Residency is a challenging time plagued by long hours, overwhelming clinical service loads, escalating documentation requirements, and inadequate resources for support. A recently published study in the New England Journal of Medicine illustrates how mistreatment in the training environment takes an additional toll on medical trainees.

The survey was administered during the national American Board of Surgery In-Training Examination to 7,409 residents at 262 training programs from across the country, encompassing approximately 99% of all the residents training to become surgeons in the United States. The study found that residents who experienced mistreatment regularly were 300 percent more likely to suffer from burnout and suicidal ideation than residents who did not regularly experience mistreatment. 

The study also found that women were more likely to experience mistreatment than their male colleagues (70.6% versus 36.1%), specifically gender-based discrimination (65.1% versus 10.0%). Gender discrimination against women came from a variety of sources: co-residents (6.3%), faculty (17.6%), nurses or other staff (23.6%), and patients or patient families (49.2%). Racial discrimination was also most likely to come from patients and patient families for both men and women (47.4%).  

As a surgical trainee, these findings were not particularly surprising to me. My current research work is focused on understanding drivers of mistreatment in the clinical learning environment in order to change the culture of medical education. I have also personally experienced mistreatment as both a medical student and as a resident. In the following interview by Christina Frangou with General Surgery News, I address questions and provide commentary on the study’s findings.  

My first question here is very broad but I’d like to get a sense of what your response is to the study. Overall, what do you think of the study and its findings?

Overall, I think this is important work and I’m glad to see it is getting so much national attention. I think this paper comes at a time when we are really starting to understand in a deeper way the impact the clinical learning environment has on trainees. I think it’s also important to realize that it’s not just trainees who are affected — the clinical environment has a significant impact on providers at all levels. 

Sadly, I’m not surprised with the findings that rates of mistreatment were so high and that they correlated with burnout and suicidal ideation more strongly than factors such as duty hour violations. Anecdotally, I can say that I have talked to many residents who have felt that their lowest points emotionally were on rotations where they were mistreated — bullied, ignored, or made to feel incompetent or stupid. In general, surgery residents are not afraid of hard work. That’s why we chose this profession, because we want to care for the sickest patients in the hospital in some of the most difficult circumstances. 

I think the reason mistreatment correlates so strongly with increased suicidal ideation it that being mistreated or bullied can lead to intense feelings of shame. Because shame is not something we feel comfortable talking about, this can lead to feelings of isolation. When an individual feels isolated, suicide can seem like the only way out. I think the current study points to the compounding influence of isolation with their data showing that single or divorced/widowed residents were more likely to endorse suicidal ideation than those who were married or in a relationship. Suicide in medicine is a huge issue; suicide is the second leading cause of death for residents, just after neoplasms and before accidents. Sadly, since starting residency I’ve lost several colleagues to suicide — both physicians and a nurse. Suicide is a real issue for all health care providers and one we need to take seriously.

Unlike talking about experiencing mistreatment, it’s ok to talk about working long hours — and in fact this can be seen as a badge of honor, a sign of machismo, strong work ethic, or integrity. I think it can also be hard to know if you are really experiencing mistreatment, especially if you are experiencing microaggressions. Residents may not have a good standard for comparison, and there’s still a strong ethos of “well, it was worse for me when I was in training” that can make people feel even more alone in their suffering, like it is somehow their fault that they feel mistreated. 

Were you surprised by anything reported here? Why or why not?

I was actually a little surprised with the low prevalence of burnout reported by the study. Previous work has estimated the prevalence as high at 69% in surgery resident trainees. Some of that depends on how you define burnout. The present study used 6 questions from the modified version of the Maslach Burnout Inventory (aMBI) which focused only on emotional exhaustion and depersonalization, but not decreased sense of accomplishment. For the present study, they defined burnout as having at least one weekly occurrence of any of the six items. In contrast, Elmore et al. used the full 22-item MBI, and defines burnout as scoring in the highest tertile for any one of the three subscales. In their population, Elmore at al found that 24% of residents met criteria for burnout in one subscale, an additional 34% met criteria for burnout on 2 subscales, and an additional 10% met criteria for burnout on all three subscales. 

Aside from the instrument and definition used to measure burnout, I think the other important factor to consider with this study is that the survey was administered immediately after the ABSITE (American Board of Surgery In-Training Exam). The exam itself is five hours long, is required by most residency training programs, and is administered by the American Board of Surgery. The benefit of administering the survey immediately after the ABSITE was that it allowed the study team to capture a high response rate (99.4%). However, after the exam, residents are likely to be fatigued, may not have felt the survey questions were optional, and may not have been clear about how this information would be conferred to their program, or how their responses might reflect on their program. I think historically, some residents have been concerned about reporting openly about issues in the learning environment due to fears of negative impact on their program, such as program closure. The authors do a nice job of addressing these limitations of their study in their discussion.

The study showed that after accounting for mistreatment, there is no difference in rates of burnout or suicidal ideation among men and women. What would you like programs and/or organization to do with this information? 

The issue of higher rates of mistreatment experiences for women in medicine is not new. There’s an interesting article in the New England Journal of Medicine from over 25 years ago that surveyed internal medicine residents about their experiences of sexual harassment and found rates were significantly higher in female residents than their male counterparts. In the article the authors discuss many of the same issues we continue to struggle with today — underreporting, criteria for what constitutes harassment, the role of hierarchy and power, and legal issues. 

Movements like Time’s Up and #MeToo have popularized and normalized conversation around sexual harassment and discrimination. This has allowed us as a society to start to see how prevalent these issues are and how they aren’t limited to a particular socioeconomic class or occupation. Reports like the Engineering and Medicine Consensus Study on Sexual Harassment of Women published in 2018 by the National Academy of Science are formally documenting how prevalent these issues are across institutions and disciplines. Ultimately, engaging in dialogue about tough issues like sexual harassment and gender-based discrimination is critical for creating meaningful, lasting change.

I think the biggest thing institutions can do is to take responsibility for implementing structural changes that promote diversity, equity and inclusivity in medicine at all levels, from training to leadership. We need to view the issue of harassment and discrimination as an institutional, system-level problem and not an individual-level problem. We also need to understand how the multiple identities embodied by individuals — such as socioeconomic status, race, ethnicity, gender identity, and sexual orientation — intersect to compound experiences of harassment and mistreatment. Organizations can work to promote early detection of issues, responsiveness to problems one they are identified, and open conversation about these issues are all important. 

Similar to the last question, what would you like to see come out of this study?

 I hope this study helps the profession examine mistreatment behaviors in the clinical learning environment more broadly — both in who is being affecting and what we can do to change this phenomenon. We have been studying mistreatment of medical students for nearly four decades, since Silver published his 1982 commentary about the transformation of medical students during medical training and compared it to child abuse. This work opened people’s eyes to the possibility that mistreatment could occur in any setting, even those we consider to be prestigious. In 1990, when the first quantitative report of rates of medical student mistreatment was published, over 80% of students felt they had been abused at least once by their senior year. Nearly half the students who reported experiencing abuse stated the episode impacted them for a month or more, and over 16% said the abuse would affect them for the rest of their life. Studies of medical students have also shown that rates of mistreatment correlate with increased rates of burnout.

While we’ve made some progress on the issue of mistreatment of medical students — we still have lots of room for improvement — mistreatment of residents has been relatively understudied. I think medical students have been studied heavily because are considered a vulnerable population, and I think we need to view residents similarly. In many ways, I think residents are even more vulnerable than medical students. They spend more time in each rotation than medical students do and work repeatedly over a period of years with the same faculty and staff. It is also very hard for residents to leave a program for many reasons — most residents are massively in debt, they have been pursuing the goal of becoming a physician for the better part of a decade or more, and the process for finding a new residency spot is far from simple. 

I also think we need to realize that burnout and mistreatment have a reciprocal relationship. If someone feels burned out, they are more likely to engage in mistreatment behaviors, and if they are, in turn, mistreated they are more likely to feel burned out. Emerging data has shown that rates of burnout in residents correlates with increased rates of explicit and implicit racial bias. I think we are just beginning to understand how deeply these issues are interrelated.

Shifting the focus to how we can make the clinical learning environment better for everyone is also critically important. No one is immune to bullying and mistreatment. During a talk at Association for Surgical Education Conference last April, Dr. Kevin Y. Pei presented data that showed that 54% of surgical faculty witnessed bullying and 40% experienced bullying, and that 67% of surgical chairs witnessed bullying and 31% experienced bullying. Until we work to make the clinical environment better for everyone, we are going to keep seeing high rates of mistreatment, burnout, and depression.

Do you agree with their conclusions?

I appreciate that in the conclusion of the paper the authors discuss how issues of mistreatment can vary significantly between programs. There is no “one-size-fits all” solution to learner mistreatment; social, cultural, and economic context all strongly influence this issue. For example, the University of New Mexico (UNM) is situated in a minority-majority state (37% white alone, not Hispanic or Latino), and one of the missions of our medical school is to reflect the demographics of the state’s population in our medical student classes to help ensure a diverse physician workforce. However, many of our residents and faculty are recruited from outside New Mexico, and while we have relatively high rates of diversity in these groups, our residents and faculty are still less diverse than our students. Understanding these types of local institutional issues, as well as engaging in direct dialogue with stakeholder groups — students, residents, faculty, staff — about their experience and perceptions of the clinical learning environment has been critical in our work to create change and decrease rates of mistreatment at UNM. 

The study also showed women experience gender discrimination from patients and patients’ families. Is this something you’ve seen in your practice? 

I think the most frequent form of gender discrimination I have experienced and witnessed are microaggressions and microinvalidations. It’s not uncommon for me to walk into a patient’s room and have them say to a family member ‘oh, my nurse is here’. The other experience I have had — and I know other female surgeons have had, residents and faculty alike — is having the patient or their family talk to a junior male member of the team instead of addressing me directly. Also, though I’ve never personally experienced this, I’ve heard of patients asking for a different surgeon because of the gender or race of their assigned provider. One of the highly respected female vascular surgeons I work with was told by her male patient that he wanted another opinion as he was hoping for a male surgeon. (Interestingly, her partner is another female surgeon!) I’ve definitely had male patients call me nicknames like ‘sweetie’ or comment on my appearance — “you’re too pretty to be a surgeon” — and I have even had a patient ask me out on a date. Many of these comments are meant as compliments, but they are unwanted and feel demeaning. 

Unfortunately, other common occurrences are gender-based microaggressions and microinvalidations towards female surgery residents from other members of the care team. These are things that don’t happen as often to male surgery residents. This can be as seemingly innocuous as a nurse refusing to implement orders that you place, or questioning your clinical decision making. I have many friendships with female (and male) nurses, but I feel like I’ve had to work hard to cultivate them in a way my male colleagues haven’t had to. Two female faculty members at our institution recently published a great study looking at the experience of harassment and discrimination of female residents in both male- and female-dominated surgical specialties. They found these experiences of bias were common in both settings and were frequently from other female members of the care team. The following is a quote from the paper: “When describing how gender bias would affect their future in medicine, trainees in male-dominant specialties were more likely to report that due to gender bias, they ‘may leave medicine/retire early’ (33% vs 6%, p = 0.040) and that they ‘would not recommend my profession to trainees or family members’ (40% vs 6%, p = 0.015).”

How can hospitals and clinics begin to address these issues?

First, I think actively addressing these behaviors in a nonconfrontational manner when they arise is really important. One example I have hear of was a senior female faculty member (and division chief) who was repeatedly overlooked by a patient who persisted in addressing her junior male resident as “the doctor” and leader of the team. Finally, the male resident politely said to the patient “I just want to make sure you know that Dr. X is the senior physician here and the head of the division. She is my boss.” Those small statements of advocacy can really help make a difference. 

Second, having a clear institutional position about inappropriate workplace behaviors such as bullying and mistreatment is really important, as is following up with real consequences for individuals engaging in these behaviors. The American College of Surgeons has put out a powerful position statement on Harassment, Bullying and Discrimination that can serve as a model for organizations who want to address this issue proactively. Having a policy doesn’t necessarily directly address mistreatment from patients, but it helps create a culture of respect that empowers anyone in the healthcare environment to speak up and openly address these issues. 

I’ll just open it up with that and ask if there’s anything that hasn’t come up in these questions that you’d like to point out. 

I think resources for anonymous reporting and support for those reporting is also really important. At the University of New Mexico, we have created the Learning Environment Office, which is overseen by the School of Medicine and was created as a resource for students, residents, faculty, and staff. As part of the office, we created a confidential online reporting tool where mistreatment can also be reported anonymously by anyone working in the clinical learning environment. The office also works hard to ensure there is due process for investigating complaints — it is important that both sides of any conflict are fairly represented. We are also working to provide educational resources for members of the UNM Hospital community — teachers and learners alike — to empower them to embrace teaching and learning, and to help them create more positive clinical learning environments. There can also be a lot of fear around teaching and learning in medicine, so I’ve also found that a lot of our work recently has focused on creating a space for dialogue and collaboration.

Finally, I hope this study encourages the field of medicine to consider the clinical learning environment as a key part of the equation of physician wellness. Dr. Lotte Dyrbye has done great work in this arena, demonstrating that medical students come into the profession of medicine with lower rates of burnout and depression, and higher subjective quality of life (physical, mental, and emotional) than their age-matched peers. But by the time they finish medical school, their rates of depression and burnout are significantly higher. Increases in burnout and declines in empathy are specifically seen when students enter the clinical portions of medical education. This trend continues into residency, and these experiences can impact people for the rest of their professional lives. I think we see evidence of this in the high rates of burnout seen in practicing physicians. Of course, multiple factors impact the wellness of clinicians, but we need to acknowledge the impact the training process itself has on medical providers. We also need to move forward with the clear intention of continuing to improve the clinical learning environment for everyone. These findings illustrate how important it is to attend to the culture of educational at our training institutions if we want to truly attend to the mental and emotional health of physician trainees.

Editor’s note: This interview was originally published in General Surgery News.

Image credit: Swann-Morton Scalpel Handle No. 3 by Brett Jordan is licensed under CC BY 2.0.