Using questionnaire answers from thousands of internal medicine residents, primarily from U.S. training programs, a research team at Johns Hopkins Medicine says it has added to the evidence that bullying of medical trainees is fairly widespread. Bullying affects about 14% of medical trainees overall, but is particularly more prevalent among foreign-born trainees. 

In a report on the findings, published Aug. 13 in JAMA, the researchers say those who report they felt harassed repeatedly by superiors described that this bullying resulted in burnout, depression and other ill health effects.

Moving forward, researchers hope that the study will alert residency training program directors to the rates of bullying within their programs and move them to take necessary action to create a more safe and supportive learning environment. 

“We hope our study will further raise awareness among educational leaders of just how ubiquitous bullying is, and that it will encourage them to do more to prevent it,” says Scott Wright, M.D., professor of medicine and director of general internal medicine at Johns Hopkins Bayview Medical Center.

Previous studies, Wright says, have documented varying rates of trainee bullying -- defined as more than one episode of verbal, physical, sexual or other types of harassment from a person in a position of power or authority -- ranging from 10% to 48% depending on country and level of training in medical education. A recent survey study of internal medicine residency training program directors in the Journal of Graduate Education by Wright and his team found that only 31% were aware of bullying taking place within their programs.

In a bid to learn more about the prevalence of bullying and its health consequences on medical trainees, the researchers studied more than 24,000 internal medicine residents, mostly in the United States. These trainees completed a five-question survey about bullying in 2016, which was attached to the end of the Internal Medicine In-Training Examination (IM-ITE) -- an exam given by the American College of Physicians to residents to assess their personal progress every year.

Of the 21,212 who completed the survey and allowed their answers to be used for research, 55.7% were male and 68.8% said English was their primary language.

Residents were asked whether they were bullied during residency, the type of bullying, whether they sought help and whether there were consequences for their health.

A total of 2,876 internal medicine residents reported being bullied since the beginning of their residency training, an overall rate of about 13.6%. Women were bullied at a rate of 14.4%, and men were bullied at a rate of 12.9%.

Significantly, Wright noted, more than 40% of the residents who reported being bullied spoke a native language other than English. Results also showed that compared with U.S. residency training programs, internal medicine residents training at international programs had approximately 60% higher odds of experiencing bullying.

When it came to performance on the internal medicine knowledge exam, the rates of bullying increased among those with lower exam scores. Students who scored in the top third of the scores were bullied at a rate of 12.3%, while those in the second or bottom third were bullied significantly more often at rates of 13.8% and 14.4%, respectively.

In the survey, residents were given a list of nine choices about personal or professional consequences that stemmed from perceived bullying, including “none of the above.” The most prevalent consequence they reported was feeling burned out, which was acknowledged by 57% of the respondents, followed by worsened performance (39%) and depression (27%). The other consequences of bullying reported by trainees included change in weight, alcohol use, improved performance and illicit drug use.

Some 62 residents reported that they left the program as a result of bullying. Wright explains that burnout among residents can have many causes, including fatigue, stress and the intense learning curves that residents face. But he says his team’s findings affirm that bullying contributes significantly to the problem for many, and it’s a factor that can be entirely prevented.

Wright cautioned that the rate of bullying reported in this study was subject to the residents’ interpretation of the definition of bullying. Besides bullying, trainees may be exposed to less egregious microaggressions, which weren’t measured by this study. 

Co-authors were Manasa Ayyala, of Rutgers University, and Rebeca Rios, of Georgetown University.

Wright received support for his work as the Anne Gaines and G. Thomas Miller Professor of Medicine through the Johns Hopkins Center for Innovative Medicine.

No investigator reported any conflict of interest in the preparation of the study.