Prevalence, Types, and Sources of Bullying Reported by US General Surgery Residents in 2019 (2024)

Surgical resident mistreatment is concerning.¹ Bullying, one type of mistreatment, defined as persistent negative and aggressive behaviors, primarily of a psychological nature, with the effect of humiliating, intimidating, frightening, or punishing,² has been associated with adverse outcomes such as depression.³ However, bullying during surgical training has not been well characterized, with prior evaluations limited by low survey response rates and inclusion of few institutions.²^,4 We aimed to examine the prevalence, types, sources, and factors associated with bullying reported by US general surgery residents.

Methods

A voluntary, confidential survey was administered electronically to US general surgery residents following the 2019 American Board of Surgery In-Service Training Examination (ABSITE). The Short-Negative Act Questionnaire (S-NAQ), a validated workplace bullying assessment, was used to measure how often residents experienced 9 specific behaviors within that academic year (Table 1). Answers were reported using a Likert scale (never: response attributed a score of 1; now and then: 2; monthly: 3; weekly: 4; and daily: 5 [total score range, 9-45]). Occasional bullying was defined as a score of 12 to 15 and frequent bullying as a score of 16 or greater.³ For responses indicating that bullying behaviors occurred more often than never, residents were asked to identify a source from a predetermined list (Table 1).

Burnout was defined as any emotional exhaustion or depersonalization symptom (from an abbreviated Maslach Burnout Inventory) experienced at least weekly. Residents were also asked if they had thoughts of leaving their program within that academic year or of suicide within the past 12 months.¹ Associations between frequent bullying and these outcomes were evaluated using χ² tests.

A multivariable logistic regression model was constructed to identify factors associated with frequent bullying. Resident and program characteristics were obtained from the American Board of Surgery and the Accreditation Council for Graduate Medical Education (Table 2). Corrected risk ratios were calculated from logistic regression odds ratios.⁵ A 2-tailed P < .05 was considered statistically significant. All analyses were performed using Stata version 15.1. The Northwestern University institutional review board deemed this study exempt.

Results

There were 6956 responses to the survey (85.6% response rate) from residents in 301 accredited US programs. Of the 6264 residents who answered the S-NAQ, 4191 (66.9%) reported experiencing at least 1 bullying behavior. Occasional bullying was reported by 2744 (43.8%) residents and frequent bullying by 1133 (18.1%). The proportion of residents within a program reporting frequent bullying ranged from 0% to 66.7%.

Of residents who reported any bullying behavior, 42.3% reported repeated reminders of mistakes, 39.3% being shouted at, 31.8% withholding of important information, 30.3% persistent criticism, and 24.3% hostility. Attending surgeons were the most common source of these behaviors. Being the subject of gossip was reported by 32.7% of residents, while 31.2% reported exclusion, 23.4% offensive remarks, and 9.1% unwanted jokes. When a source was identified, these behaviors were most commonly attributed to other residents (Table 1).

Residents were more likely to report frequent bullying if they were women (20.3% vs 16.4% among men), divorced or widowed (27.1% vs 16.2% among married), racial/ethnic minorities (21.0% vs 15.9% among non-Hispanic white), training at a community program (20.9% vs 16.6% among academic), in the Northeast (21.0% vs 15.7% in the Southeast), or had low ABSITE scores (22.9% vs 14.8% with high scores) (Table 2). Residents who were frequently bullied had higher rates of burnout (61.1% vs 37.0%; P < .001), thoughts of suicide (10.4% vs 3.1%; P < .001), and thoughts of attrition (28.2% vs 7.8%; P < .001) compared with those who were not frequently bullied.

Discussion

Frequent bullying was reported by 18% of surgery residents, which often originated from surgeons (attendings and other residents), suggesting that interventions should focus on surgeon professionalism. Poor ABSITE performance and minority status were associated with frequent bullying. Women were more frequently bullied, and training in a program with more women or with departmental leaders who were women was not associated with decreased bullying. The wide variability in program-level bullying rates suggests that surgical training can occur without bullying.