This study is different from previously published reports in the following aspects: 1) We present data only from North America, precluding cultural differences that likely exist in medical schools, residency programs and departments from countries outside of North America [76, 77]; 2) Although we recognize that incivility occurs across the health professions, we limited our pertinent articles to those dealing with individuals in academic health centers representing the continuum of medical education, exclusive of continuing professional education, as there was no literature addressing this aspect of education; and 3) We sought to identify specific factors that would provide more insight and detail into incivility including the perpetrators, victims, settings, types of incivility, and the impact on the individuals and department/institution.
Our study re-confirms previous studies that incivility and mistreatment across the medical education continuum is a persistent, pervasive, and often inadequately reported and addressed problem in North America. Reporting of mistreatment is mandated at the undergraduate level through the Graduation Questionnaire administered by the Association of American Medical Colleges. At the graduate level, there is no national mandate to report incivility, although there is a mechanism through an ombudsperson to report potential problems. For faculty encountering different forms of incivility, it is unclear how many medical school-affiliated departments have mandatory reporting mechanisms. Whereas the purpose of our study was to the capture detailed data on the topic published, from the articles we found, there still appears to be a great deal of underreporting, making the true prevalence of incivility difficult to determine [20, 23].
Through our review, we hoped to extract more detailed information than previous articles on the topic, in order to advance the field by identifying perpetrators, victims, and where incivility occurs. While the studies in our review did identify both victims and perpetrators in general terms, more granular descriptions of perpetrators, victims, and likely settings of incivility were not available. As an example, studies did not enumerate faculty seniority or rank, resident level, or gender information either as perpetrators or victims. The settings in which incivility occurred were not always identified, making it difficult to tailor an approach to the problem. Although our review was not able to identify detailed characteristics regarding all aspects of incivility, it may be possible to capture this data more effectively via other processes (e.g., confidential focus groups) which address specific victim groups, perpetrator groups, and/or settings.
As an overview of our study, there were determinants identified that the authors deemed significant. In terms of study design, a majority of studies used a quantitative methodology, with about 20% using qualitative methods and three studies reporting mixed methods. Based on examining study results using any of the three methodologies, none appeared advantageous regarding producing more specific data to assess the root causes of incivility. In addition, the study populations were evenly split between medical students and residents, with faculty-focused incivility representing fewer studies. Lastly, the types of incivility included vague categories such as mistreatment and more specific areas like sexual harassment, verbal and physical abuse, gender discrimination, bullying and public humiliation, among others.
The types of incivility identified in the study covered a wide spectrum amongst trainees and faculty, from verbal abuse to sexual harassment. Sexual harassment and verbal abuse occurred across the spectrum of medical students, residents and faculty and were not specific for any one group. There is another area of incivility that is less frequently identified or addressed, i.e., what the authors label as covert incivility. Covert incivility occurs when trainees are ignored, not included in team functions, and when their input is not valued as team members. This kind of incivility is more subtle and unlike verbal and physical abuse, is one of exclusion, although it can have the same effect as more overt behaviors on one’s professional development. The authors suggest that Bandura’s Social Learning theory helps to account for this perpetuation of incivility from generation to generation [13]. What is clear is that incivility is imbedded in an unsafe learning climate, resulting in a proclivity to more patient errors, thus compromising patient safety. In addition, this has led to burnout, depression, change of jobs, and to the extreme, suicidal ideation and behavior, in trainees and faculty, compromising the effective functioning of the health care team [9, 78, 79].
Because perpetrators of incivility have not been consistently identified with details regarding their gender, professional rank (e.g., intern vs junior residents; junior vs. senior faculty), age, and cultural identity, it is difficult to suggest specific prevention and remediation measures based on demographic characteristics as the target group is diverse. While perpetrators and victims of incivility were frequently linked by power differentials, three perpetrator groups were identified in the literature that may be overlooked, namely, nurses, patients, and medical school peers. While nurses have been associated with mistreatment of students, trainees, and faculty [16, 20, 31, 42, 56, 63, 40], additional data is needed to determine the kinds of incivility that have occurred and analyze the root causes of this behavior. What is clear is that the patient care model of nurses providing day-to-day patient care in both ambulatory and high acuity areas of the health system (e.g., the delivery room, the ICU, surgery and inpatient) remains reasonably stable, and trainees rotate through those areas for limited periods during their training. Anecdotally, nurses may develop a protective attitude about their ‘work turf’ through which trainees transiently pass and trainees may be inadequately prepared for work in an interdisciplinary team environment with high stress staffed by seasoned nurses.
Patients also represented an unanticipated perpetrator group, but the specific types of incivility committed by this group were not described in detail [20, 23, 31, 40]. There were notations in studies about physical and verbal abuse, sexual harassment and safety issues, but these acts were not enumerated upon. Perpetrating physician violence can certainly occur when patients are mentally unstable and under the influence of drugs. In addition, they can inappropriately and relentlessly demand tests, treatments and prescriptions from medical students, residents, and physicians, resulting in excessive counseling time, unnecessary and sometimes costly medical care, and dissatisfaction with medical care [80]. It is important to differentiate those patients that are very vocal and proactive about their care versus those who are unreasonably demanding of tests and procedures not in accordance with the standard of medical care, in addition to being inappropriate with language and physical contact.
Incivility perpetrated toward medical students by peer medical students was also reported in our search [16, 42, 51]. Incivility involving medical students as both perpetrators and victims is a disturbing finding and one that could emanate from faculty and residents modeling inappropriate behavior as well as the competitive environment of medical school; i.e., the Bandura effect. Many medical schools have adopted the AMA Code of Ethics in which chapters 9 and 10 address how physicians should interact with fellow professionals and self-regulate regarding their professional behavior [81]. Adhering to these ground rules is a reasonable expectation and deviations from the norms should be opportunities to counsel students and observe behavior change over time. There is also a study that identified resident incivility against peers [35] and the same principles for addressing this behavior applies.
Assessing the characteristics of the victims did not provide a uniform, single victim profile from our review. Whereas specific studies focused on particular groups within the continuum and suggested incivility followed the training hierarchy, most articles did not provide enough information about the victims that would be of value in the identification and approach to treatment. Additional detail regarding victims’ gender, point in training or professional rank, age, and cultural identity can help to understand the victims and determine an approach that is coordinated with the problem(s) identified. To generalize from our data, female medical students were more likely to be victims of incivility than males, fellows and residents were likely to be bullied, under-represented minorities were more likely to be on the receiving end of racial or ethnic bias versus non-Hispanic whites, and females were more likely to be sexually harassed than males.
The reported settings of incivility were diverse enough that it is not possible to pinpoint specific settings in which incivility occurs. Some departments and clinical settings (e.g. obstetrics and gynecology, surgery, operating room, emergency room) seem to report higher rates of incivility but the underlying reasons, i.e., root causes, for this remain unclear. Further research might help identify factors that cause higher rates of incivility in these areas and determine if they are associated with the culture, fast-paced environment, and high-risk decision-making. If indeed incivility behaviors occur in specific areas, these could then be the focus for further data collection in terms of if there are embedded cultural issues, personnel, or structural issues that might be contributing to this problem.
It is evident that incivility has been reported to have had a significant effect on individuals, including health effects [31, 68], diminished self-confidence and self-esteem [23, 29, 54, 60], and burnout and diminished career satisfaction [14, 29, 60, 82]. Medical students report a high burnout rate, isolation, alcohol abuse and think differently about their career choice when they are the subjects of incivility. The burnout phenomenon is not new to medicine as one traverses the arduous task of formal education and clinical training over years. However, there is recent evidence that burnout can result from a learning climate that is not safe, especially when there is incivility inherent in the culture. This also has been shown to pose a risk for patient safety and increased medical errors. Not tolerating incivility and teaching trainees and faculty what the characteristics are of a safe learning climate will be helpful in changing this culture. Lastly, and not surprisingly, faculty report leaving their academic jobs or in fewer instances, clinical medicine altogether, because of adverse work climate issues that impact their satisfaction and performance [83, 84].
The institutional impact has been reported infrequently but we noted institution-wide changes in how incivility is reported and the creation of guidelines that address how the organization seeks to identify this behavior and then how to deal with it [16, 20, 65, 70, 40]. The LCME guidelines specifically address medical student mistreatment and challenge medical schools to set up a reporting and remediation process to confront incivility as residents and faculty interact with students [85]. It is too early to determine the effects of these programs as students may still not feel empowered to confront the hidden curriculum that has permeated the medical culture for so long [12]. The Accreditation Council for Graduate Medical Education (ACGME) also requires programs to ‘identify resident mistreatment’ but there does not appear to be any national repository to collect data to assess the prevalence of this problem [86]. The Joint Commission has also mandated that academic health centers have processes in place to manage disruptive behavior [10]. The possible compromise of patient care, decreased work productivity, discordance of team functioning and faculty (and trainees less so) leaving their jobs all have a clear-cut impact on the institution.
Whereas bullying or incivility in school-aged children, politics, and in the workplace makes headlines, the incidence and ultimate impact appear to be underreported in medical education [16]. Underreporting may be due to fear of consequences on the part of the victim, an ingrained culture of negativity towards those lower in the medical education hierarchy, and perhaps because this behavior has been tolerated and accepted due to power differentials between perpetrators and victims. Another possible cause for underreporting is the subjectivity of the matter. Incivility investigations often result in a difference of opinions, unless another outside witness can verify events, which changes the anonymity of the process. In previous years, intervention programs based on education and anonymous reporting systems were established at institutions in the United States, with little to no decrease in mistreatment [40]. Anonymous reporting makes verification of events nearly impossible, but identified reporting perpetuates the fear of retaliation. This makes interventions that much more of an obstacle. It also makes generalization and application of systems for change rather difficult as well.
One of the barriers and limitation of the study was that the authors encountered numerous and varied terms; i.e., keywords, used in the literature to identify studies on incivility. Consequently, searching the literature for evidence and pervasiveness of incivilities was a challenge. Based on our experience reviewing the literature, we recommend using ‘incivility’ to describe all forms of mistreatment across the continuum of medical education for more clarity in further research. Incivility is a broader term that includes any behavior within the field that negatively affects the individual, team and/or institution. Based on this scoping review, the authors suggest that the topic of incivility has been investigated and addressed enough, with newer publications not adding additional information to the existing literature in terms of addressing the problem. It is disheartening to see the same incivilities reported over and over again, with too-often recommendations made that further studies need to be done to define the problem. Intervention systems and models will only be pursued when incivility in medical education is seen as a priority issue to be addressed.
The reporting of incidents should not imply there will be punitive action against individuals; instead, we should seek educational interventions to make the learning environment safer, e.g., mandating workshops for faculty, staff and trainees on the characteristics of a safe learning climate, with a special focus on the teacher-learner, provider-patient, and health care professional to health care professional relationships. Content should include burnout, patient safety, hierarchical relationships, and institutional and individual impact.
Incorporating communication skills training into the curriculum at the undergraduate and graduate levels that addresses inappropriate and aggressive patient behavior towards trainees should be considered for teaching trainees how to recognize the problem and negotiate with these patients. Patient abuse of trainees is not acceptable, and educators should incorporate techniques into the curriculum that make boundaries clear and provide trainees with response strategies.
With peer-on-peer incivility not acceptable, educational interventions also need to be directed towards that problem. Students have been the products of a competitive environment from the beginning of their education in which attaining the highest levels has been the benchmark for realizing medical school acceptance and residency selection. Course directors, residency training program and clerkship directors, in addition to educational deans should proactively address unacceptable behavior that has been noted in peer-on-peer incivility in the literature. Orientation of trainees at all levels that specifically address peer-on-peer incivility and state a zero-tolerance policy with significant consequences should be an integral part of our educational culture.
The authors suggest that educators consider creating interactive workshops incorporating role-play or simulated scenarios that address the workings of interprofessional/interdisciplinary teams (nurses, allied health professionals, and the hierarchy inherent in teams) to decrease incivility in the clinical setting. Our data was specific to nurse abuse of trainees but expanding education to the training involving other health professionals would also be proactive in identifying and dealing with these incidents [87]. These are teachable behaviors and based on our findings, should be part of the training across the continuum of education.
Finally, incivility is not tolerated in the workplace in some countries, the U.S. being an exception [88]. The authors suggest that this approach be considered for the continuum of medical education, reducing the incidence of what all would agree is unacceptable behavior in a learning environment that needs support for learners at all levels. Emphasizing what should not be tolerated in the workplace as opposed to making exceptions for physicians and other healthcare providers because they create revenue or are looked upon as favored employees is critical, i.e., zero-tolerance regulations. Whereas further studies need to be completed to establish details that our study was not able to extract, academic centers and national accrediting organizations should be looking to change the climate by establishing national standards in the workplace. Starting with establishing transparency regarding acceptable and unacceptable behaviors and making it clear that there is a zero-tolerance policy on incivility should be uniform policy across academic health centers. Medicine has tolerated this unacceptable behavior long enough and responsible leadership need not wait longer to improve the health care environment for our trainees, faculty, and patients.