Mistreatment Of Residents Research Articles

Addressing medical resident mistreatment: A resident-centred approach

Introduction Mistreatment negatively impacts the wellbeing of medical learners and is related to worse patient outcomes and team functioning. Resident perspectives on improving mistreatment reporting structures and investigations have not been explored. We aimed to understand residents’ views on safe reporting structures, investigations, and resolution processes. Method We conducted an exploratory sequential mixed method study beginning with a series of qualitative interviews to inform an anonymous online survey to all Dalhousie University residents (N = 645). Results When interviewed, residents (N = 10) discussed personal experiences with mistreatment, barriers to reporting, and how these processes could better serve them. Themes from the interviews were imbedded in an anonymous online survey to explore their prevalence among a larger group. Residents (N = 120; 19%) completed the online survey and revealed that mistreatment was very common yet underreported. Barriers to reporting included confidentiality concerns, perceptions that reporting would not change anything, and fear of retaliation. Desired outcomes for perpetrators depended on the perpetrator’s position and incident severity, and most prefer a remedial approach. Conclusion Resident mistreatment remains prevalent and current processes of dealing with reports may be inadequate. Residents have thoughtful insights for improving institutional policies and procedures and should be meaningfully engaged.

Patient and Family Mistreatment of Residents in the Surgical Learning Environment

Identify the frequency and types of mistreatment experienced by residents from patients and their families (P&F) and determine whether the types and frequency varied based on resident gender. An anonymous survey was distributed to residents to assess the types of P&F mistreatment toward residents and the association with resident gender. The survey was distributed to the general surgery and urology programs at a large academic medical center in the mid-Atlantic. Participants: 23 of 53 residents (43% response rate) participated in the anonymous survey. Residents: 15 male residents (65%), 8 female residents (35%). Results: 12 of 23 responding residents (52%) indicated they experienced at least one form of mistreatment from P&F. Women were more likely to experience mistreatment (88% vs. 33%), with verbal assault was the most frequent (50% for female residents, 33% for male residents). Patients were more often the source than families (52% vs. 41%); verbal assault or threats of physical harm were the most common (50% for female residents, 33% for male residents). Residents experience mistreatment from multiple sources. This paper provides insight into the experiences of surgical residents with mistreatment from their P&F, with differences in frequency of behaviors dependent upon the perpetrator group and resident gender. Patients and their family mistreatments are likely underreported and may be more difficult to prevent. It is important to identify mitigation strategies and ensure resources are available for those residents experiencing mistreatment. A strong culture against mistreatment and providing specific resources may minimize the experience and negative effects of mistreatment.

Development and Validation of a Novel Instrument to Measure the Community Well-Being of Residency Programs.

To develop and validate the Residency Community Well-Being (RCWB) instrument, a novel instrument to measure the subjective community well-being of an individual residency program, and to explore differences in RCWB scores between demographic groups. An initial questionnaire to measure a residency program's community well-being was developed after literature review. Items were pilot tested, and the questionnaire was reviewed by experts in the fields of residency education, survey design, and sociology. The questionnaire was administered electronically between March and July 2021 to U.S. residents in 18 specialties recruited through convenience and snowball sampling using social media, a listserv, and personal emails to residency program leaders. Three previously validated instruments were administered as well to examine criterion validity: the Professional Fulfillment Index, the Brief Inventory of Thriving, and a single-item burnout measure. Data were analyzed with descriptive statistics, and exploratory factor analysis was performed using principal axis factoring with direct oblimin rotation to reduce the items and identify subscales. Of the 366 participants who opened and started the survey, 219 completed it (completion rate: 59.8%). Most respondents were women (133, 60.7%), 26-30 years old (132, 60.3%), and White (149, 68.0%). Three subscales emerged with 18 items: program leadership, structures, and practices (PLSP); resident interpersonal relationships (RIR); and resident mistreatment (RM). The Cronbach's alphas were 0.96 for PLSP, 0.92 for RIR, 0.82 for RM, and 0.95 for the overall RCWB. RCWB score positively correlated with professional fulfillment ( r = .52, P < .001) and thriving ( r = .45, P < .001) and inversely correlated with burnout ( r = -.39, P < .001). The RCWB instrument demonstrates strong internal consistency and content and criterion validity that shows that a residency program's subjective community well-being is primarily composed of program leadership quality, supportive interpersonal relationships, and the absence of mistreatment.

Addressing Peer-to-Peer Resident Mistreatment Through the Use of Forum Theatre: A Pilot Intervention.

Residents may experience mistreatment by faculty, peers, nurses, or patients. While faculty are reportedly the primary contributors to mistreatment, residents can also be offenders, which merits study. Forum theatre (FT) is an experiential learning modality requiring a peer group to develop problem-solving strategies. FT was piloted to address mistreatment among residents. The objective was to determine whether FT was feasible, acceptable to resident learners, and could lead to self-reported changes in perceptions or behaviors, providing program directors a focused option to address professionalism as a competency. This initiative was conducted from September 2019 through February 2021 in obstetrics-gynecology and urology residencies at UT Health San Antonio and consisted of 3 phases: a focus group to identify mistreatment experienced by residents, resident volunteers to create and act out the FT scenario, and enactment of the FT scenario during didactic time. Residents completed anonymous retrospective pre- and postsurveys, as well as at 6-8 months after, to assess knowledge, attitudes, and self-reported and observed behaviors. Wilcoxon rank-sum tests and 2-sample t tests for proportions were used to compare variables between groups. The FT was completed successfully in both departments during didactic time. Twenty-six residents participated, 24 (92%) responded. Most respondents (23, 96%) would recommend FT to colleagues for teaching professionalism. Behavior changes were reported by 15 (63%) participants after the program. After 6-8 months, self-reported mistreatment behaviors had decreased, including "making fun of others" (15 (63%) to 10 (38%), P = .04) and sending "disparaging texts" (13 (54%) to 7 (27%), P =.02). The use of FT during regularly scheduled didactic times was feasible and well received among residents. The evaluation demonstrated sustained self-reported behavior changes. Plans are ongoing to expand this approach to other medical specialties and professions institutionally.

Mistreatment in Residency: Intervening With the REWIND Communication Tool.

IntroductionThere is a lack of curricula addressing the alarming rates of resident physician mistreatment. As the ACGME works to address diversity, equity, and inclusion in GME, there has been increasing attention paid to the issue of mistreatment. Previous studies have noted a high prevalence of mistreatment within GME. Despite this, there are few published interventions to address the mistreatment of residents. We developed a workshop for residents to provide an overview of mistreatment in residency and teach them REWIND (relax, express, why, inquire, negotiate, determine), a communication tool to address mistreatment directly.MethodsWe designed a 60-minute workshop for residents with didactics on mistreatment in GME, followed by three case discussions. Four case scenarios were developed to represent different types of mistreatment and situations. We implemented the workshop twice and asked participants to self-rate proficiency around the workshop objectives with pre- and postsurveys.ResultsA total of 11 GME learners completed both the pre- and postsurveys between the two workshop implementations. GME learners who responded demonstrated significantly higher self-rated proficiency on each objective postworkshop compared to preworkshop (p < .05). Free responses on the survey demonstrated that participants particularly enjoyed the case discussions and wanted more practice with REWIND.DiscussionOur workshop improved participant self-rated proficiency around the mistreatment of resident physicians. The workshop can be used in the future as part of a multifaceted institutional response to mistreatment.

Addressing Resident Mistreatment Through the Use of a Forum Theatre Intervention.

Addressing Resident Mistreatment Through the Use of a Forum Theatre Intervention.

Incidence of resident mistreatment in the learning environment across three institutions

Introduction Mistreatment in the learning environment is associated with negative outcomes for trainees. While the Association of American Medical Colleges (AAMC) annual Graduation Questionnaire (GQ) has collected medical student reports of mistreatment for a decade, there is not a similar nationally benchmarked survey for residents. The objective of this study is to explore the prevalence of resident experiences with mistreatment. Methods Residents at three academic institutions were surveyed using questions similar to the GQ in 2018. Quantitative data were analyzed based on frequency and Mann-Whitney U tests to detect gender differences. Results Nine hundred ninety-six of 2682 residents (37.1%) responded to the survey. Thirty-nine percent of residents reported experiencing at least one incident of mistreatment. The highest reported incidents were public humiliation (23.7%) and subject to offensive sexist remarks/comments (16.0%). Female residents indicated experiencing significantly more incidents of public embarrassment, public humiliation, offensive sexist remarks, lower evaluations based on gender, denied opportunities for training or rewards, and unwanted sexual advances. Faculty were the most frequent instigators of mistreatment (66.4%). Of trainees who reported experiencing mistreatment, less than one-quarter reported the behavior. Conclusion Mistreatment in the academic learning environment is a concern in residency programs. There is increased frequency among female residents.

Training residents to intervene when mistreated by patients and their families

Purpose: Mistreatment of trainees adversely impacts their learning and well-being and can lead to medical errors and preventable adverse outcomes. However, few studies have examined mistreatment of trainees by patients and their families or the effect of a curricular intervention to address it. We hypothesized that pediatric residents commonly experience mistreatment from patients and their families and that targeted training would improve their knowledge and perceived effectiveness in responding. Methods: We collected baseline data on resident mistreatment using …

Exploring Action Items to Address Resident Mistreatment through an Educational Workshop.

Mistreatment of trainees is common in the clinical learning environment. Resident mistreatment is less frequently tracked than medical student mistreatment, but data suggest mistreatment remains prevalent at the resident level. To address resident mistreatment, the authors developed an Educational Advance to engage emergency medicine residents and faculty in understanding and improving their learning environment. The authors designed a small-group session with the following goals: 1) Develop a shared understanding of mistreatment and its magnitude; 2) Recognize the prevalence of resident mistreatment data and identify the most common types of mistreatment; 3) Relate study findings to personal or institutional experiences; and 4) Generate strategies for combating mistreatment and strengthening the clinical learning environment at their home institutions. Design was a combination of presentation, small group discussion, and facilitated discussion. Results were presented to participants from a previously administered survey of resident mistreatment. Public humiliation and sexist remarks were the most commonly reported forms. Faculty were the most frequent perpetrators, followed by residents and nurses. A majority of respondents who experienced mistreatment did not report the incident. Session participants were then asked to brainstorm strategies to combat mistreatment. Participants rated the session as effective in raising awareness about resident mistreatment and helping departments develop methods to improve the learning environment. Action items proposed by the group included coaching residents about how to respond to mistreatment, displaying signage in support of a positive learning environment, zero tolerance for mistreatment, clear instructions for reporting, and intentionality training to improve behavior.

STAFF PERSPECTIVES ON COUNTERING STAFF-TO-RESIDENT MISTREATMENT IN LONG-TERM CARE FACILITIES

In Canada, as well as in other countries, resident mistreatment is common in long-term care (LTC) facilities. In many situations, residents are mistreated by LTC staff. To address this problem, LTC facility managers and their employees must play an active role in the prevention as well as in the management of staff-to-resident mistreatment situations. However, it is still unclear what type of support they need to counter this type of mistreatment. Using an exploratory descriptive qualitative design, twenty-one managers and employees working in four different LTC facilities participated in semi-structured individual interviews. To allow participants to express themselves without risking self-incrimination or feeling pressured to report colleagues, vignettes depicting fictitious and common situations of staff-to-resident mistreatment were used as a conversation starter. Data analysis was performed using Miles, Huberman & Saldaña (2013) analytical method. Results show that participants think that staff-to-resident mistreatment is mainly caused by three staff characteristics: 1) not having the psychological profile to work in LTC facilities; 2) lack of training; and/or 3) being overworked. Consequently, participants believe that mistreatment prevention starts by improving employee selection practices to ensure candidates have adequate attitudes and training to work in LTC facilities. They also argue that staff should receive more training regarding mistreatment. Lastly, support interventions are suggested to prevent and address situations involving staff experiencing high levels of stress for personal or work-related reasons. This study shows that both individual and organisational measures are needed to fight against staff-to-resident mistreatment in LTC facilities.

See No Evil, Hear No Evil, Stop No Evil: Institutional-Level Tracking to Combat Mistreatment of Residents and Fellows.

Mistreatment of trainees, including discrimination and harassment, is a problem in graduate medical education. Current tools to assess the prevalence of mistreatment often are not administered institutionally and may not account for multiple sources of mistreatment, limiting an institution's ability to respond and intervene. We describe the utility of a brief questionnaire, embedded within longer institutional program evaluations, measuring the prevalence of different types of trainee mistreatment from multiple sources, including supervisors, team members, colleagues, and patients. In 2018, we administered a modified version of the mistreatment questions in the Association of American Medical Colleges Graduation Questionnaire to investigate the prevalence and sources of mistreatment in graduating residents and fellows. We conducted analyses to determine the prevalence, types, and sources of mistreatment of trainees at the institutional level across graduate medical education programs. A total of 234 graduating trainees (77%) from the University of Minnesota-Twin Cities completed the questions. Patients were cited as the primary source of mistreatment in 5 of 6 categories, including both direct and indirect offensive remarks, microaggressions, sexual harassment, and physical threats (paired t test comparisons from t = 3.92 to t = 9.71, all P < .001). The only category of mistreatment in which patients were not the most significant source was humiliation and shaming. Six questions concerning types and sources of trainee mistreatment, embedded within an institutional survey, generated new information for institutional-, departmental- and program-based future interventions. Patients were the greatest source for all types of mistreatment except humiliation and shaming.

Altering workplace attitudes for resident education (A.W.A.R.E.): discovering solutions for medical resident bullying through literature review.

BackgroundPhysicians-in-training are challenged every day with grueling academic requirements, job strain, and patient safety concerns. Residency shapes the skills and values that will percolate to patient care and professional character. Unfortunately, impediments to the educational process due to medical resident mistreatment by bullying remain highly prevalent in training today.MethodsA PubMed literature review was undertaken using key terms to help define resident mistreatment by bullying, determine its prevalence, identify its potential causes and sequelae, and find suggestions for changing this detrimental culture of medical training.ResultsWe identified 62 relevant articles. The most frequently noted form of mistreatment was verbal abuse, with the most common perpetrators being fellow physicians of higher hierarchical power. Mistreatment exists due to its cyclical nature and the existing culture of medical training. These disruptive behaviors affect the wellbeing of both medical residents and patients.ConclusionsThis article highlights the importance of creating systems that educate physicians-in-training about professional mistreatment by bullying and the imperative in recognizing and correcting these abuses. Resident bullying leads to increased resident stress, decreased resident wellbeing as well as risks to patient safety and increased healthcare costs. Solutions include education of healthcare team members, committee creation, regulation of feedback, and creation of a zero-tolerance policy focused on the health of both patients and residents. Altering workplace attitudes will diminish the detrimental effects that bullying has on resident training.

Toward a Humanistic Learning Environment: Addressing Resident Mistreatment

While we find the results of the study by Mullan et al1 in the March 2013 issue of the Journal of Graduate Medical Education alarming, the findings sadly do not come as a surprise. The authors administered an anonymous questionnaire to more than 500 interns at Partners Healthcare, Boston, MA, during 2010 and 2011. Of the nearly 400 participants, 93% had experienced “disruptive behavior” during internship, including condescending behavior, berating, exclusion from decision-making, inappropriate jokes, abusive language, and gender bias. Even more concerning is the fact that 54% of the interns reported experiencing these behaviors once a month or more.1 A culture of disrespect in medical training is certainly not a recent development: Rosenberg and Silver commented on the pervasiveness of verbal abuse and humiliation in medical training nearly 30 years ago.2 Fifteen years later, Kassebaum and Cutler described a similar climate of learner abuse in US medical schools, and they advocated for medical educators to “tidy up the environment for learning.”3 Though there is a paucity of data regarding perceived learner mistreatment in the US graduate medical education programs over the past decade, there continue to be reports of learner mistreatment in the undergraduate medical education community. In the 2012 Association of American Medical Colleges Graduation Questionnaire, medical students reported that interns and residents are nearly as likely as faculty to be the source of student mistreatment.4 This is concerning as it perpetuates a phenomenon in child abuse when those “abused” become the “abusers.” In fact, Silver related abused medical students to abused children in his 1982 commentary in the Journal of the American Medical Association.5 The board of directors of the Accreditation Council for Graduate Medical Education (ACGME) recently charged the Council of Review Committee Residents (CRCR) with defining the scope and magnitude of the problem of resident mistreatment in the clinical learning environment. The CRCR is currently working to further clarify what types of learner mistreatment behaviors are occurring in the graduate medical education learning environment, the prevalence of these behaviors, and the consequences of learner mistreatment. Moving forward, it should be our objective to ensure a humanistic clinical learning environment for current and future trainees. We anticipate that the Next Accreditation System of the ACGME will provide a model structure to encourage this lasting cultural change. We need to better understand the root causes of hostility, harassment, and the culture that creates “disruptive behaviors,” such as between interns and critical clinical team members such as nurses who were highlighted by Mullan et al.1 Solutions should be sought that maximize the ideals of professionalism in service to our patients and to us, as the future of medicine.

Professionalism and Ethics Education on Relationships and Boundaries: Psychiatric Residents' Training Preferences

Awareness of the privileges and limits of one's role as physician, as well as recognition and respect for the patient as a human being, are central to ethical medical practice. The authors were particularly interested in examining the attitudes and perceived needs of psychiatric residents toward education on professional boundaries and relationships given the heightened current focus on professionalism and ethics. Residents from six psychiatric residencies provided views on professionalism and ethics education on a survey encompassing 10 domains of professionalism. The authors focus on residents' perceived need for education on boundaries in the psychiatrist-patient relationship and in peer-peer and supervisor-trainee interactions. Respondents (N=134) felt that nine relationship and boundary issues arising during training should receive more education: being asked to work with inadequate supervision, resolving conflicts between attendings and trainees, resident health care, adequately caring for patients while adhering to work-hour guidelines, performing work beyond one's competence, mistreatment of residents, sexual/romantic relationships between faculty and trainees, mistreatment of medical students, and sexual/romantic relationships between residents and medical students (p<0.05 in all cases). In addition, 15 relationship and boundary issues arising during clinical practice were felt to warrant more education: responding to impaired colleagues, coping with mistakes in clinical care, reporting mistakes, balancing personal and professional life, resolving conflicts, writing prescriptions for friends or family, allocation of health care resources, providing medical advice to friends and family, physicians' social responsibilities, interacting with families, medicine as a profession, gender bias, being asked to falsify clinical information, accepting gifts from patients, and personal relationships with patients (p<0.05 in all cases). The authors found a perceived need for more education for psychiatric residents for the majority of topics pertaining to boundaries and relationships. Residents who reported encountering ethical dilemmas more frequently wanted more education on these topics.

Ethno-Racial Profiling and State Violence in a Southwest Barrio

This study, carried out in a barrio neighborhood near the U.S.-Mexican border, uses a structural violence perspective to understand the extent of and individual determinants of mistreatment of residents by immigration authorities. Results indicate that barrio residents are more likely than the U.S. population in general to experience mistreatment at the hands of state authorities. Multivariate analyses indicate that authorities dole out mistreatment especially to people who appear Mexican. Educated Latinos are also frequent targets of mistreatment, and being a native-born or naturalized U.S. citizen offers no protection. These results suggest an institutional pattern of state violence in barrios structured more by racism and nativism than by immigration status.

State Policies and Nursing Home Characteristics Associated With Rates of Resident Mistreatment

A federal complaint/incident system was implemented in 2004 with the stated purpose of promoting and protecting the health, safety, and the welfare of residents receiving health care services. This system provided the first national database of mistreatment in the nursing home setting. The purpose of this research was to identify state and nursing home characteristics associated with the rates of nursing home resident mistreatment. Outcomes were incident reports filed by nursing home staff and complaints filed by persons other than service providers obtained from the federal complaints/incidents tracking system. Predictor variables used in the analysis of the reporting system included state legislation, census demographic data, and characteristics of the nursing home including aggregate characteristics of the residents. In 2004, based on complaint and incident reports, 1.6% of the nursing home population was reported to be mistreated. The average rates per 1000 residents were 16 reports, 14 investigations, and 4 substantiations. Incident report rates per 1000 ranged from 0.04 in Virginia to 46 in Alabama. Complaint report rates ranged from 0.42 in Hawaii to 52 in New Mexico. Incident outcomes were significantly lower in states that had nursing home statutes that require the facility, rather than the individual, to report mistreatment or in states that defined mistreatment in the nursing home differently from the definitions used by adult protective service statutes. Higher complaint outcomes were associated with lower levels of staffing. After controlling for resident characteristics, mistreatment measures remained associated with nursing home staffing levels but not with elements of statutes. Documentation of nursing home mistreatment shows substantial differences in report rates across states. These differences cannot be explained by variations in the laws.

How much of a problem is resident mistreatment in child welfare institutions?

The purpose of this article is to provide information developed since 1980 by the Institutional Child Protection Project about the size and significance of the problem of mistreatment in child welfare residential institutions. In the 1.700 facilities surveyed, there are about 69.000 children and youths. Rates of utilization vary among Health and Human Services (H.H.S.) regions from 8 per 10.000 to 19 per 10.000 children and youths in the population. The average rate is 12 per 10.000. In 1961 this rate was estimated at 10 per 10,000. About 2,700 complaints were reported by facilities to the survey for 1979. Complaint rates range by H.H.S. region from 25 per 1.000 to 55 per 1.000 children and youth in care. The average complaint rate per 1.000 residents in care was 39. Observations of site visitors suggest that only one out of five complainable situations may be reported to child protection agencies. A list of complainable occurrences that came to the attention of site visitors is included to document the problem. An additional effort to assess the significance of this issue is made by comparing intrafamilial complaint rates with rates reported by child welfare facilities. The authors believe residential complaint rates may be twice as large as intrafamilial complaint rates.