Systematic review of academic bullying in medical settings: dynamics and consequences

Abstract

Purpose

To characterise the dynamics and consequences of bullying in academic medical settings, report factors that promote academic bullying and describe potential interventions.

Design

Systematic review.

Data sources

We searched EMBASE and PsycINFO for articles published between 1 January 1999 and 7 February 2021.

Study selection

We included studies conducted in academic medical settings in which victims were consultants or trainees. Studies had to describe bullying behaviours; the perpetrators or victims; barriers or facilitators; impact or interventions. Data were assessed independently by two reviewers.

Results

We included 68 studies representing 82 349 respondents. Studies described academic bullying as the abuse of authority that impeded the education or career of the victim through punishing behaviours that included overwork, destabilisation and isolation in academic settings. Among 35 779 individuals who responded about bullying patterns in 28 studies, the most commonly described (38.2% respondents) was overwork. Among 24 894 individuals in 33 studies who reported the impact, the most common was psychological distress (39.1% respondents). Consultants were the most common bullies identified (53.6% of 15 868 respondents in 31 studies). Among demographic groups, men were identified as the most common perpetrators (67.2% of 4722 respondents in 5 studies) and women the most common victims (56.2% of 15 246 respondents in 27 studies). Only a minority of victims (28.9% of 9410 victims in 25 studies) reported the bullying, and most (57.5%) did not perceive a positive outcome. Facilitators of bullying included lack of enforcement of institutional policies (reported in 13 studies), hierarchical power structures (7 studies) and normalisation of bullying (10 studies). Studies testing the effectiveness of anti-bullying interventions had a high risk of bias.

Conclusions

Academic bullying commonly involved overwork, had a negative impact on well-being and was not typically reported. Perpetrators were most commonly consultants and men across career stages, and victims were commonly women. Methodologically robust trials of anti-bullying interventions are needed.

Limitations

Most studies (40 of 68) had at least a moderate risk of bias. All interventions were tested in uncontrolled before–after studies.

Strengths and limitations of this study.

• This systematic review is comprehensive, including 68 studies with 82 349 consultants and trainees, across several countries and including all levels of training.

• We defined inclusion criteria a priori and used established tools to assess the risk of bias of included studies.

• The included studies varied in their definitions of bullying, sampling bias was noted among the surveys and intervention studies were suboptimally designed.

Background

Bullying behaviours have been described as repeated attempts to discredit, destabilise or instil fear in an intended target.¹ Bullying can take many forms from overt abuse to subtle acts that erode the confidence, reputation and progress of the victim.² Bullying is common in medicine, likely impacting mental health, professional interactions and career advancement.^3–6 It may also impact a physician’s ability to care for patients.⁷ Surveys from the National Health Service (NHS) in the UK showed that 55% of staff experienced at least one type of bullying; 31% were doctors in training.⁸ Bullying is closely related to harassment and discrimination, in which mistreatment is based on personal characteristics or demographics such as sex, gender or race.⁹ Within academic settings, victims may experience all three and the distinction may be less clear. Unlike harassment and discrimination, which have specific legal definitions, bullying is an amorphous term and victims are often left without legal recourse.

The hierarchical structure of academic medicine—in which there are power imbalances, subjective criteria for recruitment and career advancement, and siloed departments with few checks in place for toxic behaviours—may offer an operational environment in which bullying may be more widespread than in non-academic medical settings. Academic bullying is a seldom-used term within the literature, but is intended to describe the forms of bullying that may exist in academic settings. Academic bullying can be defined as mistreatment in academic institutions with the intention or effect of disrupting the academic or career progress of the victim.¹⁰ The prevalence of academic bullying in medical settings is unknown likely due to a lack of definition of bullying behaviours, a fear of reporting and insufficient research. There is not much known about the characteristics of perpetrators and victims, and about the impact of bullying on academic productivity, career growth and patient care. Furthermore, institutional barriers and facilitators of bullying behaviour have not been reported, and the effectiveness of interventions in addressing academic bullying has not been evaluated.

The purpose of this systematic review is to define and classify patterns of academic bullying in medical settings; assess the characteristics of perpetrators and victims; describe the impact of bullying on victims; review institutional barriers and facilitators of bullying; and identify possible solutions.

Methods

Data sources and searches

This study followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. Two reviewers (TA, YE) searched two online databases (EMBASE and PsycINFO) for English-language articles published between 1 January 1999 and 7 February 2021, and relevant to academic bullying in medicine. An outline of the search is provided in figure 1. A combination of medical subject heading, title, and abstract text terms encompassing ‘Medicine’; ‘Bullying’ and ‘Academia’ were used for the full search. The terms of the search are included in online supplemental figure S1. Two authors (TA, YE) independently screened articles for inclusion. Differences were resolved by discussion, and if necessary, by a third author (HGCVS).

Figure 1.

PRISMA diagram of included studies. We identified 68 articles relevant to academic bullying. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Study selection

We included studies conducted in academic medical settings in which victims were either consultants or trainees. We defined academic medical settings as hospitals or clinics that were either university affiliated or involved trainees. In the case of preclinical medical students, academic medical settings included the university where medical instruction took place. Studies were included if they described: the method and impact of bullying; the characteristics of perpetrators and victims; or interventions used to address the bullying. Studies that included trainees or consultants in both academic and non-academic settings were included. We excluded editorials, opinion pieces, reviews, conference abstracts, theses, dissertations and grey literature.

Data extraction and quality assessment

Two reviewers (TA, YE) independently extracted data on: study design, setting (academic or non-academic), definition, description and impact of academic bullying, characteristics of perpetrators and victims, barriers and facilitators of bullying, and interventions and their outcomes. Two reviewers independently assessed studies for risk of bias. We assessed before–after studies using the National Heart, Lung, and Blood Institute quality assessment tool¹¹ and assessed prevalence surveys using the Joanna Briggs Institute critical appraisal tool.¹² We classified survey studies as low risk of bias if at least 8 of 9 criteria were met, medium risk of bias if 7 of 9 were met, and high risk of bias if less than 7 were met. We classified bias in before–after studies as low if at least 11 of 12 criteria were met, medium if at least 9 of 12 were met, and high if less than 9 were met.

Data synthesis and analysis

We developed a definition for academic bullying through narrative synthesis of the definitions provided by studies included in this systematic review. We pooled the results of surveys on the basis of similarity of survey themes to facilitate a descriptive analysis. For survey studies on the prevalence or impact of bullying, we solely pooled the results of studies that asked respondents about specific bullying behaviours or impacts, respectively. We then separated results by gender and level of training. We classified groups ensuring consensus between authors. We presented our results as numbers and percentages. We calculated the denominators from the total number of individuals who completed surveys on types of bullying behaviours, the impact of bullying, characteristics of bullies and victims, or barriers to addressing academic bullying. The numerators were calculated from the number of individuals who experienced a specific behaviour or impact, were bullied by a perpetrator at a specified level of training or endorsed a specific reason for not making a formal report. We also reported the number of studies that described each specific bullying behaviour or impact, demographic characteristics of victims and perpetrators, barriers and facilitators of academic bullying, and specific reasons for not making a formal report. We could not perform a meta-analysis due to the conceptual heterogeneity between studies.

Patient and public involvement

Patients or the public were not involved in the design, conduct, reporting or dissemination plans of our research.

Results

Screening results

We identified 1342 unique articles, 68 of which met inclusion criteria. Reasons for exclusion are described in figure 1.

Characteristics of included studies

Studies were most frequently set in the USA (reported in 31 studies)^{3 13–41} and the UK (reported in 5 studies)^{8 42–45} and were set in academic hospitals (reported in 54 studies)1 3–6 13–15 17 19–21 23 24 26 27 29 30 32–35 37–39 41–65 at both teaching and non-teaching sites (reported in 14 studies).8 16 25 28 36 40 66–73 Twenty-five studies included medical students,3–5 13 15 21 22 24 26 33–35 37 39 48 50 52 57–60 63 64 74 75 27 included residents or fellows1 14 16–18 20 22 23 25 27–32 44 45 49–51 55 56 61 62 65 69 72 and 25 included consultants6 8 16 19 20 25 28 36 38 40–43 46 47 53 66–73 75 (table 1).

Table 1.

Summary of studies investigating bullying in academic medicine

Author (year), country	Study design	Setting	Definition of academic bullying	Target	Perpetrator	Source of bias	Risk of bias
Huber et al (2020), USA18	Survey	Academic and non-academic hospitals	Data not provided	Residents	Consultant (83.0%) and resident (63.0%)	Inadequate sample size	Low
Hammoud et al (2020), USA22	Survey	Academic hospitals	Study-based graduation questionnaire	Residents and medical students	For resident victims: consultant (58.7%), resident (27.9%), nurses (26.4%), other employees (10.2%) and administration (5.4%) For medical student victims: consultant (66.4%), resident (50.9%), nurses (22.4%), other employees (13.8%), administration (5.2%) and students (12.0%)	Low response rate	Low
Balch Samora et al (2020), USA28	Survey	Academic hospitals	A behaviour that a reasonable person would expect might victimise, humiliate, undermine or threaten a person to whom the behaviour is directed	Residents, fellows and consultants	Multiple*	Inappropriate statistical analysis and low response rate	Moderate
Brown et al (2020), Canada65	Survey	Academic hospitals	Gender-based discrimination included belittling remarks, inappropriate comments and jokes, denial of opportunities, and behaviours that are perceived as hostile or humiliating	Residents	Nurses, consultants and residents	Inadequate sample size, analysis not conducted in full coverage of the sample, inappropriate identification of bullying and low response rate	High
Zhang et al (2020), USA29	Survey	Academic and non-academic hospitals	NAQ† used	Residents	Consultants, co-residents, nurses and administrators	Study subjects not described in details	Low
Lind et al (2020), USA26	Before–after	Academic	Public belittlement or humiliation; physical harm; denied opportunities for training or rewards, or receiving lower evaluations or grades, based solely on gender; and being subjected to racially or ethnically offensive remarks	Medical students	Data not provided	Unblinded outcome assessors, small sample size, high loss to follow-up and analysis of change score not applied	High
Colenbrander et al (2020), Australia64	Survey	Academic hospitals	Data not provided	Medical students	Data not provided	Inadequate sample size, analysis plan, data analysis coverage and unreliable measurement of bullying	High
Iqbal et al (2020), Pakistan68	Survey	Academic and non-academic hospitals	NAQ† used	Consultants	Data not provided	Inadequate sample size and statistical analysis	Moderate
Elghazally and Atallah (2020), Egypt63	Survey	Academic	Behaviour that is intended to cause physical or psychological damage due to the imbalance of power, strength or status between the aggressor and the victim	Medical students	Professors (30.1%), students (51.2%) and staff (18.7%)	None	Low
Raj et al (2020), USA19	Survey	Academic	Harassment defined as unwanted sexual advances, subtle bribery to engage in sexual behaviour, threats to engage in sexual behaviour or coercive advances*	Consultants	Data not provided	None	Low
Kemper and Schwartz (2020), USA17	Survey	Academic and non-academic hospitals	Data not provided	Residents	Faculty (43.0%), clinical staff (60.0%), resident (28.0%), medical student (3.0%) and admin (9.0%)	None	Low
Stasenko et al (2020), USA16	Survey	Academic and non-academic hospitals	Harassment is defined as an unwelcome sexual advances or other forms of physical and verbal aggression that is sexual in nature	Consultants and fellows	Data not provided	Low response rate	Low
Afkhamzadeh et al (2019), Iran75	Survey	Academic hospitals	Physical or verbal violence, or bullying	Medical students and consultants	Data not provided	None	Low
Wolfman and Parikh (2019), USA32	Survey	Academic and non-academic hospitals	Repeated negative actions and practices that are carried out as a deliberate act or unconsciously; these behaviours cause humiliation, offence and distress to the target	Residents	Data not provided	Inappropriate sampling frame, and identification of bullying condition, low response rate	High
Chowdhury et al (2019), USA31	Survey	Academic and non-academic hospitals	NAQ† used	Residents	Data not provided	Inadequate sample size, description of subjects and setting and low response rate	High
Ayyala et al (2019), USA30	Survey	Academic and non-academic hospitals	Harassment that occurs repeatedly (>once) by an individual in a position of greater power	Residents	Data not provided	Inappropriate methods of bullying identification	Low
Hu et al (2019), USA27	Survey	Academic and non-academic hospitals	Discrimination and harassment on the basis of gender, race, or pregnancy or childcare	Residents	Consultants (52.4%), admin (1.1%), co-residents (20.2%) and nurses (7.9%)	None	Low
Brown et al (2019), International69	Survey	Academic and non-academic hospitals	Data not provided	Residents or fellow and consultant	Data not provided	Inappropriate methods of bullying identification and low response rate	Moderate
Zurayk et al (2019), USA25	Survey	Academic and non-academic clinics	Study-based sexual experience questionnaire	Consultants and residents	Residents (60.0%), lecturers (33.0%), professors (44.0%), nurses (10.0%) and hospital staff (29.0%)	Inadequate sample size, inappropriate sample frame	Moderate
Castillo-Angeles et al (2019), USA23	Before–after	Academic hospital	Study-based abuse sensitivity questionnaire	Residents	Data not provided	Small sample size, inadequate blinding of outcome assessors and loss to follow-up	High
Kappy et al (2019), USA21	Before–after	Academic hospital	Harassment; discrimination; humiliation; physical punishment; and the use of grading and other forms of assessment in a punitive manner	Medical students	Consultant, co-resident and nurse	Intervention and outcomes not well defined	Moderate
D’Agostino et al (2019), USA20	Survey	Academic and non-academic hospitals	Abuse or harassment particularly of a sexual type	Residents, fellows and attending	Consultants (64.5%), co-resident (38.7%), ancillary staff (25.8%)	Inappropriate methods of bullying identification, inadequate statistical analysis plan and low response rate	High
Chung et al (2018), USA33	Survey	Academic	Feeling of intimidation, dehumanisation, or threat to grade, or career advancement	Medical students	Attending physician (68.4%), resident (26.3%) and nurse (10.5%)	Inappropriate sample methods, non-validated method of bullying identification	High
Kemp et al (2018), USA34	Survey	Academic hospital	Disrespect for the dignity of others that interferes with the learning process	Residents, consultants and fellows	Data not provided	Inadequate statistical analysis plan and low response rate	Moderate
Benmore et al (2018), England42	Before–after	Academic hospital*	Data not provided	Residents	Senior consultants	Insufficient enrolment, inadequate sample size, no blinding of outcome assessors, high loss to follow-up, lack of statistical analysis or ITS design	High
Duru et al (2018), Turkey46	Survey	Academic hospital	Data not provided	Consultants, researchers, administrators, nurses	Specific occupations of bullies not specified	Inappropriate sampling and inadequate sample size	Moderate
Chambers et al (2018), New Zealand47	Survey	Academic and non-academic hospitals	Data not provided	Specialist consultants	Primarily men. Senior medical staff (52.5%), non-clinical managers (31.8%) and clinical leaders (24.9%)	Low response rate	Low
House et al (2018), USA24	Before–after	Academic hospital	Data not provided	Medical students	Faculty most frequently were the source of bullying followed by residents. Exact breakdown not specified	Insufficient enrolment, inadequate sample size, no blinding of outcome assessors, outcomes not clearly described, lack of statistical analysis, individual-level analysis or ITS design	High
Kulaylat et al (2017), USA5	Survey	Academic hospital	Verbal abuse, specialty-choice discrimination, non-educational tasks, withholding/denying learning opportunities, neglect and gender/racial insensitivity	Medical students	Faculty (57.0%), residents, fellows (49.0%) and nurses (33.0%)	Inappropriate sampling, inadequate sample size, classification bias, and non-validated identification or measurement of bullying	High
Malinauskiene et al (2017), Lithuania6	Survey	Academic hospitals	Data not provided	Family consultants	Supervisor (25.3%), colleague (9.8%), subordinate (2.9%)	Inappropriate sampling, inadequate sample size and coverage bias	Moderate
Chrysafi et al (2017), Greece70	Survey	Academic and non-academic hospitals	Data not provided	Consultants	Surgeons most frequently followed by internal medicine consultants, then radiologists/laboratory consultants	Low response rate and coverage bias	Moderate
Kapoor et al (2016), India58	Survey	Academic hospital	Data not provided	Medical students	Data not provided	Inappropriate sampling and inadequate description of study population	Moderate
Chadaga et al (2016), USA14	Survey	Academic hospitals	NAQ† used	Residents and fellows	Consultants (29.0%), nurses (27.0%), patients (23.0%), peers (19.0%)	Low response rate, inadequate sample size and coverage bias	Moderate
Llewellyn et al (2016), Australia62	Survey	Academic hospitals	Data not provided	Residents	Senior medical staff: (58.3%) in 2015, (60.6%) in 2016 Non-medical staff: (33.2%) 2015, (33.9%) 2016 Manager: (5.2%) in 2015, (1.2%) in 2016 Junior resident: (3.3%) in 2015, (4.3%) in 2016	Low response rate, biased sampling, coverage and classification bias	High
Rouse et al (2016), USA36	Survey	Academic clinics	NAQ used	Family medicine consultants	Data not provided	Low response rate	Low
Shabazz et al (2016), UK43	Survey	Academic and non-academic hospitals	Belittle and undermine an individual’s work; undermining an individual’s integrity; persistent and unjustified criticism and monitoring of work; freezing out, ignoring or excluding and continual undervaluing of an individual’s effort	Gynaecology consultants	Senior consultants (50.9%), junior consultants (22.3%), medical director (4.5%)	Low response rate and classification bias	Moderate
Peres et al (2016), Brazil59	Survey	Academic hospital	Data not provided	Medical students	Data not provided	Low response rate and classification bias	Moderate
Ling et al (2016), Australia49	Survey	Academic hospitals	NAQ used	General surgery residents and consultants	For trainee victims: staff surgeon (48.0%), trainee surgeon (13.0%), admin (13.0%), nurses (11.0%), other consultants (6.0%) For consultant victims: (31.0%) staff surgeons, (28.0%) admin, (13.0%) other consultants, (11.0%) nurses, other (10.0%), trainees (4.0%)	Low response rate	Low
Kulaylat et al (2016), USA37	Before–after	Academic hospital	Data not provided	Medical students	Faculty (57.0%), residents/fellows (49.0%) and nurses (33.0%)	Inadequate sample size, no blinding of outcome assessors	Moderate
Ahmadipour and Vafadar (2016), Iran50	Survey	Academic hospital	Being assigned tasks as punishment, being threatened with an unjustly bad score or failure	Medical students, interns and residents	Data not provided	Inadequate sample size	Low
Jagsi et al (2016), USA38	Survey	Academic hospital	Data not provided	Consultants who won a career advancement award	Data not provided	Inadequate sampling frame and classification bias	Moderate
Crebbin et al (2015), Australia and New Zealand72	Survey	Academic hospitals	Data not provided	Residents, fellows and consultants	Surgical consultants (50.0%), other medical consultants (24.0%) and nursing staff (26.0%)	Low response rate	Low
Cresswell et al (2016), UK44	Before–after	Academic hospital	Data not provided	Residents	Data not provided	Insufficient description of study purpose, inadequate enrolment and sample size, no blinding of outcome assessors, outcomes not clearly described, lack of statistical analysis or ITS design and high loss to follow-up	High
Loerbroks et al (2015), Germany51	Survey	Academic hospitals	Data not provided	Residents	Data not provided	None	Low
Malinauskiene and Bernotaite (2014), Lithuania73	Survey	Non-academic clinics	NAQ used	Family medicine consultants	Bullying from patients (11.8%), from colleagues by (8.4%), from superiors by (26.6%)	None	Low
Mavis et al (2014), USA15	Survey	Academic hospitals	Mistreatment either intentional or unintentional occurs when behaviour shows disrespect for the dignity of others and unreasonably interferes with the learning process	Medical students	Clinical faculty in the hospital (31.0%) residents/interns (28.0%), nurses (11.0%)	Low response rate, inadequate description of study population and statistical analysis	Moderate
Oser et al (2014), USA13	Survey	Academic hospital	Data not provided	Medical students	Residents>clerkship faculty>other attendings>other students>preceptors =nurses	None	Low
Oku et al (2014), Nigeria4	Survey	Academic hospital	Data not provided	Medical students	Medical students (23.7%), consultants (21.7%), lecturers (17.5%), consultants (16.5%), nurses (16.5%), other staff (4.1%)	None	Low
Gan and Snell (2014), Canada60	Survey	Academic hospital	Data not provided	Medical students	Consultants	Low response rate, inappropriate sampling, small sample size and classification bias	High
Fried et al (2015), USA3	Before–after	Academic hospital	Power mistreatment defined as made to feel intimidated, dehumanised, or had a threat made about a recommendation, your grade, or your career	Medical students	Residents (49.7%), clinical faculty (36.9%), preclinical faculty (7.9%)	None	Low
Al-Shafaee et al (2013), Oman48	Survey	Academic hospitals	Being coerced into carrying out personal services unrelated to the expected role of interns and instances in which interns were excluded from reasonable learning opportunities offered to others, or threatened with failure or poor evaluations for reasons unrelated to academic performance	Residents	Internal medicine (60.3%), surgery (29.0%), paediatrics (15.5%), specialists (51.7%), consultants (50.0%), residents (12.1%), nurses (24.1%)	Inappropriate sampling, inadequate sample size, inadequate description of study population and coverage bias	High
Owoaje et al (2012), Nigeria52	Survey	Academic hospital	Data not provided	Medical students	Consultants (69.1%), residents/fellows (52.4%), other students (15.7%), nurses (7.8%), laboratory technicians (4.1%)	Low response rate	Low
Askew et al (2012), Australia66	Survey	Academic and non-academic hospitals	Data not provided	Consultants	Consultants (44.0%), managers (27.0%), patients (15.0%), nurses/midwives (4.0%), junior consultants (1.0%)	Low response rate	Low
Meloni and Austin (2011), Australia53	Before–after	Academic hospital	Data not provided	Hospital employees	Data not provided	Lack of blinding of outcome assessors, high loss to follow-up, lack of statistical analysis or ITS design, and unit of analysis not clearly described	High
Dikmetas et al (2011), Turkey61	Survey	Academic hospital	Data not provided	Residents	Surgeons>internists	Low response rate	Moderate
Eriksen et al (2011), Norway67	Survey	Academic hospital	NAQ used	Hospital employees	Colleagues; specific occupations not described	Low response rate, inappropriate sampling and inadequate statistical analysis	Moderate
Imran et al (2010), Pakistan54	Survey	Academic hospitals	Threats to professional status, threats to personal standing, isolation, overwork and destabilisation	Residents	Consultants	Inappropriate sampling, classification and coverage bias	Moderate
Ogunsemi et al (2010), Nigeria55	Survey	Academic hospital	Data not provided	Residents	Administrative staff (58.0%), from the hospital chief executive (41.4%), from patient relatives (40.4%), nurses (32.7%), residents (30.0%), patients (20.0%)	Inadequate sample size	Low
Best et al (2010), USA39	Before–after	Academic hospital	Data not provided	Unspecified	Data not provided	Study purpose not clearly described, insufficient enrolment, no blinding of outcome assessors, lack of statistical or individual-level analysis or ITS design	High
Nagata-Kobayashi et al (2009), Japan56	Survey	Academic hospitals	Assigned you tasks as punishment; threatened to fail you unfairly in residency; competed maliciously or unfairly with you; made negative remarks to you about becoming a consultant or pursuing a career in medicine	Residents	Surgery (27.6%), internal medicine (21.4%), emergency medicine (11.5%), anaesthesia (11.3%), consultants (34.1%), patients (21.7%), nurses (17.2%)	Low response rate	Low
Scott et al (2008), New Zealand1	Survey	Academic hospital	A threat to professional status and personal standing, isolation, enforced overwork, destabilisation	Residents	Consultants (30.0%), nurses (30.0%), patients (25.0%), radiologists (8.0%), residents/fellows (7.0%)	Low response rate, inadequate sample size and description of study population	Moderate
Gadit and Mugford (2007), Pakistan71	Survey	Academic and non-academic hospitals	Data not provided	Consultants	Senior colleagues	Inadequate sample size	Low
Shrier et al (2007), USA40	Survey	Academic and non-academic hospitals	Data not provided	Consultants	Colleagues (24.0%), patients (19.0%), teachers (18.0%), supervisors (15.0%)	Inappropriate sampling, inadequate sample size and coverage bias	Moderate
Cheema et al (2005), Ireland45	Survey	Academic hospitals	Data not provided	Residents	Senior residents (51.0%–70.0%), nursing staff (47.0%–59.0%), administration (15.0%–16.0%), colleagues (12.0%–13.0%)	Low response rate	Low
Rautio et al (2005), Finland57	Survey	Academic hospital	Data not provided	Medical students	Lecturers (27.9%), research/senior research fellows (27.7%), professors (16.6%), associate professors (13.6%)	Low response rate, inappropriate sampling, inadequate sample size and coverage bias	High
Wear and Aultman (2005), USA35	Survey	Academic hospital	Data not provided	Medical students	General surgeons and obstetricians	Low response rate, inappropriate sampling, inadequate sample size, classification and lack of validated measurement tool	High
Carr et al (2000), USA41	Survey	Academic hospitals	Data not provided	Consultants	Superiors and colleagues	None	Low
Quine (1999), UK8	Survey	Non-academic clinics	Data not provided	Consultants	54.0% greater seniority, 34.0% same seniority, 12.0% less senior; 49.0% of bullies older than victims	None	Low

Academic hospitals/clinics were defined as teaching hospitals/clinics with a university affiliation.

*Regarding sexual harassment: the most common sources were attending surgeons (69% overall, 71% women, 18% men); trainees (46% overall, 47% women, 9% men); attending non-surgical (22%, 22% women, 18% men); other allied health professionals (16%, 15% women, 36% men); nursing (14%, 12% women, 73% men); admin staff (4%, 2% women, 36% men). Regarding harassing behaviours: the most common sources were attending orthopaedic surgeons (76% overall, 75% women, 86% men); trainees (30%, 32% women, 14% men); attending physicians; non-surgical (eg, anaesthesiologist, internist) (20%, 21% women, 11% men); nursing staff (18%,18% women, 20% men); administration staff (13%, 12% women, 17% men); and other allied health professionals (9%, 10% women, 9% men).

†The NAQ is a validated tool for assessing the prevalence of workplace bullying.

ITS, interrupted time series; NAQ, Negative Acts Questionnaire.

Definition of academic bullying

Six papers provided definitions for academic bullying.33 48 50 56 58 63 Common behaviours included abusing and punishing the victim through overwork, isolation, blocked career advancement and threats to academic standing. Thus, we defined academic bullying as the abuse of authority by a perpetrator who targets the victim in an academic setting through punishing behaviours that include overwork, destabilisation, and isolation in order to impede the education or career of the target. Multiple studies used the complete or partial Negative Acts Questionnaire, a standardised list of bullying behaviours (reported in 24 studies).1 3 4 6 13–15 24 29 31 36 47–52 54 55 57 60 61 67 73

Patterns of academic bullying behaviours

There were 35 779 consultant and trainee respondents to surveys of bullying behaviours (reported in 28 studies), but not all were offered the same options to select from (table 2). Bullying behaviours were grouped into destabilisation (reported in 15 studies), threats to professional status (reported in 23 studies), overwork (reported in 7 studies) and isolation (reported in 17 studies). Undue pressure to produce work was commonly reported (38.2% of respondents affected, reported in 7 studies).14 36 45 47 49 54 67 Of the 15 studies that described destabilisation, common methods included being ordered to work below one’s competency level (36.1%, reported in 10 studies)31 36 45 47–49 52 67 71 72 and withholding information that affects performance (30.7%; reported in 9 studies).14 29 31 36 47–49 54 67 Of the 23 studies that described threats to professional status, common methods were excessive monitoring (28.8%; reported in 6 studies)14 36 47 49 54 67 and criticism (26.9%; reported in 12 studies).14 21 29 36 45 47 49 52 54 67 71 72 Of the 17 studies that described isolation, the most common method was social and professional exclusion (29.1%; reported in 17 studies).4 14 21 24 29 31 36 40 47–49 52 54 63 67 70 72

Table 2.

Self-reported description of specific bullying behaviours

Behaviour	No of studies/ total studies*	Total cohort No affected/total participants who completed surveys on behaviours (%)*	Men No affected/total men who completed surveys on behaviours (%)†	Women No affected/total women who completed surveys on behaviours (%)†
Threats to professional status
Persistent unjustified criticism	12/28	4495/16 700 (26.9)	535/1690 (31.7)	552/1402 (39.4)
Excessive monitoring of work	6/28	1752/6079 (28.8)	442/1525 (27.7)	441/1298 (34.0)
Intimidatory use of discipline	15/28	1531/19 471 (7.9)	366/2381 (15.4)	363/2209 (16.4)
Spread of gossip/rumours	7/28	2977/10 060 (29.6)	88/596 (14.8)	94/453 (20.8)
False allegations	6/28	613/3796 (16.1)	59/596 (9.9)	54/453 (11.9)
Refusal of leave, training or promotion	9/28	1604/8551 (18.8)	296/2594 (11.4)	458/2340 (19.6)
Isolation
Social/professional exclusion	17/28	6160/21 099 (29.1)	420/2027 (20.7)	1064/2814 (37.8)
Overwork
Undue pressure to produce work	7/28	2509/6562 (38.2)	233/1525 (15.3)	355/1570 (22.6)
Setting impossible deadlines	6/28	1571/6079 (25.8)	164/1525 (10.8)	189/1298 (14.6)
Destabilisation
Shifting goalposts	1/28	54/417 (12.9)	Not reported	Not reported
Removal of areas of responsibility without consultation	8/28	1397/6193 (22.6)	160/1525 (10.5)	171/1298 (13.2)
Withholding information that affects performance	9/28	3836/12 503 (30.7)	219/1553 (14.1)	267/1328 (20.1)
Ordered to work below one’s competence level	10/28	2934/8119 (36.1)	81/625 (13.0)	99/483 (20.5)

*Total number of studies that described types of bullying behaviours, including studies that did not stratify results by sex. As a result, the denominator for the number of participants in total is not the sum of the denominators for men and women. The denominator was calculated from the total number of individuals who completed surveys on specific bullying behaviours, while the numerator was calculated from the number of individuals who indicated they experienced the specified bullying behaviour. Not all survey studies offered respondents the same options to respond to, and as a result the denominators for each bullying behaviour differ.

†Of the studies that separated data by gender or solely included the results of one gender and included the specified bullying behaviour.

There were 6179 consultant and trainee respondents to surveys that separated the prevalence of bullying behaviours by gender (reported in 11 studies). A greater proportion of women experienced all bullying behaviours (reported in 11 studies)14 16 19 22 36 40 48 52 57 63 65 (table 2). There were 34 175 respondents to surveys that analysed results by level of training (reported in 24 studies) (online supplemental table S1). A greater proportion of consultants experienced refusal of applications for leave, training or promotion (26.3%, reported in 3 studies),^{19 36 47} and removal of areas of responsibility (27.8%, reported in 2 studies)^{36 47} than residents (11.0%, reported in 3 studies; 10.7%, reported in 3 studies, respectively)14 22 54 55 or medical students (13.4%; 19.6%, reported in 1 study).^{22 24} Compared with medical students (4.6%, reported in 6 studies)13 15 22 24 52 57 and consultants (3.4%, reported in 2 studies),^{36 71} a greater proportion of residents experienced the intimidatory use of discipline procedures (17.8%, reported in 6 studies).14 22 48 54 55 65 A greater proportion of medical students experienced persistent criticism (66.4%, reported in 2 studies)^{21 52} than residents (28.3%, reported in 5 studies)14 29 45 54 72 and consultants (20.8%, reported in 3 studies).^{36 47 71}

Characteristics of bullies

Thirty-one unique studies representing 15 868 consultants and trainees described the characteristics of bullies, although not all were offered the same options to select from. Common perpetrators included consultants (53.6%, reported in 30 studies),1 3 4 6 8 14 15 17 18 20 22 27 28 33 37 40 43 45 47–49 52 54 56 60 62 63 66 72 73 residents (22.0%, reported in 22 studies)1 3 6 8 15 17 18 20 22 25 27 28 33 37 45 48 49 54 56 60 62 and nurses (14.9%, reported in 21 studies).1 3 4 14 15 17 20 22 25 27 28 33 37 45 48 49 54 56 60 62 73 Of the 4277 individuals who identified the gender of their bullies, most reported primarily men (67.2%, reported in 5 studies),8 36 43 47 72 followed by primarily women (26.1%, reported in 5 studies),8 36 43 47 72 and both (6.7%, reported in 3 studies).^{8 43 47} Among 6084 medical students, perpetrators were commonly consultants (43.1%, reported in 8 studies),3 4 15 22 33 37 52 60 residents (35.7%, reported in 6 studies),3 15 22 33 37 60 nurses (12.4%, reported in 7 studies)3 4 15 22 33 37 60 and other medical students (8.8%, reported in 5 studies).3 4 22 52 63 Among 6289 residents, perpetrators were commonly consultants (52.2%, reported in 12 studies),1 14 17 18 22 27 45 48 49 54 56 62 nurses (24.3%, reported in 11 studies)1 14 17 22 27 45 48 49 54 56 62 and other residents (20.6%, reported in 12 studies).1 14 17 18 22 27 45 48 49 54 56 62 Of the 1500 consultants, perpetrators were their peers (39.2%, reported in 7 studies),6 8 40 47 49 66 73 senior consultants (23.7%, reported in 5 studies)6 8 40 43 73 and administration (17.7%, reported in 4 studies).43 47 49 66

Six unique studies representing 1698 interns and medical students described the prevalence of academic bullying according to the specialty rotation of the learner. Academic bullying was common in surgery (32.9% of respondents, reported in 6 studies),1 13 34 48 56 60 72 obstetrics and gynaecology (25.5%, reported in 2 studies)^{13 60} and internal medicine (21.4%, reported in 5 studies).1 13 48 56 60 72

Characteristics of victims

Forty-one unique studies described the characteristics of victims, and 29 included the proportion of those who experienced bullying. Of the 15 704 women and 19 495 men who responded to surveys that analysed results by gender, women were more likely to report being bullied than men (54.6% of all women compared with 34.2% of all men, reported in 27 studies).3 4 14 16 17 19 20 27 28 36 38 41 47–52 55–57 62 63 65 69 72 75 There were 10 730 consultant and trainee respondents to surveys that separated the results by demographic characteristics other than gender, but not all characteristics were captured by each study. A greater proportion of international graduates/non-citizens experienced bullying than citizens (48.0% compared with 43.3%, reported in 4 studies),14 17 45 72 and a greater proportion of overweight participants (body mass index (BMI) >25) experienced bullying than those with a BMI ≤25 (17.8% compared with 11.8%, reported in 1 study).⁵¹ The relationship between age and bullying varied based on the cut-off used and the survey sample in each study. Among consultants, a greater proportion of those with full professorship experienced bullying than assistant professors (68.0% compared with 51.9%, reported in study).⁴¹

Impact of academic bullying

There were 24 894 consultant and trainee respondents to surveys on the psychological (reported in 20 studies) and career impact (reported in 25 studies) of academic bullying (table 3), although not all were offered the same options to select from. Respondents commonly reported psychiatric distress (39.2%; reported in 14 studies),6 17 18 27 29 30 43 47 52 56 59 62 71 73 considerations of quitting (35.9%; reported in 7 studies)25 31 43 47 66 70 72 and reduced clinical ability (34.6%; reported in 8 studies).25 30 31 45 47 52 56 59 Respondents agreed that academic bullying negatively affected patient safety (68.0%; reported in 2 studies).^{18 31} Nine studies representing 13 418 individuals described the impact of bullying according to gender (table 3). A greater proportion of women experienced loss of career opportunities (43.6%, reported in 8 studies),16 19 36 38 40 41 52 65 while a greater proportion of men experienced decreased confidence (32.1%, reported in 2 studies)^{41 52} and clinical ability (26.1%, reported in 1 study).⁵²

Table 3.

Self-reported impact of academic bullying

Effect of academic bullying	No of studies/ total studies*	Total cohort No of affected participants/total participants who completed surveys on the impact of bullying (%)*	Men No of affected men/total men who completed surveys on the impact of bullying (%)†	Women No of affected women/total women who completed surveys on the impact of bullying (%)†
Psychological
Psychological distress including depressive/PTSD symptoms	14/33	5597/14 285 (39.1)	1750/5172 (33.8)	1636/3529 (46.4)
Reduced confidence in clinical skill	8/33	564/2112 (26.7)	68/212 (32.1)	97/597 (16.2)
Career
Missed career opportunities	17/33	2823/9442 (29.9)	357/1898 (18.8)	1104/2530 (43.6)
Considerations of quitting	7/33	1034/2880 (35.9)	Not reported	Not reported
Termination of employment	5/33	228/4419 (5.2)	4/139 (2.9)	4/150 (2.7)
Leave of absence	2/33	50/748 (6.7)	Not reported	Not reported
Self-reported worsening of clinical performance	8/33	1673/4841 (34.6)	42/161 (26.1)	22/101 (21.8)

*Total number of studies that described the impact of bullying, including studies that did not stratify results by gender. Not all participants were given the same options to select from.

†Of the studies that separated data by gender or solely included the results of one gender and included the impact of bullying.

PTSD, post-traumatic stress disorder.

There were 16 523 consultant and trainee respondents to surveys that separated results by level of training (online supplemental table S2). A greater proportion of medical students experienced psychiatric distress (72.9%; reported in 2 studies)^{52 59} than residents (40.8%; reported in 6 studies)17 18 29 30 56 62 and consultants (17.9%; reported in 4 studies).43 47 71 73 A greater proportion of residents endorsed loss of career opportunities (35.0%; reported in 3 studies)^{55 65 72} compared with medical students (16.0%; reported in 3 studies)^{13 15 52} and consultants (30.6%; reported in 8 studies).19 36 38 40 41 47 70 71

Barriers and facilitators of academic bullying

Thirty-five unique studies pertained to barriers to victims making a formal report (reported in 26 studies) and institutional facilitators (reported in 25 studies) of academic bullying (table 4). There were 9239 consultant and trainee respondents to surveys on their actions taken in response to bullying and reasons for not making a formal report, although not all were given the same options to select from. Victims commonly did not formally report the bullying1 3 4 15 36 43 47 49 50 54 56 60 62 66 72; only 28.9% of respondents made a formal report. Deterrents to reporting included concern regarding career implications (41.1%; reported in 15 studies),1 4 15 25 28 35 47 48 50 56 62 65 66 70 72 not knowing who to report to (26.5%; reported in 15 studies)1 4 16 22 25 33 47 48 50 56 62 65 66 70 75 and poor recognition of bullying (11.4%; reported in 5 studies).5 15 25 33 35 37 42 48 56 Of the 26 studies, 7 studies representing 1139 individuals reported the outcomes of reporting1 36 43 47 49 65 72 although only a small range of outcomes were offered among options. Submitting a formal report often had no perceived effect on bullying (35.6%; reported in 5 studies)36 43 47 49 72; a greater proportion of victims endorsed worsening (21.9%; reported in 3)^{36 49 65} than improvement (13.7%; reported in 5 studies)1 36 43 49 72 in bullying following reporting.

Table 4.

Barriers to addressing academic bullying

Barrier	No of studies/total studies*	No of participants/total participants (%)
Low reporting rates
Lack of awareness of what constitutes bullying	5/35	73/642 (11.4)
Lack of awareness of reporting process	15/35	1115/4215 (26.5)
Lack of perceived benefit	9/35	667/1621 (41.1)
Fear that bullying would worsen	13/35	969/2696 (35.9)
Fear of career ramifications	15/35	1094/2664 (41.1)
Concerns regarding confidentiality	4/35	56/445 (12.6)
Institutional factors
Hierarchical nature of medicine	7/35	Not reported
Recurring cycle of abuse	3/35	Not reported
Normalisation of bullying	10/35	Not reported
Lack of enforcement	13/35	586/1400 (41.9)

*Total number of studies that described barriers of bullying behaviours.

In the 25 unique studies that described institutional facilitators of bullying, common facilitators were lack of enforcement (reported in 13 studies),1 16 20 25 28 36 43 47 49 50 54 56 65 the hierarchical structure of medicine (reported in 7 studies)26 54 56 57 63 64 71 and normalisation of bullying (reported in 10 studies).3 15 19 23 26 31 34 47 62 65 Individual-level data were not pooled as institutional facilitators of bullying were most commonly elicited via free-response portions of surveys with varying completion rates.

Suggested strategies, interventions and outcomes

Forty-nine unique studies suggested strategies to address academic bullying. These strategies included promoting anti-bullying policies (reported in 13 studies),3 14–16 35 45 53 54 56 58 59 66 71 education to prevent academic bullying (reported in 20 studies),1 3 4 14 15 20 25 26 31 33 35 45 48 54 59 63–65 71 72 establishing an anti-bullying oversight committee (reported in 10 studies),21 22 26 28 30 34 39 58 69 71 institutional support for victims (reported in 5 studies)35 46 58 62 72 and internal reviews in which hospitals develop targeted solutions for their environment (reported in 5 studies)15 22 24 60 63 (online supplemental table S3).

Of the 49 unique studies, 10 implemented organisation-level interventions which included workshops with vignettes to improve recognition of bullying (reported in 4 studies)23 37 42 44; a gender and power abuse committee that established reporting mechanisms and held mandatory workshops on mistreatment (reported in 1)³; a gender equity office to handle reporting (reported in 1)³⁹; a professionalism-focused approach that included professionalism in employee contracts and performance reviews, and a professionalism office to handle student complaints (reported in 1)²⁶; zero-tolerance policies (reported in 1)⁵³ and institutional-level tracking of mistreatment to provide targeted staff education (reported in 2).^{21 24} All 10 studies had an uncontrolled before–after design, and as such, did not establish causality. In the studies of vignettes, common bullying behaviours were demonstrated to improve recognition of both subtle and overt acts of bullying. Of the 4 studies that involved bullying recognition workshops, 3 reported an associated improvement in bullying recognition.^{37 42 44} In a study that developed a gender equity office, reporting was handled through an intermediary; decisions were binding with consequences for retaliation including termination of employment³⁹ and 96% of all formal reports were resolved. In a study where a gender and power abuse committee was formed, there was an associated reduction in academic abuse.³ Similarly, in a study that used a multifaceted approach of developing a professionalism committee, and including professionalism in contracts and performance reviews, there was a 35.9% decrease in reporting of mistreatment and improved awareness of the reporting process.²⁶ In a study where a clerkship committee monitored unprofessionalism, there was an associated reduction in narrative comments regarding unprofessionalism on end of rotation surveys.²¹ In a study assessing the impact of a professionalism retreat about mistreatment for consultants, there was no reduction in medical student mistreatment.¹³ In a study assessing the implementation of zero-tolerance policies, there was an associated improvement in awareness of bullying reporting processes.⁵³

Assessment of bias

Twenty-eight studies had a low risk of bias,3 4 8 13 16–19 22 27 29 30 36 41 45 47 49–52 55 56 63 66 71–73 75 21 had a moderate risk of bias1 6 14 15 21 25 28 34 37 38 40 43 46 54 58 59 61 67–70 and 19 had a high risk of bias.20 23 24 26 31–33 35 37 39 42 44 48 53 57 60 62 64 65 Among the 58 survey studies, 14 sampled participants inappropriately,5 6 14 19 33 35 40 46 48 54 57 58 60 62 67 19 had inadequate sample sizes or did not justify their sample size,1 5 6 14 18 25 31 35 40 46 48 50 55 57 60 64 68 69 71 7 did not sufficiently describe the participants,1 15 29 31 35 48 58 9 had coverage bias,6 14 40 48 54 57 62 64 65 8 did not have an appropriate statistical analysis15 20 28 34 35 64 67 68 and 30 had a low response rate1 5 14–16 20 22 28 31 32 34–36 43 45 47 49 52 56 57 59–62 65–67 69 70 72 (online supplemental figure S2). Among the 10 before–after trials, 1 did not have prespecified inclusion criteria⁴⁴; 5 had low sample sizes or did not justify their sample size23 24 37 42 44; 3 did not have clearly defined, prespecified, consistently measured outcomes^{21 24 44}; 9 did not blind participants3 23 24 26 37 39 42 44 53; 5 did not account for loss to follow-up in their analysis23 26 42 44 53 and 6 lacked statistical tests to assess for significant pre-intervention to post-intervention changes24 26 39 42 44 53 (online supplemental figure S3).

Discussion

In this systematic review, we established a definition for academic bullying, identified common patterns of bullying and reported the impact on victims. We defined academic bullying as the abuse of authority by a perpetrator who targets the victim in order to impede their education or career through punishing behaviours that include overwork, destabilisation and isolation in an academic setting. Victims reported that academic bullying often resulted in stalled career advancement and thoughts of leaving the position. A majority of academic bullies were senior men, and a majority of victims were women. Barriers to reporting academic bullying included fear of reprisal, perceived hopelessness and institutional non-enforcement of anti-bullying policies. Strategies to overcome academic bullying, such as anti-bullying committees and adding professionalism as a requirement for career advancement, were associated with an improvement in the prevalence of bullying and resolution of formal reports (figure 2). Our review differs from other systematic reviews of bullying in medicine in its scope and population studied. We included studies involving all medical and surgical disciplines, but limited our analysis to physicians and physician trainees. While prior reviews have focused on the prevalence of bullying⁷⁶ or anti-bullying interventions,⁷⁷ our comprehensive review expanded the focus to also include characteristics of bullies and victims, impact and outcomes of bullying, anti-bullying strategies and facilitators of academic bullying.

Figure 2.

The definition, manifestations, impact, victims and perpetrators of academic bullying. Academic bullying is defined as an abuse of authority through punishing behaviours that include overwork, destabilisation and isolation. Victims are commonly women and ethnic minorities, while perpetrators are commonly men consultants. Individual and institutional factors contribute to the ongoing cycle of bullying.

Several factors contribute to the prevalence of bullying within academia. The hierarchical structure lends itself to power imbalances and prevents victims from speaking out, especially when the aggressor is tenured.⁷⁸ The relative isolation of departments within universities allows poor behaviour to go unchecked. Furthermore, the closed networks within departments lend themselves to mobbing behaviour and cause victims to fear of being blacklisted for speaking out.⁷⁹

A lack of clarity around the definition can limit awareness and reporting.⁵⁰ The Graduation Questionnaire administered to all American medical students found that in years where respondents were asked if they had been bullied, the estimated prevalence was lower than when they were asked about specific bullying behaviours.¹⁵ Surveys on bullying should include a list of defining behaviours to increase clarity and accuracy in responses.⁸⁰ Even in institutions with established reporting systems, respondents were often unaware of how to file a report.⁴⁷ We found that victims of academic bullying rarely filed reports, primarily due to fear of retaliation. Reporting was not consistently effective and was more likely to worsen bullying.

We found that consultants were the most common perpetrators of bullying at all levels of training. Residents often bullied medical students. No studies assessed the relative contribution of fellows and senior residents to resident bullying. Among studies that analysed bullying among consultants by seniority, senior consultants were a commonly reported source of bullying.6 8 40 43 73 Women and ethnic minorities reported higher rates of bullying among demographic groups surveyed, although race and ethnicity were infrequently assessed in the surveys included in this study. While some argue that the increasing proportion of women trainees^{81 82} may change dynamics in healthcare settings, the leaky academic pipeline in which women remain under-represented in several academic specialties and in positions of leadership makes them vulnerable to the power asymmetries in academic medicine.⁸³

Our review illustrates the self-reported harms of academic bullying. Victims experienced depressive symptoms, self-perceived loss of clinical ability and termination of employment. Academic bullying has been linked to depression,⁵¹ substance abuse,⁸⁴ and hospitalisation for coronary artery or cerebrovascular disease.⁸⁵ Bullying costs the NHS of the UK £325 million annually due to reduced performance and increased staff turnover.⁸⁶ Disruptive behaviour, linked to bullying in the perioperative setting, has been linked to 27% of patient deaths, 67% of adverse events and 71% of medical errors.⁷ Reasons for consultant error include intimidation leading to a fear of communicating sources of harm and slow response times.⁸⁷ We found that academic bullying negatively impacted patient safety. In a study of emergency medicine residents, 90% reported examples in which disruptive behaviour affected patient care, and 51% were less likely to call an abusive consultant.¹⁸

Interventions reported as effective were organisation level. Anti-bullying committees involving staff and learners can research bullying within their institution and address the most common disruptive behaviours through targeted interventions.⁶⁷ An organisation-level, rather than individual-level approach, may address the root causes of academic bullying as well as the organisational culture that facilitates ongoing bullying. We found that anti-bullying committees typically included three elements: (1) a multidisciplinary team that includes clinicians and other front-line staff; (2) development of anti-bullying policies and a reporting process; and (3) an education campaign to promote awareness of policies. Owing to their multifaceted nature, it is challenging to evaluate the relative contributions of their components. Without well-designed trials, the effects of anti-bullying interventions are unknown. All of the intervention studies used before–after designs, which did not account for confounding variables, co-interventions, and background changes in policy or practice; the majority were at high risk of bias. Furthermore, among studies that implemented anti-bullying workshops, the majority interviewed participants immediately after the workshop without longitudinal follow-up to determine if benefits were sustained.

The need for a confidential reporting process was raised in the studies included in this review, but few described how confidentiality could be maintained when the report has to describe details of the bullying that may be only privy to the perpetrator and victim. The reporting process could take the form of the Office of Gender Equity at the University of California, where the accuser and the accused do not meet face to face; the discipline process is through an intermediary.³⁹ A unique, non-punitive approach is the restorative justice approach used at Dalhousie University where victims, offenders, and administrators work collaboratively to address sexual harassment and reintegrate offenders.⁸⁸ Reporting may have been ineffective in this review due to the impunity offered to prominent consultants. Senior personnel, particularly those who are well-known and successful in grant funding, are often considered ‘untouchable’, beyond reproach by their institutions.⁸⁹ Behaviour is often learnt and modelling positive behaviours may break the cycle of bullying in medicine.⁹⁰ One approach would be making professionalism a requirement for promotion and career advancement, as in the Department of Medicine at the University of Toronto in Canada⁹¹ or the University of Colorado School of Medicine.²⁶

Strengths and limitations

The strengths of this review include its broad scope, capturing several aspects of academic bullying, and its size (n=68 studies, 82 349 consultants and trainees). The cohort included was diverse, comprising several specialties and countries. We explicitly defined eligibility criteria and extracted data in duplicate. We used established tools to assess the risk of bias.

There are several limitations that should be acknowledged. There is no validated definition of academic bullying, and the included studies varied in their description of bullying. Most studies used questionnaires that were not previously validated. The survey instruments across studies differed from each other, and their results had to be pooled according to themes. We could not account for differences in institutional culture and hospital systems in the responses of survey participants. Estimates of the prevalence of bullying must be interpreted in light of the self-reported nature of bullying surveys. Data on bully/victim demographics were under-represented. Selection bias was a significant concern: 14 studies used convenience sampling, and 2 included voluntary focus groups for victims of bullying. Overall, the response rate was 59.2%, with a range of 12%–100%. Surrogate outcomes such as awareness of bullying were used, and the reporting of outcomes was inconsistent. As such, the effect of anti-bullying interventions must be interpreted cautiously.

Future directions

Significant gaps exist in the quality of the academic bullying literature, particularly with inconsistent definitions and limitations in study methodology. Our definition may be used to provide the breadth and granularity required to sufficiently capture cases of academic bullying in medicine. Studies on the impact of academic bullying would benefit from standardised, validated survey instruments. Although randomisation and blinding are not always possible to test the effect of interventions, a control group should be included in anti-bullying intervention studies.

Conclusions

Academic bullying refers to specific behaviours that disrupt the learning or career of the intended target and commonly consists of exclusion and overwork. The consequences include significant psychiatric distress and loss of career opportunities. Bullies tend to be men and senior consultants, whereas victims tend to be women. The fear of reprisal and non-enforcement of anti-bullying policies are the greatest barriers to addressing academic bullying. Results of bullying interventions must be interpreted with caution due to their methodological quality and reliance on surrogate measures. There is a need for well-designed trials with transparent reporting of relevant outcomes and accounting for temporal trends.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplemental information.

Ethics statements

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