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Table 1 Studies included in this review

From: Incivility in medical education: a scoping review

Study

Study Population

Quantitative—Qualitative

Types of incivility

Outcomes reported

Power day: Addressing the use and abuse of power in medical training (Angoff et al. 2016, 203–213) [19]

Medical students

Qualitative

Power-based

• Positive and negative examples of uses of power

Professionalism in the teacher-learner relationship in medical schools: mistreatment(Antonelli 2009, 88–89) [20]

Medical students

Quantitative

Verbal, sexual and gender-based

• Perpetrators by professional role

• Reasons for not reporting student mistreatment

Awareness of Bullying in Residency: Results of a National Survey of Internal Medicine Program Directors (Ayyala et al. 2018, 209–213) [21]

Residents

Quantitative

Less than 1/3 respondents reported bullying, with verbal > physical abuse

• Decreased performance and depression

Perceived Bullying Among Internal Medicine Residents (Ayyala, Rios, and Wright 2019, 576–578) [22]

Residents

Quantitative

Bullying and verbal abuse

•Concerns about burnout, decreased performance, depression, weight change/nutrition

"I'm too used to it": a longitudinal qualitative study of third year female medical students' experiences of gendered encounters in medical education(Babaria et al. 2012, 1013–1020) [23]

Medical students

Qualitative

Sexual and gender-based

•Perpetrators via student-patient and student-supervisor relationships

•Impact on student self-image

•Students’ adaptations to managing inappropriate behavior

The learning environment in the obstetrics and gynecology clerkship: an exploratory study of students' perceptions before and after the clerkship (Baecher-Lind, Chang, and Blanco 2015, 27,273) [24]

Medical students

Qualitative

Verbal, sexual, physical

•Perceptions of mistreatment pre-clerkship and post-clerkship

Underlying mechanisms of mistreatment in the surgical learning environment: A thematic analysis of medical student perceptions (Brandford et al. 2018, 227–232) [25]

Medical students

Qualitative

Exclusion form medical team, obstruction of student learning, not being fair or respectful, exploiting student vulnerability, assigning non-educational tasks

•Students need to be encouraged to report mistreatment

Clerkship-Specific Medical Student Mistreatment (Breed et al. 2018, 477–482) [26]

Medical students

Quantitative

Public humiliation, gender discrimination

• Occurs more often in the operating room

• Surgery > Ob > Internal Medicine

Sexual Harassment in Ophthalmology: A Survey Study (Cabrera et al. 2019, 172–174) [27]

Faculty and residents

Quantitative

Sexual harassment

• Interfered with the ability to work

• 15% changed jobs and/or careers

• American Academy of Ophthalmology has established zero tolerance policy for sexual harassment

Sexual Harassment in Radiology (Camargo, Liu, and Yousem 2017, 1094–1099) [28]

Faculty and residents

Quantitative

Sexual harassment

• Needs to be transparency of reporting

• Females less likely to report

• Females > males

A "ton of feathers": Gender discrimination in academic medical careers and how to manage it (Carr et al. 2003, 1009–1018) [29]

Faculty

Qualitative

Quantitative

Gender-based

• Effect of gender discrimination on academic medicine career

Mistreatment and the learning environment for medical students on general surgery clerkship rotations: What do key stakeholders think? (Castillo-Angeles et al. 2017, 307–312) [30]

Medical students

Qualitative

Mistreatment, neglect, unclear expectations, not integrating into the team, negative attitudes about lack of knowledge, humiliation, sexual harassment

• Focus on learning environment

Bullying in the American graduate medical education system: A national cross-sectional survey (Chadaga, Villines, and Krikorian 2016, e0150246) [31]

Residents

Quantitative

Verbal

• Most common types of bullying and association of personal attributes with risk of bullying

• Perpetrators by professional role

• Impact on health

Workplace Bullying of Urology Residents: Implications for the Patient and Provider (Chowdhury, Husainat, and Suson 2019, 30–35) [32]

Residents

Quantitative

98% reported bullying

• Perceptions is that this had negative effects on personal behavior and patient care

Intraoperative Disruptive Behavior: The Medical Student's Perspective (Chrouser and Partin 2019, 1231–1240) [33]

Medical students

Qualitative

Verbal abuse in the operating room

• Personal and team consequences with a result of decreased work

Exploring medical students' barriers to reporting mistreatment during clerkships: a qualitative study (Chung et al. 2018, 1478170) [34]

Medical students

Qualitative

Mistreatment, verbal and physical abuse

• Barriers to reporting: fear of reprisal, perceptions that medical culture includes mistreatment, the difficulty of reporting subtler forms of mistreatment, can damage teacher-students relationship, reporting process cumbersome and is reporting beneficial

The prevalence of medical student mistreatment and its association with burnout (Cook et al. 2014, 749–754) [14]

Medical students

Quantitative

Mistreatment

• Frequency of mistreatment by faculty and residents

• Prevalence of burnout in medical students by degree of reported mistreatment

A Survey Study of Resident Experiences of Sexual Harassment during Dermatology Training (DeWane et al. 2019) [35]

Residents

Quantitative

Sexual harassment by patients, faculty and fellow residents

• Greater in females than males

• Sexist hostility and gender harassment

Feedback matters: the impact of an intervention by the dean on unprofessional faculty at one medical school (Dorsey, Roberts, and Wold 2014, 1032–1037) [36]

Medical students

Quantitative

Verbal

• Unprofessional faculty behaviors most frequently mentioned by graduating medical students

An Empirical National Assessment of the Learning Environment and Factors Associated with Program Culture (Ellis et al. 2019, 585–592) [37]

Residents

Quantitative

Verbal and physical abuse, gender discrimination, sexual harassment, burnout

• Wellness inversely proportional to duty hours

• Program culture determined by wellness and negative exposures

Medical student abuse from multiple perspectives (Elnicki, Ogden, and Wu 2007, 153–158) [38]

Medical students

Residents

Faculty

Nurses

Quantitative

Verbal, ethnic, sexual

• Agreement regarding if scenarios represented abuse and if type of behavior should be reported

Screening for Harassment, Abuse, and Discrimination among Surgery Residents: An EAST Multicenter Trial (Fitzgerald et al. 2019, 456–461) [39]

Residents

Quantitative

Sexual harassment

• Impact on learning climate, promoting anger, frustration and embarrassment

Eradicating medical student mistreatment: a longitudinal study of one institution's efforts (Fried et al. 2012, 1191-1198) [40]

Medical students

Quantitative

Verbal, power-based, sexual, ethnic, physical

• Types of mistreatment before and after adoption of ‘Statement Supporting an Abuse-Free Academic Community’

• Perpetrators by professional role including patients

Association Between Perceived Medical School Diversity Climate and Change in Depressive Symptoms Among Medical Students: A Report from the Medical Student CHANGE Study (Hardeman et al. 2016, 225–235) [41]

Medical students

Quantitative

Negative role modeling, mistreatment, negative racial climate, ignored, humiliated

• Increased depressive symptoms related to negative behavior

• Call for creating an institutional climate that is inclusive, fair and equitable

Formation of medical student professional identity: categorizing lapses of professionalism, and the learning environment (Hendelman and Byszewski 2014, 139) [42]

Medical students

Quantitative

Verbal, power-based, cultural or religious, sexual

• Types of professionalism lapses witnessed by pre-clerkship and clerkship medical students

• Prevalence of witnessing professionalism lapse during medical school

• Perpetrators of professional lapses during pre-clerkship and clerkship

'Am I being over-sensitive?' Women's experience of sexual harassment during medical training (Hinze 2004, 101–127) [43]

Residents

Quantitative

Qualitative

Sexual

• Experiences of and discomfort with specific sexist treatment variables

• Settings by specialty

Patterns of Disrespectful Physician Behavior at an Academic Medical Center: Implications for Training, Prevention, and Remediation (Hopkins et al. 2018, 1679–1685) [44]

Medical staff

Quantitative

Disrespectful behavior

• For faculty, this was highest in the operating room; for trainees this was highest on the med/surg units

• Higher in procedural areas than non-procedural

• Males > females, medicine > surgery

Tracking Student Mistreatment Data to Improve the Emergency Medicine Clerkship Learning Environment (House et al. 2018, 18–22) [45]

Medical students

Qualitative

Ignored or marginalized, treated unprofessionally

• Need for data over time and faculty development to confront issue

Professionalism in plastic surgery: attitudes, knowledge, and behaviors in medical students compared to surgeons in training and practice–one, but not the same (Hultman and Wagner 2015, S247-54) [46]

Medical students

Faculty

Quantitative

Verbal, physical, sexual

• Types of unprofessional behavior witnessed by medical students and faculty

• Prevalence of observation of unprofessional behavior by health care personnel

Impact of a program to diminish gender insensitivity and sexual harassment at a medical school (Jacobs, Bergen, and Korn 2000, 464–469) [47]

Faculty

Quantitative

Sexual

• Prevalence of sexually harassing behaviors during multi-year program to educate faculty on gender issues and diminish sexual harassment

Sexual harassment and discrimination experiences of academic medical faculty (Jagsi et al. 2016, 2120–2121) [48]

Faculty

Quantitative

Sexual, gender-based

• Types of sexual harassment experienced

• Prevalence of gender-based bias or advantage and sexual harassment

• Effect of gender-based bias on professional advancement

Identifying Medical Student Mistreatment in the Obstetrics and Gynecology Clerkship (Kappy et al. 2019) [49]

Medical students

Quantitative

Qualitative

Treated as ‘stupid’; Discouraged from asking questions; ignored; marginalized; nonprofessional behavior

• Students reported a high rate of mistreatment

• Conclusion is to improve the learning environment

Reported Mistreatment During the Surgery Clerkship Varies by Student Career Choice (Kemp et al. 2018, 918–923) [50]

Faculty and residents

Quantitative

Verbal/physical abuse, negative physician attitudes, sexual harassment, gender discrimination, public humiliation

• Mistreatment appears to be improving

• Career choice of students correlated with perceptions of mistreatment

Verbal aggressiveness among physicians and trainees (Lazarus et al. 2016, 756–760) [51]

Medical students

Residents

Faculty

Quantitative

Verbal, physical

• Prevalence bullying in medical school

• Sources of trainee bullying

• Settings

• Association of Infante Verbal Aggressiveness Scale (IVAS) with specialties, attending and trainee characteristics

Post-traumatic Stress Disorder in Resident Physicians (Lo et al. 2019, e4816) [52]

Residents

Quantitative

Bullying, violence

• Concerns about post-traumatic stress disorder

Medical student mistreatment: understanding 'public humiliation' (Markman et al. 2019) [53]

Medical students

Qualitative

Public humiliation

• May be amenable to intervention through teaching faculty the importance of orientation and clear communication of intent

Learning about medical student mistreatment from responses to the medical school graduation questionnaire (Mavis et al. 2014, 705–711) [16]

Medical students

Quantitative

Verbal, physical, sexual, racial/ethnic, sexual orientation

• Prevalence of types of mistreatment

• Perpetrators of mistreatment

• Awareness regarding school policies; reporting practices

Perception of Shame in otolaryngology-head and neck surgery training (McMains et al. 2015, 786–790) [54]

Residents

Faculty

Quantitative

Shaming

• Prevalence of shaming

• Sources of shaming

• Settings

• Effects of shaming on individual

The Culture of Academic Medicine: Faculty Behaviors Impacting the Learning Environment (Moutier et al. 2016, 912–918) [55]

Faculty

Quantitative

Derogatory behavior, anger, hostile email and verbal communication, bullying, sexual harassment

• Decreased work production, jeopardized patient care

• Strategies should be directed to improve the learning climate

Interns' experiences of disruptive behavior in an academic medical center (Mullan, Shapiro, and McMahon 2013, 25–30) [56]

Residents

Quantitative

Verbal, gender-based, racial, physical

• Types of disruptive behavior

• Perpetrators of disruptive behavior

A qualitative study of gender differences in the experiences of general surgery trainees (Myers et al. 2018, 127–134) [57]

Residents

Qualitative

Lewd remarks, interpreting other’s behavior as aggressive

Females affected more than males

• Women perceive lack of mentorship, discomfort, pressure to accept/participate in unprofessional behavior, difficulty completing tasks, more barriers during training that interfere with self-identification as surgeons versus men

Medical students' perception of lesbian, gay, bisexual, and transgender (LGBT) discrimination in their learning environment and their self-reported comfort level for caring for LGBT patients: a survey study (Nama et al. 2017, 1368850) [58]

Medical students

Quantitative

Negative comments about sexual orientation, jokes rumors, bullying, harassment

• This is peer-on-peer incivility and based on perceptions

• Anti-LGBT discrimination and heterosexism noted by peers, although not affecting the care of LGBT patients

• This discrimination presents a difficult learning environment for these students

Gender discrimination and sexual harassment in medical education: perspectives gained by a 14-school study (Nora et al. 2002, 1226–1234) [59]

Medical students

Quantitative

Sexual, gender-based

• Prevalence of gender discrimination/sexual harassment

• Settings by specialty

Faculty self-reported experience with racial and ethnic discrimination in academic medicine (Peterson et al. 2004, 259–265) [60]

Faculty

Quantitative

Racial/ethnic

• Prevalence by race

• Effect on career satisfaction, job stability, professional confidence

Sexual Harassment of Canadian Medical Students: A National Survey (Phillips et al. 2019, 15–20) [61]

Medical students

Quantitative

Sexual harassment

• Predominantly by patients, then fellow students and faculty

• Perpetrators all male and 98% victims female

• Resulted in shame and self-blame of victims

• Silence to this problem not acceptable

To the point: undergraduate medical education learner mistreatment issues on the learning environment in the United States (Pradhan et al. 2019) [62]

Medical students

Quantitative

Public humiliation, sexual remarks

• Resulted in negative learning climate

• Remedies need to be directed to faculty, residents and students with a zero tolerance policy

Supervisor-trainee relationship boundaries in medical education (Recupero et al. 2005, 484–488) [63]

Residents

Quantitative

Supervisor-trainee boundaries, sexual

• Types of boundary violations

• Perpetrators by supervisory role

Patterns and predictions of resident misbehavior–a 10-year retrospective look (Resnick et al. 2006, 418–425) [64]

Residents

Quantitative

Verbal, physical

• Types of mistreatment

• Victims

• Perpetrators by surgical specialty,

Impact and implications of disruptive behavior in the perioperative arena (Rosenstein and O'Daniel 2006, 96–105) [65]

Residents

Faculty

Nurses and other perioperative staff

Quantitative

Verbal, physical

• Types of disruptive behavior

• Perpetrators by professional role

• Effect on individual and clinical care

Workplace bullying of general surgery residents by nurses (Schlitzkus et al. 2014, e149-54) [66]

Residents

Quantitative

Verbal

• Types of bullying

Workplace violence and harassment against emergency medicine residents (Schnapp et al. 2016, 567–573) [67]

Residents

Quantitative

Physical abuse and verbal harassment by patients, sexual harassment

• 75% felt safe at work

• Need to understand the prevalence of workplace violence for prevention

Training-related harassment and drinking outcomes in medical residents versus graduate students (Shinsako, Richman, and Rospenda 2001, 2043–2063) [68]

Residents

Quantitative

Verbal, sexual

• Types of harassment

• Victims’ gender and Michigan Alcoholism Screening Test (MAST) scores

Mistreatment of medical students in the third year may not be the problem (Slavin and Chibnall 2017, 891–893) [69]

Medical students

Quantitative

Working with unhappy residents and attending physicians, ignored, feeling incompetent, unfair evaluations

• Assess underlying reasons why attending physicians and residents are unhappy, leading to burnout

Does students' exposure to gender discrimination and sexual harassment in medical school affect specialty choice and residency program selection? (Stratton et al. 2005, 400–408) [70]

Medical students

Quantitative

Gender-based, sexual

• Setting by specialty

• Influence on specialty choice and residency rankings

Emergency medicine resident wellness: Lessons learned from a national survey (Taher et al. 2018, 721–724) [71]

Residents

Quantitative

Verbal harassment

• Results were falling asleep at the wheel, motor vehicle accidents, stress, fatigue, mood swings, suicidal ideation

• Call for more investigation with validated tools for stakeholders

Prevalence of Horizontal Violence Among Emergency Attending Physicians, Residents, and Physician Assistants (Volz et al. 2017, 213–218) [72]

Faculty, residents, physician assistants

Quantitative

Verbal aggression, demeaning remarks, not respected re: professional decisions, subject of rumors, isolation

• 9% stated this impacted their health and the care of their patients

Gender-based discrimination is prevalent in the integrated vascular trainee experience and serves as a predictor of burnout (Wang et al. 2019) [73]

Residents

Quantitative

Public humiliation, others taking credit for one’s work, assigned tasks as punishment, physical violence, gender/race/ethnicity mistreatment, sexual harassment

• Negative workplace experience

• Affected relationships with staff, women > men

Resident bullying in diagnostic radiology (Wolfman and Parikh 2019, 47–52) [74]

Residents

Quantitative

Bullying

• 28% experienced bullying and 33% witnessed bullying