When Enough is Enough: Ending the Mistreatment of Obstetrics and Gynecology Residents

Omar M. Young, MD.

Every physician in this country on entering medical school traditionally recites the Hippocratic oath, an age-old standard of medical ethics that holds those who practice medicine to a duty of beneficence and, most important, nonmaleficence: Do no harm.¹ But are we really holding true to these words? Through repeated episodes of microaggressions and macroaggressions, mistreatment of medical trainees remains a symptom of a much larger problem within our American health care system, and it must stop now.

In obstetrics and gynecology, mistreatment had never been examined on a national scale, although a single-specialty survey of 60 residency programs had already found sexual harassment reported by 69.1% of both male and female trainees.² In the August issue of O&G Open, Keller et al³ are the first to describe mistreatment of obstetrics and gynecology residents nationally, building on prior work documenting similarly high rates of discrimination, abuse, and harassment among general surgery residents.⁴ The current culture of health care is harming itself, permanently harming those who survive and causing burnout. Cross-sectional data from a 2022 study by Winkel et al⁵ showed high rates of mental health concerns among trainees in obstetrics and gynecology, with over 60% of trainees reporting burnout and 71% reporting anxiety with 3% voicing suicidal ideation. These numbers were significantly increased when historically minoritized trainees were considered.⁵

The numbers reported by Keller et al³ are staggering: 77.9% (3,191 of 4,094) of obstetrics and gynecology residents reported at least one experience of mistreatment. More than three in four residents, training in a specialty devoted to caring for patients across the reproductive spectrum at the most vulnerable moments of their lives, have themselves been mistreated. This is unconscionably high.

Mistreatment in this study emanated from all aspects of the health care team. Patients and patients' families, attending physicians, and nurses were all frequent sources. A majority of residents who experienced mistreatment even reported that it came from their own fellow trainees.³ The pattern of who mistreats whom is telling. When residents reported gender discrimination, the source was most often a patient or a patient's family. The most common source of racial discrimination was nurses at 80.3%. Attending physicians were the most common source of verbal or emotional abuse (72.4%), pregnancy- or childcare-based discrimination (67.9%), and sexual harassment (54.4%).

More than anywhere else, these incidences of mistreatment occurred predominantly on labor and delivery units. This is not coincidental. Labor and delivery is a high-pressure environment where everyone is stretched thin, where resources are too often poorly allocated, and where clinical situations can turn dire within minutes. It is a place where some of the best moments of a person's life unfold while simultaneously being bitterly toxic for the people who work there. It is that toxicity, if left unaddressed, that will be the undoing of the clinical learning environment. There is no excuse for any of the mistreatment described in this article to ever occur.

Mistreatment does not stay contained to the moment it occurs. Public health and health equity researcher Arline Geronimus's⁶ weathering hypothesis describes how repeated exposure to structural stress produces cumulative physiologic and psychologic erosion. The same logic operates inside our training programs. Mistreatment weathers residents. Weathering produces burnout. Burnout drives people aware from the specialty all together—or worse. When experienced clinicians leave, it is our patients who will ultimately bear the consequences of a thinner, ever-depleted workforce.

The authors of this study should be commended for bringing to light an issue, the burden within obstetrics and gynecology that so many of us have carried in silence. None of us entered medicine to be abused. Mistreatment is not “part of the job” or some hazing ritual in which, because someone before you sustained it, you must as well. That type of thinking is dangerous and only reinforces a culture of implicit and explicit academic violence.

Words are meaningless without actions. We must do better.

So, what should we do?

First, we must advocate for and create environments of psychologic safety. This is not a soft or sentimental goal. Chronic stress measurably impairs the prefrontal circuitry that supports working memory, judgment, and knowledge acquisition.⁷ A resident who is bracing for the next verbal assault is neurobiologically less able to learn to counsel a patient with abnormal uterine bleeding, execute the proper steps for a hysterectomy, or manage any obstetric emergency. Learners should expect to be taught evidence-based medicine in a constructive, nonjudgmental manner that fosters independent critical thinking skills and open expression of thought and questioning. Psychologic safety means embracing, not erasing, the diversity of our identities and experiences. Contrary to a recent and troubling trend, diversity is not a dirty word. Learning from colleagues whose backgrounds differ from our own improves both clinical reasoning and working conditions.

Second, we need upstander training, not bystander tolerance. Simulation-based programs that teach trainees and faculty to intervene in real time when they witness bias or mistreatment have already been shown to change behavior and confidence.⁸ These programs deserve broad, funded implementation across all obstetrics and gynecology residency programs, not one-off workshops.

Third, we must build environments that are collegial in practice, not merely in name. Physicians and nurses must work within a shared paradigm of evidence-based medicine and extend each other the presumption of good intent. When there is absent trust, devaluing of one another's humanity, and nonexistent mutual goodwill, there will be no patient safety. Moreover, when presenting to care, patients and their families must be educated on what is acceptable and respectable behavior. Health systems should strive not to allow patients’ and their families’ disrespectful behavior to undermine medical treatment across the clinical spectrum.

Fourth, health care systems must concertedly invest in themselves. When individuals are asked to work in financially strained, resource-limited conditions, it should surprise no one when they act in ways we would otherwise deem “unprofessional.” Underresourcing is not a neutral backdrop to mistreatment; it is one of its engines.

The civil rights activist Eldridge Cleaver said the following: “There is no more neutrality in the world. You either have to be part of the solution, or you're going to be part of the problem.”⁹ Our trainees deserve our commitment to mistreatment mitigation. The article by Keller et al³ really shines a light on the mistreatment our trainees are sustaining today. It is our responsibility to stop this. Insanity is doing the same thing incessantly and expecting different results. Enough is enough.