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Dr. Christopher Lemieux felt helpless the first time he witnessed a supervising physician humiliate a fellow resident.
“The doctor was reviewing a consult with the resident and just ripped it up, telling them in front of everybody that it would be easier to do it again himself than to correct the consult,” recalls Lemieux, now secretary of the Fédération des médecins résidents du Québec (FMRQ). “I wasn’t able to do anything and the resident didn’t do anything.”
For years, many residents across the country have reported similar experiences. FMRQ and Resident Doctors of Canada (RDoC) first called attention to widespread harassment and intimidation of medical trainees in 1996. At that point, residents reported “no effective or enforceable policy to deal with this problem in any jurisdiction.” Medical schools, residency programs and accrediting bodies responded, introducing policies and programs to address complaints and support the overall wellbeing of trainees and faculty. Two decades on, rates of bullying remain high, says Lemieux, likening the problem to a resistant infection.
Some 73% of residents surveyed by RDoC in 2012 said they were exposed to inappropriate behaviour during training that made them feel diminished. Other surveys show similarly high rates of intimidation and harassment, with 45%–93% of residents reporting at least one experience. The mistreatment comes from all corners: in a 2008 survey, 55% of residents reported being bullied by nurses, 45% by patients, 42% by supervising physicians and 26% by other residents.
Lemieux and others share stories of surgeons throwing medical instruments at trainees who make mistakes, of nurses belittling or ignoring residents’ clinical decisions, of pressure to disobey restrictions on working hours, of yelling, threats and sleazy comments, among other abuses. RDoC reports that about a third of these incidents are never officially reported.
Dr. Breanna Balaton, cochair of RDoC’s wellness committee, says the problem is no longer a lack of procedures to address abuse. “If you look hard enough, there are a lot of resources: through your program and postgraduate medical education office, the wellness offices with people who will keep these things confidential and the provincial health staff organizations.”
Now, the main problem is that residents still don’t know or trust these resources, she explains. RDoC’s 2013 national survey showed that 33% of respondents believed reporting would not have changed the situation, 21% didn’t do anything for fear of reprisal, 13% identified confidentiality as a concern and 11% were unaware of reporting procedures.
Some residents also rationalized the abuse as an unavoidable, even necessary evil of medical education, Balaton adds. “If that’s what we’re seeing, then that’s what we pick up and how we go on to teach others.”
According to Marie-Pier Bastrash, vice president of student affairs for the Canadian Federation of Medical Students (CFMS), these beliefs are often set during undergraduate medical education. “We’re working in teams with residents who work with staff, so often the same issues of humiliation and belittlement come up.”
CFMS, RDoC and FMRQ each have initiatives underway to educate medical students and residents about the forms of recourse available to them. These initiatives include developing simple guides to reporting abuse at medical schools and residency programs across Canada. The groups will also publish the results of new wellness surveys of their memberships in coming months and are updating recommendations for reducing abuse.
FMRQ released a new position paper on Jan. 27, which recommends reinforcing the positive behaviour of physicians who model collegiality, and is planning a social media campaign to celebrate these roles models, says Lemieux.
According to Dr. Glen Bandiera, associate dean of postgraduate medical education at the University of Toronto, the change to a culture of zero-tolerance for bullying in medicine will ultimately be “evolutionary as opposed to revolutionary.”
“The new incoming cohort of students and residents over the last few years are more willing to identify these issues, and are more willing to exercise the options available to them,” he says. “That also bears out in faculty over time: as people have experienced different ways of learning, the old environment is gradually going to disappear.”
Top–down measures, such as stronger accreditation standards requiring medical schools and residency programs to have effective mechanisms for addressing abuse, are part of that evolution, says Bandiera, who chairs the committee on accreditation for the Royal College of Physicians and Surgeons of Canada. “We’ve taken a very aggressive stance on reviewing programs ... and we’re currently rewriting the standards of accreditation in Canada to increase their rigor,” he explains. “There’s going to be a new standard, called the learners, teachers and administrators’ standard, and it has a lot to do with the positivity of the learning experience.”
The degree to which residency programs can “demonstrate concrete positive outcomes to residents, that’s probably the most important thing,” Bandiera adds. This is often complicated by the need to preserve confidentiality of investigations, even after they’ve been resolved, he says. “Sometimes the perception may be nothing is happening, when in fact a lot of work may be happening in the background.”
Medical schools and residency programs are also making it easier and safer for trainees to log complaints through web-based reporting tools and options to flag abuse anonymously, among other strategies. At the University of Toronto, for example, residents have “multiple routes to access the system, whether through a direct supervisor, a rotation coordinator, a program director or a third party,” says Bandiera.
Dr. Armand Aalamian, associate dean of postgraduate medical education at McGill University in Montréal, says preventing abuse will also require putting more resources into supports for trainees and faculty. “We’re all dealing with a system, in Quebec and across Canada, that is under quite a bit of stress in terms of budget cuts, in terms of working hours, in terms of resources, so when people are stressed that’s when you have issues of behaviour conflicts.”