Harassment or intimidation are uncomfortable topics for most of us to address and even worse things to experience.
Part of the struggle for those who experience harassment/intimidation is deciding if what they are experiencing is a normal part of training to be tolerated to become a doctor. A number of definitions exist to help you decide if how you are being treated is harassment. One definition comes from the Bullying and Harassment of Doctors in the Workplace report from the British Medical Association (BMA, 2006). That report defines bullying and harassment as “unwanted conduct affecting the dignity of people in the workplace and may be related to age, sex, religion, race, disability, sexual orientation or any other personal characteristic. It may be persistent or an isolated event, but in all cases, the actions or comments are viewed as demeaning and unacceptable to the victim.” AMA provides examples of inappropriate faculty behavior including: “physical punishment or physical threats; sexual harassment; discrimination based on race, religion, ethnicity, sex, age, sexual orientation, gender identity, and physical disabilities; repeated episodes of psychological punishment of a student by a particular superior (e.g. public humiliation, threats and intimidation, removal of privileges); grading used to punish a student rather than to evaluate objective performance; assigning tasks for punishment rather than educational purposes; requiring the performance of personal services; taking credit for another individual’s work; intentional neglect or intentional lack of communication.” (AMA Teacher-Learner Environment in Education H-295.555 cited in Resident Intimidation and Mental Health Report of AMA-RFS January 2007)
Harassment and intimidation occur in medical training. An AMA survey of residents and fellows (AMA Section on Medical Schools Interim Meeting, Presentation Summaries, Nov 10,2007, S. Desai, MD, vice-chair AMA Resident and Fellow Section) found that of 688 respondents 25% noted they had been threatened with nonphysical harm, 22% felt pressured to report inaccurate duty hours, 25% reported experiencing intimidation and 50% reported they would not feel comfortable in reporting intimidation. 75% of the respondents noted the importance of having AMA address the issue. A review of the literature in the BMA report (BMA 2006) found incidents of harassment and intimidation for medical students and residents ranged from 16% to 38% in part depending on the type of medical professional instigating the mistreatment. Patient initiated harassment was reported by 25% of residents. The Association of American Medical Colleges 2017 Graduate Questionnaire (N=14, 405) found 14.8% noted having been subjected to offensive sexist remarks or names.
Impact on learning: Feeling unsafe, vulnerable and anxious are not conducive to acquiring, integrating and utilizing vast amounts of information and new skills. Effective learning requires a setting of support, respect and safety. ACGME makes a strong statement on how harassment and intimidation have no place in training in the ACGME Bulletin article on The Environment for Resident Professional Development (Leach, 2007). Please see the article at: http://www.acgme.org/acWebsite/bulletin/bulletin11_07.pdf. This is built into the 2017 revision of the Common Program Requirements for all residency programs in VI.B.6: Programs must provide a professional, respectful, and civil environment that is free from mistreatment, abuse, or coercion of students, residents, faculty, and staff. Programs, in partnership with their Sponsoring Institutions, should have a process for education of residents and faculty regarding unprofessional behavior and a confidential process for reporting, investigating, and addressing such concerns. (ACGME 2017).
Impact on morale: Working in an emotionally unsafe environment disrupts the sense of mutual support critical to successfully managing the challenges of residency. Compromised morale, in turn, places residents in a more vulnerable position to experience compassion fatigue, burnout and depression. These, in turn, increase the risk for errors in patient care
Impact on retention: Harassment, intimidation and bullying are associated with considerations for leaving training and even leaving medicine altogether. (BMA, 2006).
Policies regarding harassment
Tolerance for harassment/intimidation in the workplace is decreasing at the institutional and personal level. It reflects, in part, generational changes in priorities and expectations. This is also true in medicine. Marshfield Clinic’s policy for zero tolerance of harassment is very clear.
ACGME is also very clear on its intolerance for harassment in training by noting in its Institutional Requirements that each training center must have specific policies covering harassment including a safe, confidential way in which residents can report harassment.
Things to do when you experience harassment/intimidation or threats of violence:
ACGME Institutional Requirements related to harassment
AMA Statement on Sexual Harassment and Exploitation
ACGME Common Program Requirements VI 2017
Practical guidance to reduce risk of unprofessional behavior/harassing behavior