Bullying and harassment in medical schools

Recent changes in undergraduate medical education have been rapid and profound. Faced with the explosion of knowledge, ongoing technological advances, patients' changing expectations, the recognition of health inequalities worldwide, and better understanding of educational theory, medical educators have striven to provide undergraduate programmes that equip students with basic knowledge, skills, and attitudes that recognise their immediate progression into independent practice and their need to develop skills as lifelong learners.

What remains familiar at the core of medical education is exposure to patients with their multifaceted problems and the experience of health care at the point of delivery. Sadly, clinical practice also exposes medical students to some of the best recognised yet least easily solved problems in medical education: bullying and harassment. A study by Frank and colleagues in this week's BMJ reports the experiences of US medical students of this important but uncomfortable issue that needs to be tackled.¹

Bullying and harassment occur in all organisations, although rates seem to be higher in healthcare institutions,²,³ and such behaviour may be more common in medical faculties than in other higher education departments.⁴ Many definitions of bullying and harassment exist,⁵,⁶ and can be categorised into threats to professional status, threats to personal standing, isolation, overwork, and effects on self confidence. In all cases bullying behaviour is persistent, malicious, and undermining. It has important effects on the psychological wellbeing of the bullied and harassed person in terms of future performance, career choice, and retention within the profession.

Frank and colleagues describe the extent to which belittlement and harassment were reported by medical students in the United States in a large study of more than 2300 students from16 medical schools at three different time points in their studies.¹ By the end of the course 85% of students reported having been harassed or belittled and 40% had experienced both. These findings were not influenced by ethnic origin or gender. The perpetrators included other students and patients, but residents and attending doctors or clinical professors were most often to blame. In all, 13% of respondents reported these incidents to be severe.

The authors asked about specific groups of medical staff and patients but not about other healthcare professionals. In a recent cross sectional survey by the British Medical Association of 297 UK medical students,⁷ bullying was reported, but UK students held nurses (a group not reported in the US study) to be the second most likely perpetrators. Interestingly, rates of bullying and harassment were much lower among UK students than US ones—83% reported no incidents through their entire medical school career.

These data and the results of numerous other studies should be interpreted with caution. Many studies are small, cross sectional, and conducted by faculty members of the students' institution; others ask for specific instances of abuse such as sexual harassment or racism. In general, bullying and harassment are more commonly reported by female students. However, the high rate of reported incidents of bullying in Frank and colleagues' study is striking.¹

Medical students in the US tend to be older than their UK counterparts and may have a greater awareness of unacceptable professional behaviour or a lower threshold of tolerance. Other cultural, educational, and contextual differences may underpin the results from the US. Given that the incidence of bullying and harassment in the United Kingdom's health service is high,² it is unlikely that UK medical students are not exposed to these behaviours. Most probably UK students develop coping strategies such as peer support, deliberate intervention in teaching sessions, or ignoring unwanted events as they arise.⁸

Not all students have the psychological characteristics to respond in this way, however, and those that do may perpetuate the problem as they qualify and move into the workforce. Other students may be reluctant to report incidents of harassment, may just regard it as normal behaviour, or may even think that harassment and humiliation are useful educational experiences.⁹ On the contrary, it is clear from the available evidence that bullying and harassment can have profoundly negative effects. Severe harassment and belittlement may be associated in students with higher rates of alcohol misuse, depression, and suicidal intent and with lower satisfaction with their chosen career as a doctor.¹

It is not easy to prevent bullying and harassment in the workplace. It requires people to moderate their behaviour so that they become positive role models and demands considerable changes in institutional culture. The negative impact that bullying and harassment have on the wellbeing of students and doctors, overall morale in the medical workforce, and recruitment and retention in the profession demand our continuing efforts to resolve these problems.