Abstract
This study assesses the prevalence of bullying and barriers to its eradication among US surgeons.
Workplace incivility is well known among surgeons; there are stories of instrument throwing, verbal tirades, and sexual harassment.1,2 Fear of humiliation and bullying is strong among medical students,3 and examples of student mistreatment almost invariably involve some surgical anecdote. These stories may reflect a specialty culture of acceptance and a code of silence that facilitate bullying at the workplace.
There is no consensus definition of bullying, but an operational one for this study is “a situation where one or several individuals persistently over a period of time perceive themselves to be on the receiving end of negative actions from one or several persons”4; such interactions usually involve a power differential.5,6 Not all unprofessional conduct involves bullying, and the lack of a practical standard definition has made it difficult to assess its prevalence among surgeons.
Anecdotally, workplace bullying is a common occurrence among surgeons, but little is known about its prevalence and effect. The aim of this study is to assess the prevalence of bullying and barriers to its eradication among US surgeons.
Methods
US surgeons from 4 societies (Association for Academic Surgery [n = 2732], Resident and Associate Society of the American College of Surgeons [unknown distribution sample size], Association for Surgical Education [n = 2480], and Society of University Surgeons [n = 1235]) were invited to participate in an anonymous, online survey using the Negative Acts Questionnaire–revised (NAQ-R). The survey consisted of questions about demographics, NAQ-R, and institutional policies and perceptions. The NAQ-R is a validated instrument measuring bullying in diverse workplaces5 that consists of 22 questions about the frequency with which one personally experienced negative acts (listed as observable behaviors) using a Likert-type scale (1 indicates never; 2, now and then; 3, monthly; 4, weekly; 5, daily). In addition, this instrument also asks whether participants have witnessed others being bullied within the last 6 months. Participants are also asked about the source of bullying and barriers to reporting bullying. NAQ-R scores are presented as mean (SD). This study was approved by the institutional review board at Yale School of Medicine and deemed exempt. Participants were provided informed electronic consent. Multivariate logistic regression was used to assess factors associated with bullying. Data were collected from July to August 2018, and analysis began September 2018.
Results
Of 775 respondents, 180 (23.2%) were residents. Most faculty respondents were male (345 [58%]) and from universities (481 [81.0%]); 204 (36%) were professors. The mean (SD) NAQ-R score was 40.3 (17.8) among residents and 34.8 (14.7) among faculty (scores >34 suggest risk of bullying). Female sex was associated with being bullied after adjusting for other participant characteristics (odds ratio, 1.98; 95% CI, 1.45-2.70). A total of 59 residents (39.9%) and 212 faculty (40.0%) reported being bullied, and 83 residents (58.5%) and 283 faculty (54.3%) witnessed bullying. Reasons cited for bullying included stressful work, strict hierarchy, and lack of institutional policy. Barriers to reporting included negative effect on career, reputation, and additional bullying. Eight residents (20.0%) and 38 faculty (24.4%) experienced retaliation after reporting (Table 1), while 83 residents (60.6%) and 242 attending physicians (48.4%) reported no institutional policy against bullying (Table 2). Overall, 118 residents (85.5%) and 411 attending physicians (82%) valued 360° evaluations.
Table 1. Experiences With and Barriers to Reporting for Personal Bullyinga.
| Question | Option | No. (%) | |
|---|---|---|---|
| Resident | Attending physician | ||
| Did you seek to address bullying behavior in any of the following ways? | No, I have not tried to address the bullying behavior. | 18 (30.00) | 42 (20.10) |
| I addressed it directly with the person. | 14 (23.33) | 86 (41.15) | |
| I brought to the attention of my supervisor or manager. | 17 (28.33) | 92 (44.02) | |
| I made an informal or formal complaint to human resources. | 4 (6.67) | 34 (16.27) | |
| I discussed it with a peer. | 37 (61.67) | 126 (60.29) | |
| I discussed it with a senior colleague or mentor. | 16 (26.67) | 90 (43.06) | |
| I discussed with family, friends, or personal network. | 35 (58.33) | 125 (59.81) | |
| I discussed with a lawyer or legal service. | 2 (3.33) | 31 (14.83) | |
| I referred to police. | 0 (0.00) | 1 (0.48) | |
| What was the result of the action(s) you took as identified? | Complaint has not yet been finalized. | 4 (10.00) | 20 (12.82) |
| Complaint was not pursued by the receiving body. | 11 (27.50) | 43 (27.56) | |
| I received an apology. | 5 (12.50) | 10 (6.41) | |
| My employer made changes to the workplace to prevent this behavior in the future. | 5 (12.50) | 11 (7.05) | |
| This behavior stopped. | 4 (10.00) | 20 (12.82) | |
| This behavior continued. | 20 (50.00) | 84 (53.85) | |
| There was retaliation for making a complaint. | 8 (20.00) | 38 (24.36) | |
| I left my job. | 1 (2.50) | 23 (14.74) | |
| Did you experience any of the following as potential barriers in your decision about whether to take action or not? | Effect on future career options | 43 (79.63) | 132 (71.35) |
| Potential for victimization | 28 (51.85) | 70 (37.84) | |
| Concern of not being believed or taken seriously | 22 (40.74) | 92 (49.73) | |
| Loss of reputation for self | 42 (77.78) | 104 (56.22) | |
| Loss of reputation for perpetrator | 7 (12.96) | 15 (8.11) | |
| Fear of being blamed | 23 (42.59) | 66 (35.68) | |
| Loss of support | 31 (57.41) | 83 (44.86) | |
| The stress associated with filing a complaint | 26 (48.15) | 92 (49.73) | |
Per the Negative Acts Questionnaire–Revised, bullying is defined as “a situation where one or several individuals persistently over a period of time perceive themselves to be on the receiving end of negative actions from one or several persons, in a situation where the target of bullying has difficulty in defending him or herself against these actions. We will not refer to a one-off incident as bullying.”4
Table 2. Perspectives on Institutional Environment.
| Question | Option | No. (%) | P value | |
|---|---|---|---|---|
| Resident | Attending physician | |||
| Is there a policy in place to specifically address bullying behavior? | Yes | 54 (39.42) | 258 (51.60) | .01 |
| No | 83 (60.58) | 242 (48.40) | NA | |
| Why do you think bullying occurs among surgeons at the workplace? | Stressful work | 99 (72.26) | 301 (60.93) | NA |
| Strict hierarchy | 93 (67.88) | 199 (40.28) | ||
| Lack of institutional policy | 33 (24.09) | 124 (25.10) | ||
| Accepted culture | 115 (83.94) | 342 (69.23) | ||
| Tradition | 67 (48.91) | 188 (38.06) | ||
| Other | 9 (6.57) | 75 (15.18) | ||
| Do you think all department leadership should undergo 360° evaluations to assess professionalism? | Definitely yes | 81 (58.70) | 313 (62.48) | .16 |
| Probably yes | 37 (26.81) | 98 (19.56) | NA | |
| Might or might not | 15 (10.87) | 52 (10.38) | ||
| Probably not | 3 (2.17) | 31 (6.19) | ||
| Definitely not | 2 (1.45) | 7 (1.40) | ||
Abbreviation: NA, not applicable.
Discussion
In this study, bullying was reported to be common among participants, and most did not report to leadership fearing negative consequences. Perhaps the most important findings were the lack of reporting and the fear of retaliation. This study is limited by lack of response rate and potential for participant bias. Work remains to be done in this field and will likely take the collaborative efforts of the academic medical community to eradicate surgical workplace bullying.
References
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