Resident Intimidation
Seemal R. Desai, MD
Vice-Chair, AMA-RFS Governing Council
Honolulu, Hawaii
Interim Meeting
Introduction
• Overview of Intimidation
• AMA-RFS recognition of the issue
• History of graduate medical education
• Recent changes in GME
• Is intimidation an issue?
• Consequences of intimidation
• Proposed solutions
Intimidation
• Definition -- attempt to frighten by acting
in a dominating manor with the goal of
making people do what the intimidator
wants.
• Behavioral trait – present in everyone
• Behavioral theorists suggest it is seen in
children as a consequence of being
intimidated by others
AMA-RFS
• Section within the AMA
• Approx. 25,000 resident and fellow
members
• 76 State and specialty societies
• Annual and Interim Assemblies
AMA-RFS
• Member Connect Survey –
• 688 Residents and Fellows responded
• Identified four issues of importance
•
•
•
•
Medical Liability
Educational Loan Debt
Uninsured
Intimidation
• Over 75% of residents think it is important
that the AMA address the issue of
intimidation
Member Connect Survey
• Prevalence
• Resident members asked if they have
experienced:
•
•
•
•
Non-physical harm threatened
Pressure to report work hours inaccurately
Sexual Harassment
Physical Harm Threatened
• 25% have had non-physical harm threatened
• 22% have been pressured to report
inaccurate duty hours
Perpetrators
Who Perpetrated the Intimidation?
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
72%
64%
53%
44%
42%
34%
30%
21%
14%
14%
Nonphysical harm
threatened
Pressure to Report
Work Hours
Incorrectly
Sexual Harrassment
Senior Resident/Fellow
36%
Attending
20%
Physical Harm
Threatened
Other
Member Connect Survey
• Reporting –
• 68% of residents believe they would know
how to report intimidation
• 50% responded they would not be
comfortable reporting intimidation to their
residency program
Reporting
How Comfortable Would You Be in Reporting Intimidation in Your
Residency Program?
Very
Uncomfortable
23%
Somewhat
Uncomfortable
27%
Very Comfortable
29%
Somewhat
Comfortable
21%
History of Graduate Medical Education
• 1914 – CMEH approved list of hospitals
for internship
• 1923 – CMEH approved list for GME
• 1928 – Essentials of Approved
Residencies and Fellowships – set
standards
• 1953 – RRC was developed
• 1981 – LCGME became the ACGME
• Now 26 RRC’s, TYRC, IRC
Trend in Graduate Medical Education
Standardization of Medical Education
1914
1910
1920
2006
1930
1940
1950
1960
1970
1980
1990
2000
Trend in Graduate Medical Education
Standardization of Medical Education
1914
2006
Learners
Learners
1910
1920
1930
Teachers
Teachers
1940
1950
Learners
1960
1970
1980
Teachers
1990
2000
Trend in Graduate Medical Education
Standardization of Medical Education
1914
2006
Learners
Learners
1910
1920
1930
Teachers
Teachers
1940
1950
Learners
1960
1970
Educational Values
1980
Teachers
1990
2000
Trend in Graduate Medical Education
Standardization of Medical Education
1914
2006
Learners
Learners
1910
1920
1930
Teachers
Teachers
1940
1950
Learners
1960
1970
1980
Educational Values
Generation Gap Conflict
Teachers
1990
2000
Sir William Osler
• Father of Medical Education
• Established the sleep-in residency
program
• Residencies were open-ended and had a
long tenure
• Residents led restricted and almost
monastic lifestyle
• System spans the generations
• May now be obsolete
Generations
• Traditionalists
• Baby Boomers
• Generation X
• Generation Y
Generations
• Traditional or Silent Generation 1925-1945
• Term was title of Nov 5, 1951 cover of Time
• Raised during the post-war depression
• Faith in institutions, government, business, family, or
church
• William Manchester commented:
• Withdrawn, cautious, unimaginative, indifferent
• Respect authority
• Subscribe to a top-down model of authority
• Included: Johnny Carson, Sandra Day O’Connor, Clint
Eastwood, Neil Armstrong
Generations
• Baby Boomer 1946-1964
•
•
•
•
Born during economic prosperity post WWII
First generation that had advanced degrees
Vietnam War
Idealistic leaders that succeed by leading in the worst
of times
• Political leaders today
• It is estimated that the Boom Generation will hold a
plurality in Congress until 2015, the White House until
2021, and will have a majority in the Supreme Court
from 2010 to 2030.
Generations
• Generation X 1961-1981
• Term popularized by Coupland’s 1991 novel
“Generation X…” described the loss of the icons of the
baby boomer generation
• Jane Deverson – coined term in a text where she
described this gen. “sleeps together before marriage,
don’t believe in God, dislike the Queen, and don’t
respect parents”
• Skeptical, raised during recession and downsizing
• More concerned with work-life balance than boomers
• Self driven, learners, skilled individuals
Generations
• Generation Y – 1977-2003
• Technology driven
• Tolerant of multiculturalism
• Customizing of everything
• Typically received positive affirmation from
parents
• Expect the same affirmation by teachers
• Insist on a work-life balance
Why is there a problem now?
• More Intimidation or Less Tolerance?
• Sentinel Events
• ACGME Core Competencies
• 2003 Residency Work Hour Reforms
• Diversification of the workplace
• Is medicine the only industry affected?
• Military
• Corporate workplace
Institute for Safe Medication Practices
• Survey published in March, 2004
• 2095 staff from different hospitals
• >80% felt mild intimidation
• 48% suffered strong verbal abuse
• 43% experienced threatening body language
• 4% physically abused
Consequences of Intimidation
Patient Care
• Dishonesty
• Individual
• Relationship injuries
• Reporting
• Depression
• Patient data
• Fatigue
• Fear to act
• Congested
communication
• Compromises in
patient care
• Resignation or Transfer
• Perpetuation of cycle
Solutions
• Education
• Identification
• Enforcement
Education
• Education Goals
• Diversity Training
• Behavioral Training
• Generation Gap Training
• Forum
• Medical School
• Workshops/Seminars
• On-line curriculum
Identification
• Natural History of Reporting
• Fear of consequences
• Doubt of anonymity
• Whistleblower
• Monitoring mechanisms
• Exit interviews
• Ombudsman program
• Hotline for reporting intimidation
Enforcement
• Benign Enforcement
• Resident-Faculty Compact
• Faculty-Resident Compact
• Ombudsman Program
• Punitive Enforcement
• Requires identification of a systems problem
• Labor intensive
Summary
• 75% of AMA-RFS members rank
intimidation as a top issues for residents
• Generation Gaps create conflict that
lends itself to intimidation
• The consequences of intimidation are
destructive to education and patient care
• Solutions to intimidation involve a
multidirectional approach including:
education, identification, and enforcement
Contact Information
Seemal Desai, MD
Vice-Chair, AMA-RFS Governing Council
The University of Alabama Birmingham
seemald@yahoo.com