WELLNESS COMMITTEE
Stop Normalizing the Abuse of Residents Brendan James Flanagan, MD
R
esidency is a notoriously brutal training process. The hours are long and the pay is inadequate. But one of the largest sources of moral injury to residents is the mistreatment that they experience throughout the course of their training. In addition to working too many hours for too little money, residents are plunged into a medical training culture that can only be described as abusive. Occupying the lowest spot in an organization that is obsessed with hierarchy, residents are routinely subjected to harassment, hostility and public humiliation from a variety of sources including attendings, colleagues, other hospital staff and, frequently, patients. In a recent survey published by the ACGME, nearly half of emergency medicine residents reported some type of workplace mistreatment in the past academic year.1 This disturbingly high number is still likely an underrepresentation, as many in our profession have simply come to accept this behavior as commonplace and others may fear retaliation for reporting these transgressions. In the world of academic medicine, there remains a pervasive ethos of character-building through abuse. The mistreatment of residents is seen not as an unfortunate byproduct of an antiquated medical training system, but rather, the purpose of the system itself. Enduring abuse from attendings, consultants, and other colleagues is supposed to give residents the thick skin that they will need to survive and thrive in our professional culture. But there is ample data to suggest that how we treat our trainees is more deleterious than salutary. Despite the prevailing culture, there is little evidence that the current model of aggressive training actually produces more resilient doctors and abundant evidence that it may be doing exactly the opposite. In the 2017 National Emergency Medicine Wellness Survey, an overwhelming majority of emergency medicine residents report symptoms consistent with burnout.2 Burnout itself has long been associated with a wide array of negative outcomes for both physicians and the patients they care for, including increased medical errors, worse 38
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clinical outcomes, and an increased incidence of depression, substance abuse, and suicide.3 While burnout is obviously multifactorial, there is evidence that residents who experience harassment are more likely to experience burnout symptoms and suicidal thoughts.4 Most disturbingly, it seems that when residents do experience abuse, they are very hesitant to report it for fear of retaliation from their superiors.5 Much of the misery of residency is tolerated because it is temporary. EM residents know that after three or four years they will become the attendings and enjoy the increase in money, status, and respect that they have earned from their hard work. What this fosters, however, is a cycle of abuse whereby today’s trainees who suffer from mistreatment often become tomorrow’s aggressors. Even physicians who do not abuse residents have been trained in a culture where doing so is considered normal and thus goes underreported and uncorrected. While many of us are not in a position to meaningfully change resident work hours or compensation, we can all do our part in changing medical culture and ending this cycle of abuse. All institutions should establish a zero-tolerance policy for abuse of any kind in the workplace. Mistreatment of trainees should be zealously identified and rooted out in much the same way as we approach patient safety events. Anyone who experiences or witnesses abuse should feel comfortable reporting the incident without fear of retaliation. Repeat offenders should not be insulated from professional consequences for their behavior because of their place in the medical hierarchy. Residents, along with everyone else in healthcare, deserve to be treated with compassion and respect and we should aim to model this behavior for those who will become the future leaders of our field.
While many of us are not in a position tomeaningfully change resident work hours or compensation, we can all do our part in changing medical culture and ending this cycle of abuse.”
References: 1. Lall, Michelle D., Karl Y. Bilimoria, Dave W. Lu, Tiannan Zhan, Melissa A. Barton, Yue-Yung Hu, Michael S. Beeson, James G. Adams, Lewis S. Nelson, and Jill M. Baren. “Prevalence of Discrimination, Abuse, and Harassment in Emergency Medicine Residency Training in the US.” JAMA Network Open 4, no. 8 (August 19, 2021): e2121706–e2121706. https://doi. org/10.1001/jamanetworkopen.2021.21706. 2. Lin, Michelle, Nicole Battaglioli, Matthew Melamed, Sarah E. Mott, Arlene S. Chung, and Daniel W. Robinson. “High Prevalence of Burnout Among US Emergency Medicine Residents: Results From the 2017 National Emergency Medicine Wellness Survey.” Annals of Emergency Medicine 74, no. 5 (November 2019): 682–90. https://doi.org/10.1016/j. annemergmed.2019.01.037. 3. Stehman, Christine R., Zachary Testo, Rachel S. Gershaw, and Adam R. Kellogg. “Burnout, Drop Out, Suicide: Physician Loss in Emergency Medicine, Part I.” Western Journal of Emergency Medicine 20, no. 3 (May 2019): 485–94. https:// doi.org/10.5811/westjem.2019.4.40970. 4. Hu, Yue-Yung, Ryan J. Ellis, D. Brock Hewitt, Anthony D. Yang, Elaine Ooi Cheung, Judith T. Moskowitz, John R. Potts, et al. “Discrimination, Abuse, Harassment, and Burnout in Surgical Residency Training.” The New England Journal of Medicine 381, no. 18 (October 31, 2019): 1741–52. https://doi.org/10.1056/ NEJMsa1903759. 5. Leisy, Heather B., and Meleha Ahmad. “Altering Workplace Attitudes for Resident Education (A.W.A.R.E.): Discovering Solutions for Medical Resident Bullying through Literature Review.” BMC Medical Education 16 (April 27, 2016): 127. https://doi.org/10.1186/s12909-016-0639-8.
