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.