Abstract
This survey study examines the prevalence and sources of mistreatment toward internal medicine residents.
Mistreatment of trainees, defined as discrimination, harassment, or abuse in the workplace, is common1,2,3 and associated with burnout, depression, and decreased self-confidence.1,2,4 Recently, 2 national surveys of surgical residents provided details of mistreatment types and their sources.1,4 Less is known about internal medicine residents and how their experience with mistreatment compares with that of surgical residents. To our knowledge, no large national studies of internal medicine residents have been conducted, so we sought to assess the prevalence and sources of mistreatment with a national survey.5,6
Methods
In August 2019, an anonymous 5-question optional survey was administered to internal medicine residents after they completed the American College of Physicians Internal Medicine In-Training Examination. We included the residents in US and Puerto Rico training programs. The Duke University School of Medicine institutional review board exempted the study from review.
Residents were asked whether in their role as residents (ie, at any time during their residency) they had personally experienced or witnessed “inappropriate comments or actions [subsequently referred to as mistreatment] based on identity markers (eg, gender, race, ethnicity, sexual orientation, disabilities),” with response options for both comment and actions being “never,” “infrequently,” “sometimes,” and “frequently.” Residents were asked to identify the sources (“choose all that apply”) from “patients,” “patients’ families,” “nurses,” “faculty,” “residents,” “allied health personnel,” “other,” and “not applicable.” Residents were also asked if their program formally assessed residents regarding mistreatment.
Because experiencing and witnessing mistreatment based on identity markers should ideally be an event that never occurs, we combined the responses of “infrequently,” “sometimes,” and “frequently” and compared these answers with the “never” responses. We used Pearson χ2 test of independence to analyze whether experiencing or witnessing mistreatment significantly varied across gender or English as their primary language and to identify whether sources of mistreatment varied by the same factors. For all tests, we used an α of .05. Data analysis was conducted in Q Research Software (version 5.12.4.0).
Results
Of 26 942 US and Puerto Rican residents who took the in-training examination in 2019, 25 619 (95.1%) completed the survey, and 21 931 consented to have their responses used for publication (81.4% response rate). Of the 21 931 residents, 9500 (43.3%) were women, with 13 643 (62.2%) being US medical graduates and 15 656 (71.4%) reporting English as their primary language (Table). A total of 7466 (34.0%), 7595 (34.6%), and 6871 (31.3%) residents were in postgraduate year (PGY) 1, 2, and 3, respectively, and 19 065 (86.9%) were in categorical programs.
Table. Source of Inappropriate Comments or Actions Reported by Internal Medicine Residentsa.
| Source | Residents in US residency programs, including Puerto Rico, No. (%) | ||||||
|---|---|---|---|---|---|---|---|
| All residents (n = 21 931) | Male (n = 12 431) | Female (n = 9500) | USMG (n = 13 643) | IMG (n = 8288) | Native English speaker (n = 15 656) | Non–native English speaker (n = 6275) | |
| Patients | 11 263 (51.3) | 5512 (44.3) | 5751 (60.5)b | 7974 (58.4)b | 3289 (39.7) | 8818 (56.3)b | 2445 (39.0) |
| Patients’ families | 8313 (37.9) | 4079 (32.8) | 4234 (44.6)b | 5994 (43.9)b | 2319 (28.0) | 6562 (41.9)b | 1751 (27.9) |
| Nurses | 4395 (20.0) | 2207 (17.8) | 2188 (23.0)b | 3118 (22.9)b | 1277 (15.4) | 3411 (21.8)b | 984 (15.9) |
| Faculty | 3522 (16.1) | 1742 (14.0) | 1780 (18.7)b | 2562 (18.8)b | 960 (11.9) | 2800 (17.9)b | 722 (11.5) |
| Residents | 3280 (14.9) | 1782 (14.3) | 1498 (15.8)c | 2253 (16.5)b | 1027 (12.4) | 2521 (16.1)b | 759 (12.1) |
| Allied health personnel | 1760 (8.0) | 933 (7.5) | 827 (8.7)c | 1305 (9.6)b | 455 (5.5) | 1417 (9.1)b | 343 (5.5) |
| Other | 1178 (5.4) | 584 (4.7) | 594 (6.3)b | 696 (5.1) | 482 (5.8)d | 805 (5.1) | 373 (5.9)d |
| Not applicablee | 7949 (36.2) | 5430 (43.7)b | 2518 (26.5) | 4225 (31.0) | 3723 (44.9)b | 5127 (32.7) | 2821 (45.0)b |
Abbreviations: ACP, American College of Physicians; IMG, international medical graduate; USMG, US medical graduate.
Period: residents were asked to answer the question based on their time as a resident.
P ≤ .001.
P ≤ .01.
P ≤ .05.
The percentages in not applicable are similar to the never witnessed respondents in the Figure, but not exact. This is because the ACP examination does not allow branching logic, and respondents who selected never to having witnessed or experienced inappropriate comments or actions may have selected sources in this question.
Overall, 10 587 residents (48.3%) reported experiencing mistreatment, and 13 675 (62.4%) reported witnessing mistreatment (Figure). Additionally, 12 582 residents (57.4%) reported that their programs assessed trainees about mistreatment.
Figure. Survey Responses by Gender.
Each bar shows the percentage of all responses to the survey questions and respondents separated by gender. Identity markers were defined as gender, race, ethnicity, sexual orientation, and disabilities. Residents were asked to answer the questions based on their time as a resident.
Women more commonly reported experiencing mistreatment than men (64.0% vs 36.2%; P < .001; Figure) and witnessing it (71.6% vs 55.3%; P < .001). Women were significantly more likely than men to report experiencing mistreatment at each training year (PGY-3: 2006 of 2976 [67.4%];PGY-2: 2279 of 3274 [69.6%] ; PGY-1: 1798 of 3250 [55.3%]; P < .001 for the comparisons with PGY-1). Residents reported that the sources of mistreatment were patients (11 263 [51.3%]), patients’ families (8313 [37.9%]), nurses (4395 [20.0%]), and faculty (3522 [16.1%]), with women, graduates of US medical schools, and native English speakers reporting a higher percentage from each group (Table).
Discussion
In this 2019 national survey of the prevalence and sources of mistreatment experienced by internal medicine residents, 48.3% of the residents who responded reported experiencing mistreatment and 62.4% reported witnessing mistreatment, with higher percentages reported by women than by men. A higher percentage of PGY-3 residents reported events, which may reflect the fact that they had a longer period during which to experience or witness mistreatment. The most common sources of mistreatment were patients and patients’ families. The findings are similar to those of the 2 recent national surveys of surgical residents.1,4 Together, the survey findings suggest the need for comprehensive, timely, and effective initiatives to address these issues. The limitations of this study include the limited number of questions asked, postexamination fatigue (which could affect responses), measurement of resident perceptions only, and a lack of demographic information about the respondents for additional analysis.
References
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