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Viewpoint
The Culture of Bullying in Medical Training Must Stop
Abstract
Among the Science, Technology, Engineering, and Mathematics professions, medical training continues to carry remnants of the medieval concept of apprenticeship. A lingering hangover of apprenticeship in medicine is the culture of teaching through shame, embarrassment, and humiliation that has persisted over the years. Estimates of the prevalence of bullying in medicine vary from as little as 13% to as high as 81%, with considerable reason to suspect under-reporting. The consequences of bullying approximate that of abuse in early childhood and are often long-lasting. Burnout, a decline in performance as a resident doctor, and depression are commonly reported consequences of bullying and abuse on medical students. Only a minority of medical students ever report abuse due to trust deficit and fear of retribution. Most medical program directors appear to be unaware of the scope and extent of abuse occurring under their watch. Most victims of bullying appear to become bullies themselves, perpetuating the bully-victim cycle of abuse. Traditional power hierarchies play a role in bullying in the medical profession, as in other professions. The cost of bullying and abuse to the health and welfare of medical students is considerable. There is a strong case to be made for compassion in medicine and for bringing back humanity into the medical humanities. Medical training must not a barrier to medical learning. The safety of survivors of abuse must also be addressed while reporting to protect them from repercussions. We must work to make training spaces safe for medical students.
Keywords: Bullying, empathy, medical education, medical training, workplace harassment
Introduction
Among the Science, Technology, Engineering, and Mathematics professions, medical training continues to carry remnants of the medieval concept of apprenticeship.[1] We must decide to dedicate one’s life to the service of others in late adolescence, abandon home and hearth to take up long years of training and residency in a hospital, provide free to subsidized service to patients during our training in return for the opportunity to learn, and then spend years or even a lifetime honing and refining the craft while trying to make our mark in the profession and acquire some repute. We even have our version of master craftsmen and teachers to whose services we must sign bonds that carry fairly stringent restrictions on our lives and hopes and are regulated by medical councils – a clear cultural hangover of erstwhile craft guilds.[2]
Another lingering and unfortunate hangover of apprenticeship in medicine
is the culture of teaching through shame, embarrassment, and humiliation that we have built up over the years. All learning, and especially learning that is so closely related to the human body and mind, must occur through trial and error. Many of us unlearn older biases and stereotypes that run under our skin (the belief that older people and women commonly exaggerate their pain, for one) and shed inhibitions about modesty (the first nude person we usually see is a dead one). However, this kind of training is traditionally associated with the belief that learning, unlearning, and relearning can only occur by shaming medical students publically and castigating them in private at periodic intervals.[3,4] As Goffman has described in his collection of essays – Asylums – the recruit must begin their career in a total institution with a systematic, though often unintentional mortificationoftheself.[5]
Prevalence of Bullying and Consequent Emotional Outcomes
Silver in 1982 pointed out striking parallels between the changes in attitudes and behaviors in children who were the
Address for correspondence:
Dr. Migita Michael D’Cruz, Department of Psychiatry, Geriatric Psychiatry Unit, National Institute of Mental Health and Neurosciences, Bengaluru – 560 029, Karnataka, India.
E-mail: migitadcruz@gmail.com
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http://www.worldsocpsychiatry.org DOI: 10.4103/wsp.wsp_30_21
Migita Michael
D’Cruz
Department of Psychiatry, Geriatric Psychiatry Unit, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
Submission: 01-07-21 Acceptance: 21-02-22
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How to cite this article: D’Cruz MM. The Culture of Bullying in Medical Training Must Stop. World Soc Psychiatry 2022;4:4-9.
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survivors of abuse and medical students shortly after their matriculation, suggesting that the changes may be the aftermath of avoidable and unnecessary abuse that went largely unrecognized and underreported.[6] His study in 1990 reported the experience of abuse in 46.4% of medical students, of whom 80.6% of students had been abused by their senior year. 69.1% of students reported that at least one episode of abuse was very upsetting, 49.6% reported that the most serious incident of abuse had affected them adversely for a month or more, and 16.2% reported that the abuse would always affect them.[7] The authors suggested that the prevention of abuse and the protection of the accused as well as of the student should be key goals in medical training.
A more recent American study by Ayyala et al. in 2019 reported bullying in 13.6% of internal medicine residents with verbal harassment being the most common form of bullying (80%).[8] Physical harassment occurred in 5.3% of residents and sexual harassment in 3.6% of residents. The consequences of abuse were potent – 57% of residents felt burnt out, 39% reported that it worsened their performance, and 27% reported depression. Of these – only about 31% of residents had ever sought help for bullying. Another study by the same group of authors examining awareness of bullying of their trainees by internal medicine program directors reported revealed that only 31% appeared to be aware of the occurrence of such bullying.
Another American study by Hu et al. in 2019 reported at least one form of mistreatment in more than 50% of surgical residents.[9] Verbal abuse was again the most common form of harassment (30.2%) followed by sexual harassment (10.3%) and physical harassment (2.2%). Of these, 38.5% of residents experienced burnout at least once a week, 34.3% emotional exhaustion, and 17.1% depersonalization. 4.5% of residents reported suicidal thoughts in the past year. Except depersonalization, all other emotional consequences of harassment were more common in women than in men. Clearly, 30 years later, little has changed with regard to the routine mortification of medicine.
An older systematic review and meta-analysis by Fnais et al. in 2014 examined 62 studies (57 cross-sectional studies, 3 cohort studies, and 3 companion reports) that examined the prevalence, risk factors, and sources of harassment and discrimination during medical training across the world.[10] 59.4% of subjects, most of whom were undergraduate students, reported having experienced harassment or discrimination during their medical training. Students reported an average of four sources of harassment, the most common being their consultants (34.4%), followed by patients and their families (21.9%), nurses (15.6%), fellows or residents (15.6%), and others (3.1%). The most common type of harassment was verbal (63.0%) and the least common was physical (15.3%).
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Closer to home, in India, an older study by Bairy et al. in 2007 reported that 51.2% of trainee doctors reported having ever been bullied. The prevalence was highest among compulsory rotatory resident internees (the equivalent of house officers or house surgeons in the West) at 89%.[11] Trainer on trainee bullying was the most common, and younger trainees were bullied more than older trainees. The study examined student attributes using a Myers–Brigg type indicator. Respondents were more likely to report as “thinkers” rather than “feelers,” with the former group appearing more likely to internalize “tough” attributes and at a higher risk of perpetuating bullying. Strikingly, 95% of bullying went unreported, with 20% being unsure of how to report abuse, 20% fearing adverse consequences from the institute, and 20% citing other reasons due to which they did not report. This is unsurprising that institutional redressal boards often remain on paper. Many of us, after reporting the abuse, go back to working with the perpetrator of our abuse in the same work environment, now carrying the unenviable tag of a trouble-maker and a whistle-blower. In several workplaces, including the ones, I have been at-the perpetrators of abuse hold positions in the institute redressal boards, not something that engenders confidence.
A more recent Indian study by Kapoor et al. in 2016 reported that 98.69% of undergraduate medical students reported having bullied others, while 88.77% reported having experienced bullying.[12] Students who consumed alcohol or tobacco were more likely to inflict physical bullying upon others. Bullying culture is internalized over time, by medical students, as a marker of having toughened up and developed the thick skin that is considered a necessary part of medical professionalism. We must be able to take abusive epithets, personal slurs, files hurled at our face, and the pushing and shoving that occurs in mid-operation in our stride and continue to attend patients immediately after without missing a beat. Most of all, we must learn to be bullies in our own right, raising our voice, if not our fist, to prove ourselves, competent medical professionals. The high octane nature of our work is supposed to justify this – as is often seen in the armed forces. Most of us have successfully learned to be bullies.[13]
Risk Factors
As with all forms of abuse and harassment, the risk factors associated with bullying and mistreatment in medical training are complex and varied and reflective of the students’ and colleges’ biopsychosocial environment.
Regional differences
The analysis of associated risk factors is limited by region of origin, with the most published literature on bullying in medical training originating from high-income rather than medium-to-low-income countries. Of published studies, higher rates of bullying are reported from the
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global North than from the global South, the reasons for which may include study methodology, cultural sensitivity of instruments used, differences in social norms and values, and teacher–student power differentials.
Trainee vulnerability
The most consistently reported risk factor is the gender of the trainee, with most studies reporting higher prevalence of all forms of abuse and harassment in women than in men. Racial, cultural, and ethnic minorities also report bullying during their training more frequently than Caucasian students. Students from socioeconomically underprivileged backgrounds, those who speak a primary language other than English, international students, and those with lower test scores in examinations are also more likely to report bullying during their training. In the same academic year, younger trainees (under 30 years) appear more vulnerable to abuse than older trainees. Pregnancy and higher childcare responsibilities were also noted to render students more vulnerable to bullying. Trainees who are overweight (BMI above 25 kg/m2) also appear to have greater vulnerability to bullying.
Training program characteristics
The likelihood of having experienced harassment as well as the absolute prevalence of bullying during training appears to increase with every year of training. The most common source of bullying is the trainer, followed by patients and patient families or other hospital staff. Some studies examining bullying across specialties report a higher prevalence in surgical specialties when compared to other specialties, though others report no significant difference by training specialty.
An Australian qualitative study by Colenbrander et al. in 2019 examined the experiences of 10 medical students to identify factors associated with mistreatment.[14] The authors identified problematic thematic elements such as hierarchy, self-sacrifice, resilience, and deference, which contributed to mistreatment in medical training. Students’ perception of being labeled as a trouble-maker, fearing adverse outcomes, uncertainty about avenues for reporting, lack of confidentiality, and uncertainty about outcomes were other structural and procedural factors that hampered reporting.
A systematic review by Averbuch et al. in 2021 examined 78 studies and similarly identified hierarchal power structures, normalization of bullying, and a lack of enforcement of institutional polices on mistreatment of medical students as facilitatory factors.[15]
Consequences
Trainee consequences
As discussed above, bullying in medicine has significant adverse emotional consequences for the trainee, including
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burnout, emotional fatigue, physical fatigue, symptoms of depression, anxiety, stress, trauma, suicidal thoughts, and vulnerability to substance abuse and other harm behaviors.[10,15]
Trainees who report mistreatment also experience adverse physical consequences, including an increased risk of developing metabolic syndrome, cardiovascular disease, and cerebrovascular disease.[7-12]
Trainees are also vulnerable to impairment of academic and occupational performance ranging from a decreased sense of clinical and academic competence to contemplation of discontinuation of the course to academic dropouts. Some longitudinal studies also indicate that students who experience academic bullying are less likely to seek tenure or careers in academic medicine, affecting long-term career trajectories.[10,15]
Staff consequences
Training environments where disruptive behavior occurs also demonstrate adverse consequences upon trainers and staff, including impairment of clinical performance, lower clinical and academic competence in staff, increased staff turnover, high workplace stress, and low morale at the workplace. An estimate by the National Health Service reports bullying costs the service about £325 million annually by impacting staff performance and increasing their turnover.[16]
Patient consequences
Downstream effects of bullying in medical training are also evident in patient outcomes. In a survey of emergency medicine residents, 90% reported disruptive behavior by consultants that negatively affected patient care.[17] 51% of residents also reported that they were less likely to call an abusive consultant. Another study of disruptive behavior in perioperative settings reported that bullying was linked to 71% of medical errors, 67% of adverse events, and 27% of patient deaths.[18]
Discussion
None of this is new. Very little of this information is surprising.[19] Bullying, naturally, also follows traditional power hierarchies in medicine as it does in medical professions. Women face more sexual harassment than men. Men face more physical abuse than women. Religious, cultural, ethnic, racial, gender, sexual, and economic minorities face more harassment than the majority community – irrespective of region of the study.[20]
We have all known colleagues throughout all our training who have experienced bullying in some way or the other. Many of us have lost friends and colleagues to bullying. Nearly, all of us might have faced the mental and physical consequences of bullying and even the aftermath of reporting the bullying. From this perspective, the numbers
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and figures quoted are probably an under estimate and a partial representation of a complex and amorphous problem.
Potential Safeguards for Trainees and Deterrents to Harassment
The complexity of bullying in medical training also implies that there are not simple or easy solutions available. Measures may be aimed at (a) safeguarding medical students from varied forms of mistreatment, (b) deterring potential abusers from harassment, and (c) improving channels for reporting/redressal/recovery in the aftermath.
Student safety and welfare
A definitive first step would be ensuring student safety and well-being during medical training, both in the classroom and in the hospital. The nature of the academic curriculum in India results in students entering undergraduate medical training shortly after graduation from high schools, while they are still legal minors. This, along with the residential nature of training, can contribute to student vulnerability to abuse. There may be merit in waiting until a student attains legal majority before introduction to a vocation and a potential role for premedical training.
Another potential safeguard may be life-skill training, along the lines of the WHO Life Skill Program, to equip students with the ability to respond effectively to abuse and ensure safety.[21] It is to be noted that this carries the same intrinsic limitation most programs and policies aimed at addressing abuse do – the onus of prevention and protection is placed upon the potential victim rather than the potential perpetrator.
Further, the academic curriculum is sufficiently dense and intensive as it stands and any additional training module would work better if it may be implemented in a manner that promotes student engagement and is interactive rather than didactic. Memorization of a list of points, alone, is unlikely to make the training program a warmer or more compassionate place for students. Addressal of identity and intersectionality may be of greater benefit than a one-size-fits-all module.
Abuse deterrents
Deterrents to abuse are best interpreted within the scope of the legal system of the country where medical training takes place and professional codes of conduct. A note is made below of relevant guidance, where available.
The American Medical Association (AMA), in 2020 adopted a policy intended to prevent bullying among health-care professionals at the workplace, which may be extrapolated to apply to medical students. The AMA defined “workplace bullying” as repeated, emotionally or physically abusive, disrespectful, disruptive, inappropriate, insulting, intimidating, and/or threatening behavior targeted at a
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specific individual or a group of individuals that manifests from a real or perceived power imbalance and is often, but not always, intended to control, embarrass, undermine, threaten, or otherwise harm the target.[22] The 2020 policy offers the following guidance for the establishment of an effective workplace policy:

1. Describe the management’s commitment to providing a safe and healthy workplace. Show the staff that their leaders are concerned about bullying and unprofessional behavior and that they take it seriously
2. Clearly define workplace violence, harassment, and bullying, specifically including intimidation, threats, and other forms of aggressive behavior
3. Specify to whom the policy applies (i.e., medical staff, students, administration, patients, employees, contractors, vendors, etc.)
4. Define both expected and prohibited behaviors
5. Outline steps for individuals to take when they feel they
   are a victim of workplace bullying
6. Provide contact information for a confidential means for
   documenting and reporting incidents
7. Prohibit retaliation and ensure privacy and
   confidentiality
8. Document training requirements and establish clear
   expectations about the training objectives.
   In India, mistreatment of students may come under the provisions of:
9. The UGC Regulations on Curbing the Menace of
   Ragging in Higher Educational Institutions, 2009
10. The Medical Council of India (Prevention and Prohibition of Ragging in Medical Colleges/Institutions)
    Regulations, 2009
11. The Protection of Medicare Service Persons and
    Medicare Service Institutions (Prevention of Violence and Damage to Property) Act, also known as the Medical Protection Act (MPA) passed by several states
12. The Sexual Harassment of Women at Workplace (Prevention, Prohibition, and Redressal) Act, 2013.
    In addition to civil and criminal law.[23] The Indian Medical Association (IMA) is yet to issue guidance addressing bullying faced by medical students during their training (aside from ragging or hazing), along the lines of the AMA. Such guidance would be very welcome and form the bones for individual institutes to draft policies, guidelines, and protocols to address bullying.
    Legal provisions alone may not be sufficient and may miss the forest for the trees in the case of the bully-victim cycle of abuse. Avenues for social safeguards such as student mentorship programs and rehabilitation pathways for abusers would be of merit. Abuse deterrents would work best within a training environment which addresses the common cognitive dissonance between demonstrating resilience to hardship during training and compassion for oneself/others.[24]
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Avenues for reporting/redressal/recovery
Bearing in mind that most abuse goes unreported for fear of retribution and adverse career outcomes, there is a need to increase the accessibility to justice within medical training. These can include:

1. Student helplines
2. Provisions for emergency response – along the lines of
   NABH emergency codes
3. Facilitation of digital reporting
4. Dissemination of information about the composition
   of the Internal Complaints Committee, Grievance
   Redressal Committee, and Student Welfare Committee
5. Contact information of requisite committee members
6. Dissemination of information about due procedure after
   contact – students often report being unsure of how to register a concern or the nature of the procedure subsequent to the same
7. Referral pathways to address the health, well-being, and safety of the student postreporting, including debriefing, addressal of trauma, and support systems
8. Legal aid as required
9. Emphasis on just, equitable, and sensitive
   outcomes–whilestudentsmaycontinuetobalkat reporting, a demonstration of ethical and compassionate redressal over time may serve to win confidence
   helplines and peer mentors to handhold throughout the process would help, too. Reporting and retribution for abuse may not be sufficient remedy, if we put our survivors of abuse back in the same spaces as their abusers, without sufficient safeguards.[27] However, most of all, we must convince ourselves that it is wrong, to suffer or indict abuse, even in the service of health and life. We must become the kind and compassionate medical teachers that we would have wanted for ourselves as medical students, once upon a time. Medice, cura te ipsu – May we physicians heal ourselves.
   Financial support and sponsorship
   Nil.
   Conflicts of interest
   There are no conflicts of interest.
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    Finally, in learnings from Judith Herman’s work on trauma and recovery – the first priority in the aftermath of abuse must be safety.[26] We must strive to make our classrooms and clinical rounds safer places for medical students. Enabling accessible pathways to help such as
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