEMALE?”
28 Participants were asked to answer this question once for male offenders and once for female offenders.
Comparison of the distributions of scores of 291 Executive Leadership in Academic Medicine alumnae who completed the Short Negative Acts Questionnaire (S-NAQ)
28 by the gender of the mistreatment offenders. The S-NAQ was administered along with the rest of the project survey in May to June 2021. The S-NAQ scores range from a minimum of 9 to a maximum of 45. The middle line bisecting each box represents the median, whereas the lower and upper borders of each box represent the interquartile range. The lines across the whiskers above and below the boxes are analogous to 2.70 SDs, whereas the circles represent extreme outliers (i.e., scores beyond 2.70 SDs). Background shading is used to represent the classification of bullying experience severity: dark gray (score, < 12) indicates not bullied or infrequent bullying, light gray (score, 13–17) indicates occasional bullying, and white (score, > 17) indicates severe target of bullying.
Experiences with bullying
A total of 187 women (61.9%) in our survey who screened positive for mistreatment also said that they had been bullied at work. Of the 187 individuals who reported being bullied at work, a statistically significant greater percentage reported experiencing bullying from men versus women (173/187 [92.5%] vs 64.7%) (effect size = 0.34, P ≤ .001). However, 111 of 187 participants (59.4%) experienced bullying from both men and women. A total of 155 (82.9%) had experienced bullying from more than 1 offender, of whom 31 (16.6%) experienced 10 or more bullies during their careers. Consistent with these reports of bullying, both the male and female mean (SD) S-NAQ scores for those 187 women (61.9%) who said they were bullied at work were statistically significantly higher than those who said they were not bullied (37.9%, 114 of 301) (yes bullied at work male S-NAQ: 21.8 [7.5], no not bullied at work male S-NAQ: 15.0 [4.2], effect size = 1.04, P < .001; yes bullied at work female S-NAQ: 17.0 [6.8], no not bullied at work female S-NAQ: 13.3 [4.1], effect size = 0.62, P < .001).
A total of 179 (95.7%) of those who were bullied experienced bullying in an academic medical center. A total of 115 respondents (61.5%) noted that the bullies were their immediate supervisor, 96 (51.3%) said that managers or supervisors were bullies, and 87 (46.5%) said that bullied were colleagues. Twenty-eight respondents (20.3%) reported nurse bullies. During the period in which bullying was experienced, 62 (33.2%) said that it was occasional or sporadic, whereas 125 (66.8%) experienced bullying at least monthly.
Content analysis
Participants reported that bullying impacted not only their own career growth and advancement but also those of other women physicians. Specifically, participants noted that bullying caused them to change their roles or leave their jobs, affected their career advancement, impacted their mental health, defamed their character and/or reputation, or influenced their relationships with family and colleagues. Table 2 lists themes with illustrative quotations.
Table 2: Impact of Bullying on Executive Leadership in Academic Medicine Women Physician Leader Careers: Representative Themes and Quotations From 187 Survey Respondentsa
Participants also contributed suggestions for how to mitigate bullying in academic medicine. Specific interventions ranged from defining, identifying, and calling out bullying behaviors to using upstander training and faculty development. Many proposed that cultures that supported bullying needed to be changed from the top down and should include zero-tolerance policies. Themes around mutual support systems, such as mentoring, coaching, or allyship, were also frequently mentioned. Table 3 lists themes with illustrative quotations.
Table 3: Executive Leadership in Academic Medicine Women Physician Leaders’ Perceptions on How to Mitigate Bullying in Academic Medicine: Representative Themes and Quotations From 187 Survey Respondentsa
Discussion
We found that among this uniquely informative sample of women physician leaders most had experienced gender-based mistreatment, including bullying, during their careers. The most commonly experienced bullying behavior was being ignored or excluded, generally by men in supervisory roles, corroborating the limited evidence in the literature. 2,34,35 Our findings also confirm that isolation, false allegations, being ignored or excluded, spreading rumors, undue pressure to produce work, and withholding information are the bullying behaviors commonly experienced by women. 2,9–11,34,35 Our participants reported bullying to be most prominent during their time in faculty practice and took place at work in the academic medical center. Most experienced bullying behavior at least monthly.
The open-ended comments vividly characterize how the 9 bullying behaviors in the S-NAQ impacted the physical, psychological, financial, personal, and professional lives of the respondents. Their descriptions illuminate the reality of toxic workplace environments that persist in academic medicine and foster a culture of incivility. Although many women leaders sought ways to overcome their bullying experiences through self-development, coaching, and supporting other targets of bullying, most avoided speaking up or reporting the bullying for fear of being blacklisted or facing retaliation. 36 Moreover, their experiences with bullying were not forgotten and still affect them to this day. Of note, when asked about how to mitigate the impact of bullying, most offered systems-level suggestions rather than advice for individual targets. This feedback is important because bullying is not something that can or should be overcome by individual actions of targets but rather by changes to culture and systems.
Outside medicine, workplace bullying is a major factor for individuals leaving the workforce. 14,20,28 Our study goes beyond the nursing literature to show that bullying has a substantial impact on the careers of even successful women physician leaders. Just as intended, bullying slowed our respondents’ career progression or caused them to leave jobs or purposely change their roles. Their effectiveness as leaders was also impacted from bullying behaviors, such as being ignored, omitted from critical emails, and excluded from crucial meetings. 34 One respondent noted that bullying made it easier for people to discount their opinions. Of note, we intentionally selected a group of women physician leaders who succeeded despite these experiences; they may have been particularly vulnerable to bullying because they exhibit counterstereotypical behaviors in seeking leadership. On the other hand, by focusing exclusively on those who reached positions of leadership, we may well have underestimated the frequency of bullying experiences that actually derailed targets’ careers. Our study, therefore, highlights the need to conduct additional research to evaluate experience with bullying in other as yet understudied groups, including women who have left medicine and those with multiple intersecting marginalized identities, such as women from racial and ethnic groups underrepresented in medicine and members of the LGBTQIA+ community.
Interventions to mitigate bullying in academic medicine
Thought leaders have said we need to intervene against bullying and have called out the paucity of evidence in which to ground such necessary interventions. 37 Our sample of women physician leaders provides a particularly valuable perspective by offering ideas for interventions grounded in the lived experiences of these leaders. Specifically, the respondents suggested that there is not only 1 intervention to stop bullying in academic medicine.
First, efforts to address bullying must take place from the top down, with leadership support to develop a climate that prohibits bullying. For trainees, medical bodies, such as the Liaison Committee on Medical Education (LCME) and the Accreditation Council on Graduate Medical Education (ACGME), should not only include questions on bullying in their annual surveys but also develop antibullying-specific policy statements, such as the American Medical Association’s statement, that provide program leadership with resources. 3,9 Organizations such as the LCME and ACGME do not govern interactions among faculty members in the way that they do for trainees, and some state licensing boards have lacked the ability to address more than the most egregious incidents; therefore, institutional leaders must take the reins to combat interfaculty bullying within their organization. 38 Quine 39 recommended that organizational leaders develop and implement antibullying policies with statements on expected standards of behavior, education to raise awareness of bullying, procedures for dealing with allegations of bullying, and protection from retaliation. Such zero-tolerance and zero-retaliation policies should include tiered consequences for bullying behavior. 40,41 Furthermore, committees dedicated to the investigation of bullying reports and mediation can be an effective channel to mitigate bullying. 42,43 Above all, these committees should “think of every incident of mistreatment as possibly predictable and potentially preventable, rather than thinking of this as an unmanageable problem.” 44
Second, efforts from the bottom up are needed. Faculty development should extend beyond traditional bias training in diversity, equity, and inclusion initiatives to specifically address bullying. Faculty development on understanding targets’ rights, methods for recourse, and fostering upstander skills may allow targets and witnesses to obtain the skills needed to call out bullying in the moment. Bystanders are individuals who witness a bullying incident but do not act to stop it. On the other hand, upstanders are people who recognize when something is wrong and do something to make it right. Upstander skills may include reporting the event or otherwise helping the individual who is being bullied even after the event and providing support. 45 Ultimately, these efforts work synergistically to foster a workplace culture that promotes civility, respect, and inclusive excellence. 46
Limitations
Although our response rate is good for a physician survey, especially because we were dealing with a sensitive topic, bias due to nonresponse is nevertheless possible. In particular, if certain ELUMs may have elected not to complete the survey, our findings may not be generalizable to the full community of women physician leaders in the program. Similarly, although we used validated measures to evaluate bullying experiences, those who responded may have been reluctant to fully share their experiences with bullying, which may lead to underestimates in our results. Accordingly, we may have been unable to accurately detect the actual prevalence and severity of bullying in the underlying population of women physician leaders. In addition, we did not ask about bullying experiences throughout one’s career but rather the most impactful experience. As a result, we did not capture the breadth of bullying for each respondent.
We also did not investigate bullying among male physician leaders, nonphysician women leaders in medicine, and early-career faculty physicians. In addition, we did not evaluate other demographic characteristics to explore intersectionality and its role in experiences with bullying. These perspectives should be collected in future studies to provide a comprehensive landscape of bullying in academic medicine. Nevertheless, given evidence from other studies that suggests that women who behave in counterstereotypical ways by seeking leadership roles may be particularly vulnerable to gender-based mistreatment, and given that these leaders were particularly well positioned to reflect on the possible impact and approaches to mitigate bullying in academic medicine, we believe the perspectives identified in this study are informative.
Conclusions
Gender-based mistreatment and bullying are prevalent among and experienced by successful women physician leaders in academic medicine, particularly from male supervisor offenders. The valuable perspectives and lived experiences of these women physician leaders highlight the importance of addressing this challenge and serve to suggest multiple potential interventions. These targeted interventions may then lead to the cultural transformation needed to eliminate gender-based mistreatment, bullying, and its adverse consequences on individual careers and the contributions these women could make to our institutions and society.
Acknowledgments:
The study investigators thank the alumnae of the Hedwig van Ameringen Executive Leadership in Academic Medicine program for participating in this study and providing examples of their lived experiences.
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