Bullying in psychiatry
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Bullying Bullying is the use of force, coercion, hurtful teasing or threat, to abuse, aggressively dominate or intimidate. The behavior is often repeated and habitual. One essential prerequisite is the perception (by the bully or by others) of an imba ...
in the
medical profession A physician (American English), medical practitioner (Commonwealth English), medical doctor, or simply doctor, is a health professional who practices medicine, which is concerned with promoting, maintaining or restoring health through the ...
is common, particularly of student or trainee physicians. It is thought that this is at least in part an outcome of conservative traditional hierarchical structures and
teaching methods A teaching method comprises the principles and methods used by teachers to enable student learning. These strategies are determined partly on subject matter to be taught and partly by the nature of the learner. For a particular teaching method t ...
in the medical profession which may result in a bullying cycle. According to Field, bullies are attracted to the caring professions, such as medicine, by the opportunities to exercise power over vulnerable clients, employees and students. While the stereotype of a victim as a weak person who somehow deserves to be bullied is salient, there is growing evidence that bullies, who are often driven by jealousy and envy, pick on the highest performing and most skilled students, whose mere presence is sufficient to make the bully feel insecure. The victim are usually high academic achievers and are likely to have been top of the class throughout their school years. As medical students have to compete against each other, this can make certain trainee doctors eager to stand out from the crowd, and some use underhand techniques to gain academic recognition. The rampant problem of
medical student A medical school is a tertiary educational institution, or part of such an institution, that teaches medicine, and awards a professional degree for physicians. Such medical degrees include the Bachelor of Medicine, Bachelor of Surgery (MBBS, MB ...
mistreatment and bullying was systematically studied and reported in a 1990 ''JAMA'' study by pediatrician Henry K. Silver which found that 46.4 percent of students at one medical school had been abused at some point during medical school; by the time they were seniors, that number was 80.6 percent. In a 2002 test, 594 BMA members were randomly selected to complete a bullying survey, and 220 of the 594 junior doctors reported having been bullied in the previous year. This survey reported no variance in job grade or age.


Psychology

Threats (of exposure of inadequacy) must be ruthlessly controlled and subjugated.
Psychological Psychology is the scientific study of mind and behavior. Psychology includes the study of conscious and unconscious phenomena, including feelings and thoughts. It is an academic discipline of immense scope, crossing the boundaries between t ...
models such as
transference Transference (german: Übertragung) is a phenomenon within psychotherapy in which the "feelings, attitudes, or desires" a person had about one thing are subconsciously projected onto the here-and-now Other. It usually concerns feelings from a ...
and
projection Projection, projections or projective may refer to: Physics * Projection (physics), the action/process of light, heat, or sound reflecting from a surface to another in a different direction * The display of images by a projector Optics, graphic ...
have been proposed to explain such behaviors, wherein the bully's sense of personal inadequacy is projected or transferred to a victim; through making others feel inadequate and subordinate, the bully thus vindicates their own sense of inferiority.
Displacement Displacement may refer to: Physical sciences Mathematics and Physics *Displacement (geometry), is the difference between the final and initial position of a point trajectory (for instance, the center of mass of a moving object). The actual path ...
is another defense mechanism that can explain the propensity of many medical educators to bully students, and may operate subconsciously. Displacement entails the redirection of an impulse (usually aggression) onto a powerless substitute target. The target can be a person or an object that can serve as a symbolic substitute. Displacement can operate in chain-reactions, wherein people unwittingly become at once victims and perpetrators of displacement. For example, a resident physician may be undergoing stress with her patients or at home, but cannot express these feelings toward patients or toward her family members, so she channels these negative emotions toward vulnerable students in the form of
intimidation Intimidation is to "make timid or make fearful"; or to induce fear. This includes intentional behaviors of forcing another person to experience general discomfort such as humiliation, embarrassment, inferiority, limited freedom, etc and the victi ...
, control or subjugation. The student then acts brashly toward a patient, channeling reactive emotions which cannot be directed back to the resident physician onto more vulnerable subjects. Beyond its ramifications for victims, disrespect and bullying in medicine is a threat to patient safety because it inhibits collegiality and cooperation essential to teamwork, cuts off communication, undermines morale, and inhibits compliance with and implementation of new practices.


Bullying cycle

Medical training usually takes place in institutions that have a highly structured hierarchical system, and has traditionally involved teaching by
intimidation Intimidation is to "make timid or make fearful"; or to induce fear. This includes intentional behaviors of forcing another person to experience general discomfort such as humiliation, embarrassment, inferiority, limited freedom, etc and the victi ...
and humiliation. Such practices may foster a culture of bullying and the setting up of a cycle of bullying, analogous to other cycles of abuse in which those who experience it go on to abuse others when they become more senior. Medical doctors are increasingly reporting to the
British Medical Association The British Medical Association (BMA) is a registered trade union for doctors in the United Kingdom. The association does not regulate or certify doctors, a responsibility which lies with the General Medical Council. The association's headquar ...
that they are being bullied, often by older and more senior colleagues, many of whom were badly treated themselves when more junior. Physician Jonathan Belsey relates in an emblematic narrative published in AMA Virtual Mentor entitled Teaching By Humiliation that "however well you presented the case, somewhere along the line you would trip up and give the predatory professor his opportunity to expose your inadequacies. Sometimes it would be your lack of medical knowledge; sometimes the question that you failed to ask the patient that would have revealed the root of the problem, or sometimes your ineptitude at eliciting the required clinical signs. On one memorable occasion, when I had appeared to cover all the bases clinically, the professor turned to me and berated me for attending his ward round wearing a plaid shirt that was clearly inappropriate for an aspiring doctor."


Impact

Bullying can significantly decrease
job satisfaction Job satisfaction, employee satisfaction or work satisfaction is a measure of workers' contentedness with their job, whether they like the job or individual aspects or facets of jobs, such as nature of work or supervision. Job satisfaction can be ...
and increase job-induced stress; it also leads to low
self-confidence Confidence is a state of being clear-headed either that a hypothesis or prediction is correct or that a chosen course of action is the best or most effective. Confidence comes from a Latin word 'fidere' which means "to trust"; therefore, having ...
, depression,
anxiety Anxiety is an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events. Anxiety is different than fear in that the former is defined as the anticipation of a future threat wh ...
and a desire to leave employment. Bullying contributes to high rates of staff turnover, high rates of sickness absence, impaired performance, lower
productivity Productivity is the efficiency of production of goods or services expressed by some measure. Measurements of productivity are often expressed as a ratio of an aggregate output to a single input or an aggregate input used in a production proces ...
, poor
team spirit Team Spirit was a joint military training exercise of United States Forces Korea and the Military of South Korea held between 1974 and 1993. The exercise was also scheduled from 1994 to 1996 but cancelled during this time period as part of diploma ...
and loss of trained staff. This has implications for the
recruitment Recruitment is the overall process of identifying, sourcing, screening, shortlisting, and interviewing candidates for jobs (either permanent or temporary) within an organization. Recruitment also is the processes involved in choosing individual ...
and retention of medical staff. Chronic and current bullying are associated with substantially worse health, according to research by Laura M. Bogart, associate professor of pediatrics at Harvard Medical School. Studies have consistently shown that physicians have had the highest depression and suicide rates compared to people in many other lines of work—for suicide, 40% higher for male physicians and 130% higher for female physicians. Research has traced the beginning of this difference to the years spent in medical school. Students enter medical school with mental health profiles similar to those of their peers but end up experiencing depression, burnout, suicidal ideation and other mental illnesses at much higher rates. Despite better access to health care, they are more likely to cope by resorting to dysfunctional and self-injurious behaviors, and are less likely to receive the right care or even recognize that they need some kind of intervention. Exposure to bullying and intimidation during formative years of medical training has been found to contribute to these consequences. Fear of stigmatisation among medical students was the subject of a study in ''JAMA'' by Thomas Schwenk and colleagues at the University of Michigan's Department of Family Medicine, USA. 53% of medical students who reported high levels of depressive symptoms were worried that revealing their illness would be risky for their careers and 62% said asking for help would mean their coping skills were inadequate, according to the study published in September 2010. "Medical students are under extraordinary demands. They feel they are making life and death decisions and that they can never be wrong. There is such tremendous pressure to be perfect that any sense of falling short makes them very anxious", says Schwenk.


Types


Medical students

Medical students, perhaps being vulnerable because of their relatively low status in health care settings, may experience
verbal abuse Verbal abuse (also known as verbal aggression, verbal attack, verbal violence, verbal assault, psychic aggression, or psychic violence) is a type of psychological/mental abuse that involves the use of oral, gestured, and written language direct ...
,
humiliation Humiliation is the abasement of pride, which creates mortification or leads to a state of being humbled or reduced to lowliness or submission. It is an emotion felt by a person whose social status, either by force or willingly, has just decr ...
and
harassment Harassment covers a wide range of behaviors of offensive nature. It is commonly understood as behavior that demeans, humiliates or embarrasses a person, and it is characteristically identified by its unlikelihood in terms of social and moral ...
(nonsexual or sexual).
Discrimination Discrimination is the act of making unjustified distinctions between people based on the groups, classes, or other categories to which they belong or are perceived to belong. People may be discriminated on the basis of race, gender, age, relig ...
based on gender and race are less common. In one study, around 35% of medical students reported having been bullied. Around one in four of the 1,000 students questioned said they had been bullied by a medical doctor. Furthermore, bullying has been known to occur among medical students. Manifestations of bullying include: * being humiliated by teachers in front of patients or peers * been
victimised Victimisation ( or victimization) is the process of being victimised or becoming a victim. The field that studies the process, rates, incidence, effects, and prevalence of victimisation is called victimology. Peer victimisation Peer victimisati ...
for not having come from a "medical family" (often people who enter medicine have an older sibling pursuing the same degree or share ties with other individuals in the profession with whom familial relationship confers some degree of protection or special influence – especially within academic settings.) Such practices extend to admissions procedures, which are regularly influenced by factors far afield of candidates' intrinsic merits, such as being related to faculty members or well-known medical luminaries. * being put under pressure to carry out a procedure without supervision. * being ostracized by other medical students for asking questions (due to the medical content being confusing for some students) through social media networks (
Facebook Facebook is an online social media and social networking service owned by American company Meta Platforms. Founded in 2004 by Mark Zuckerberg with fellow Harvard College students and roommates Eduardo Saverin, Andrew McCollum, Dustin M ...
bullying), phone, or in person. One study showed that the medical faculty was the faculty in which students were most commonly mistreated. Bullying extends to postgraduate students.


Junior (trainee) physicians

In a UK study, 37% of
junior doctors In the United Kingdom, junior doctors are qualified medical practitioners working whilst engaged in postgraduate training. The period of being a junior doctor starts when they qualify as a medical practitioner following graduation with a Bachelor ...
reported being bullied in the previous year and 84% had experienced at least one bullying incident. Black and Asian physicians were more likely to be bullied than other physicians. Women were more likely to be bullied than men. Trainee physicians who feel threatened in the clinical workplace develop less effectively and are less likely to ask for advice or help when they need it. Persistent destructive
criticism Criticism is the construction of a judgement about the negative qualities of someone or something. Criticism can range from impromptu comments to a written detailed response. , ''"the act of giving your opinion or judgment about the good or bad q ...
,
sarcastic Sarcasm is the caustic use of words, often in a humorous way, to mock someone or something. Sarcasm may employ ambivalence, although it is not necessarily ironic. Most noticeable in spoken word, sarcasm is mainly distinguished by the inflection ...
comments and humiliation in front of colleagues will cause all but the most resilient of trainees to lose confidence in themselves.
Consultants A consultant (from la, consultare "to deliberate") is a professional (also known as ''expert'', ''specialist'', see variations of meaning below) who provides advice and other purposeful activities in an area of specialization. Consulting servic ...
who feel
burnt out ''Burnt Out'' (french: Sauf le respect que je vous dois) is a 2005 French drama film directed by Fabienne Godet. Cast * Olivier Gourmet - François Durrieux * Dominique Blanc - Clémence Durrieux * Julie Depardieu - Flora * Marion Cotillard - L ...
and alienated may take their disaffection out on junior colleagues. The farewell interview from Sir Ian Kennedy (Chair of the Healthcare Commission) caused significant media interest following his statement that bullying is a 'corrosive' problem that the NHS must address.


Psychiatry

Psychiatric Psychiatry is the medical specialty devoted to the diagnosis, prevention, and treatment of mental disorders. These include various maladaptations related to mood, behaviour, cognition, and perceptions. See glossary of psychiatry. Initial psychi ...
trainees experience rates of bullying at least as high as other medical students. In a survey of psychiatric trainees in the West Midlands, 47% had experienced bullying within the last year with even higher percentages amongst ethnic minorities and females. Qualified psychiatrists are not themselves required to be psychiatrically assessed.


Nursing

Nurses Nursing is a profession within the health care sector focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life. Nurses may be differentiated from other health ca ...
experience
bullying Bullying is the use of force, coercion, hurtful teasing or threat, to abuse, aggressively dominate or intimidate. The behavior is often repeated and habitual. One essential prerequisite is the perception (by the bully or by others) of an imba ...
quite frequently. It is thought that
relational aggression Relational aggression or alternative aggressionSimmons, Rachel (2002). ''Odd Girl Out: The Hidden Culture of Aggression in Girls''. New York, New York: Mariner Books. pp. 8–9. . Retrieved 2016-11-02. is a type of aggression in which harm is cause ...
(psychological aspects of bullying such as gossiping and intimidation) are commonplace. Relational aggression has been studied among girls but not so much among adult women. Speaking of many doctors' predilection for bullying nurses, Theresa Brown writes:


Popular culture

Sir Lancelot Spratt, a character played by actor
James Robertson Justice James Robertson Justice (15 June 1907 – 2 July 1975) was a British actor. He is best remembered for portraying pompous authority figures in comedies including each of the seven films in the ''Doctor'' series. He also co-starred with Grego ...
in the film series ''
Doctor in the House ''Doctor in the House'' is a 1954 British comedy film directed by Ralph Thomas and produced by Betty Box. The screenplay, by Nicholas Phipps, Richard Gordon and Ronald Wilkinson, is based on the 1952 novel by Gordon, and follows a group of st ...
'', is often referenced as the archetypal arrogant bullying doctor ruling by fear. The film series also demonstrates bullying of student doctors by other doctors and the nursing matron. In the American sitcom ''
Scrubs Scrub(s) may refer to: * Scrub, low shrub and grass characteristic of scrubland * Scrubs (clothing), worn by medical staff * ''Scrubs'' (TV series), an American television program * Scrubs (occupation), also called "scrub tech," "scrub nurse," o ...
'', Dr. Cox uses intimidation and sarcasm as methods of tormenting the interns and expressing his dislike towards them and their company.


See also

*
Aggression in healthcare Workplace safety in healthcare settings is similar to the workplace safety concerns in most occupations, but there are some unique risk factors, such as chemical exposures, and the distribution of injuries is somewhat different from the average of ...
*
Disruptive physician A disruptive physician is a physician whose obnoxious behaviour upsets patients or other staff. The American Medical Association defines this in their code of medical ethics as "personal conduct, whether verbal or physical, that negatively affects ...
* Doctor-patient relationship * Burnout and depression of medical students *
Medical education Medical education is education related to the practice of being a medical practitioner, including the initial training to become a physician (i.e., medical school and internship (medical), internship) and additional training thereafter (e.g., Re ...
* Medical narcissism *
Medical school A medical school is a tertiary educational institution, or part of such an institution, that teaches medicine, and awards a professional degree for physicians. Such medical degrees include the Bachelor of Medicine, Bachelor of Surgery (MBBS, M ...
* Sham peer review *
Stafford Hospital scandal The Stafford Hospital scandal concerns poor care and high mortality rates amongst patients at the Stafford Hospital, Stafford, England, during the first decade of the 21st century. The hospital was run by the Mid Staffordshire NHS Foundation Trust ...
* Stress in medical students *
Whistleblowing A whistleblower (also written as whistle-blower or whistle blower) is a person, often an employee, who reveals information about activity within a private or public organization that is deemed illegal, immoral, illicit, unsafe or fraudulent. Whi ...
* Workplace safety in healthcare settings


References


Further reading

* * * * * * * * * Mistry M and Latoo
Bullying: a growing workplace menace BJMP Mar 2009 Volume 2 Number 1
* * * Vanderstar E
Workplace Bullying in the Healthcare Professions 2004 8 Employee Rights and Employment Policy Journal 455
* Wible, Pamela (2019). ''Human Rights Violations in Medicine: A-to-Z Action Guide''. * * Wood, DF
Bullying in medical schools
Student BMJ October 2006


External links


Bullying and harassment
at
British Medical Association The British Medical Association (BMA) is a registered trade union for doctors in the United Kingdom. The association does not regulate or certify doctors, a responsibility which lies with the General Medical Council. The association's headquar ...

WMA statement on bullying and harassment within the profession
at
World Medical Association The World Medical Association (WMA) is an international and independent confederation of free professional medical associations representing physicians worldwide. WMA was formally established on September 18, 1947 and has grown to 115 national m ...
{{DEFAULTSORT:Bullying In Medicine Medical ethics Social problems in medicine Workplace bullying