Nearly half of emergency medicine (EM) residents in the U.S (45.1%) reported being exposed to some form of mistreatment, a large survey study found.
The mistreatment ranged from discrimination based on race or gender to verbal and physical abuse, reported Michelle Lall, MD, MHS, of Emory University in Atlanta, and colleagues, who also found a significant association between the frequency of mistreatment and reports of suicidal thoughts among EM trainees.
A total of 243 residency programs accredited by the Accreditation Council for Graduate Medical Education participated in the survey in February 2020, garnering a study cohort of 7,680 EM residents. In all, 29.5% of respondents experienced gender discrimination (heavily skewed toward women), 29% verbal or emotional abuse, 18% racial discrimination, 14.6% sexual harassment, and 4.6% physical abuse.
Of those, patients and/or patients’ family members were responsible for 58.7% of the gender discrimination, 59.5% of the verbal or emotional abuse, 67.5% of the racial discrimination, 69.1% of the sexual harassment, and 85.2% of the physical abuse.
As the team wrote in their study in JAMA Network Open, 2.5% of trainees identified as having experienced suicidal ideation in the past year, with a similar prevalence by race and gender: 2.4% of male residents, 2.4% of female residents, 2.4% of non-Hispanic white residents, and 2.7% of non-white EM residents. Notably, the percentage of residents who reported having suicidal thoughts during the July 2019-February 2020 academic year was lower than the rate found in previous research.
In the adjusted models for suicidal thoughts, however, the prevalence of suicidal ideation was greater for those who identified as LGBTQ+ (OR 2.04, 99% CI 1.04-3.99). There was also an association between experiencing mistreatment at least a few times a month and the frequency of suicidal thoughts. When the researchers adjusted for mistreatment exposures, they found that women were less likely than men to report suicidal thoughts (OR 0.54, 99% CI 0.34-0.86).
“The results suggest that the higher prevalence of mistreatment experienced by women in medicine may be one factor associated with the higher rates of suicide among female physicians,” the researchers wrote.
Of the 8,162 eligible residents, 94.1% responded to at least one question on the survey, while 79.7% completed the survey in its entirety. The cohort was 62.1% male, 35.1% female, 64% white, 3.7% Black, 13.6% Asian/Pacific Islander, 4.3% Hispanic, and 0.4% Native American. A total of 483 EM residents (6.3% of the total) identified as LGBTQ+, and 5,951 (77.5%) reported being either married or in a relationship.
The researchers explained that most recent research on the overall topic has understandably focused on the workplace mistreatment experienced by individuals with “lower status in the medical workforce hierarchy.” The most relevant, comprehensive study on EM resident mistreatment was published in 1985, with a sample of 1,774 residents.
For the current study, Lall and co-authors used a self-report survey that was adapted from other published surveys. To gather information about the frequency of mistreatment, the team asked respondents to choose between the following categories of mistreatment: never experienced; and experienced a few times a year, a few times a month, a few times a week, or every day. The options provided for perpetrators included patients and/or their family members, attending physicians, other residents/fellows, administrators, nurses, and support staff.
Gender discrimination was reported by 2,104 residents — 65.2% of the women and 9.1% of the men (P<0.001). The most common source of the mistreatment was from patients and/or their family members (accounting for 62.8% of the gender discrimination against women and 45.2% against men) followed by from nurses or other staff members (20.2% and 14.5%, respectively).
Instances of racial discrimination were reported by 7.9% of white residents compared with 37.6% of residents from other racial/ethnic groups (P<0.001); non-white residents who reported racial discrimination also noted that this type of mistreatment occurred at least a few times a month.
Discrimination based on sexual orientation or gender identity was reported by 220 respondents (3.1%). As with the other forms of reported discrimination, the majority of those who identified as LGBTQ+ (56.2%) noted that the most common source of mistreatment came from patients and their family members; however, 13.8% said that they experienced this type of mistreatment from fellow residents.
A total of 5.1% of survey respondents reported discrimination based on pregnancy and/or childcare status, including 270 women (10.8%) and 79 men (1.8%; P<0.001); of the 186 residents who experienced mistreatment associated with parenting, 30.6% identified other residents as the primary source of mistreatment, and 29.6% identified attending physicians.
Reports of sexual harassment came from 28.8% of female residents and 6.5% of male residents (P<0.001).
The authors acknowledged that, despite respondents’ anonymity and having a secure server to store survey responses, the fear of being identified and retaliated against may still have contributed to underreporting of mistreatment by EM residents and was, therefore, a significant limitation in the study. Social-desirability bias may have also played a role in underreporting, as it is common for emergency physicians to keep up an image of “strength and stamina,” the researchers noted.
They recommended that in addition to creating training programs to help staff members learn how to best intervene in the face of watching mistreatment happen as a bystander, hospitals can also “provide cultural competency training to all emergency department staff with the goal of increasing collective knowledge about marginalized groups (women and individuals who are underrepresented in medicine or LGBTQ+) that are at increased risk of experiencing workplace mistreatment.
“This increase in knowledge and subsequent self-awareness may create a more open, safe, and supportive workplace for EM residents,” Lall and co-authors wrote.