Article Text

Original research
Bullying in UK cardiology: a systemic problem requiring systemic solutions
Free
  1. Christian Fielder Camm1,2,3,
  2. Abhishek Joshi4,
  3. Abigail Moore5,
  4. Hannah C Sinclair6,
  5. Mark Westwood7,8,
  6. John Pierre Greenwood9,10,11,
  7. Alison Calver6,12,
  8. Simon Ray13,14,
  9. Christopher Allen15,16
  1. 1 Keble College, Oxford University, Oxford, UK
  2. 2 Department of Cardiology, Royal Berkshire NHS Foundation Trust, Reading, UK
  3. 3 British Junior Cardiologists Association, London, UK
  4. 4 Cardiology Department, Barts Health NHS Trust, London, UK
  5. 5 Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
  6. 6 Cardiology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
  7. 7 Bart's Heart Centre, St Bartholomew's Hospital, London, UK
  8. 8 Vice-Chair, Cardiology Specialist Advisory Committee, London, UK
  9. 9 Cardiology Department, Leeds General Infirmary, Leeds, UK
  10. 10 Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
  11. 11 President, British Cardiovascular Society, London, UK
  12. 12 Chair, Cardiology Specialist Advisory Committee, London, UK
  13. 13 Immediate Past-President, British Cardiovascular Society, London, UK
  14. 14 Cardiology Department, Manchester University Hospitals, Manchester, UK
  15. 15 Guy's & St Thomas' Hospital, King's College, Rayne Institute, London, UK
  16. 16 British Junior Cardiologists' Association, London, UK
  1. Correspondence to Dr Christian Fielder Camm, Keble College, Oxford University, Oxford, OX1 3PG, UK; cfcamm{at}gmail.com

Abstract

Objectives Bullying of trainee doctors has been shown to be associated with detrimental outcomes for both doctors and patients. However, there is limited evidence regarding the level of bullying of trainees within medical specialties.

Methods An annual survey of UK cardiology trainees was conducted through the British Junior Cardiologists’ Association between 2017 and 2020 and asked questions about experiencing and witnessing bullying, and exposure to inappropriate language/behaviour in cardiology departments. Fisher’s exact tests and univariable logistic regression models were used to describe associations between trainee characteristics, and reports of bullying and inappropriate language/behaviour.

Results Of 1358 trainees, bullying was reported by 152 (11%). Women had 55% higher odds of reporting being bullied (OR: 1.55 95% CI (1.08 to 2.21)). Non-UK medical school graduates were substantially more likely to be bullied (European Economic Area (EEA) OR: 2.22 (1.31 to 3.76), non-EEA/UK OR: 3.16 (2.13 to 4.68)) compared with those graduating from UK-based medical schools. Women were more likely than men to report sexist language (14% vs 4%, p<0.001). Non-UK medical school graduates were more likely to experience racist language (UK 1.5%, EEA 6%, other locations 7%, p=0.006). One-third of trainees (33%) reported at least one inappropriate behaviour with 8% reporting being shouted at or targeted with spontaneous anger. Consultants in cardiology (82%) and other specialties (70%) were most commonly implicated by those reporting bullying.

Discussion Bullying and inappropriate language are commonly experienced by cardiology trainees and disproportionately affect women and those who attended non-UK medical schools. Consultants both in cardiology and other specialties are the most commonly reported perpetrators.

  • education
  • medical
  • inservice training
  • quality of healthcare

Data availability statement

Data are available upon reasonable request.

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Introduction

It’s an incredible paradox that being a doctor is so degrading and yet is so valued by society. ―Samuel Shem, The House of God

Bullying has been demonstrated to be common in the UK National Health Service (NHS), with previous surveys suggesting that ~40% of junior doctors report having been bullied.1 Similar prevalence is reported by trainee doctors in other countries.2–4 Bullying has similarly been shown to be common in other groups in the medical workforce.5 6

While the experience is subjective, workplace bullying has been associated with a number of negative outcomes. Such behaviour has been shown to have a negative impact on junior doctor performance and to be associated with an increased risk of serious medical errors.7 Bullying is associated with lower job satisfaction and those who report having been bullied are more likely to plan a reduction in working hours or cease patient care.4 More generally, bullying is associated with higher rates of suicidal ideation and other mental health problems including burnout.8–10 Such effects are experienced not just by those being bullied but also bystanders.11

Cardiologists and cardiology trainees are perceived to have a number of negative personality attributes.12 Previous small surveys of prespecialty doctors interested in cardiology have suggested a high rate of bullying during cardiology rotations.13 However, to date, no large scale surveys of bullying experienced by cardiology trainees have been reported.

Methods

British Junior Cardiologists’ Association survey

An annual survey of cardiology trainees is conducted through the British Junior Cardiologists’ Association (BJCA). The survey asks questions relating to a wide range of training issues faced by cardiology trainees. Since 2017, a specific question on bullying has been asked. A list of questions used in this study can be found in online supplemental table 1. The survey is advertised and distributed through the BJCA mailing list, as well as via Training Programme Directors and BJCA local representatives in each region. Answers were collected via an online system.

Supplemental material

Qualitative analysis

As part of the survey, participants were given the opportunity to respond to the following question: ‘In order to understand bullying, sexism and harassment within cardiology in more detail, please describe your experience below.’ Forty participants (16 male, 24 female) responded with an answer relevant to the question posed.

The free text responses were imported into NVivo for Mac (V.12) to support data management and analysis. Thematic analysis was completed using the stages of familiarisation, generating initial codes, searching for themes and writing a narrative summary.

Definition of terms

In this research, the term ‘consultant’ refers to fully qualified cardiologists who have completed their training. The term ‘registrar’ refers to a trainee cardiologist who has completed medical school as well as initial postgraduate training in general medicine.

Statistical analyses

This study used only complete cases and participants with missing variables were excluded. Logistic regression models were used to estimate ORs describing associations between baseline characteristics and reported bullying. Fisher’s exact test was used to compare reporting of inappropriate language by sex and medical school location. In order to explore associations between stage of training and reported bullying, respondents were classified as trainees undertaking core cardiology training (self-rated as ST3–ST5), advanced cardiology (ST6 and above) or non-training. As a sensitivity analysis, we assumed that those not providing an answer to whether they had experienced bullying were not bullied when considering trainee characteristics associated with reporting bullying.

Subgroup analyses were predefined and no subgroups were analysed other than those described. To adjust for multiple comparisons, a false discovery rate was set at 0.05 and controlled by use of the Benjamini-Hochberg procedures.14 Following this correction, p values of ≤0.016 were considered significant. All statistical analyses were undertaken using SAS (V.9.3).

Patient and public involvement

This study reports the results of a survey of cardiology trainees within the UK. As such, the survey was designed and conducted by cardiology trainees who were the participant group in this research. Furthermore, the reporting of these survey results was discussed with the lay member of the cardiology Specialist Advisory Committee.

Results

Of 2057 survey respondents, 552 were excluded with missing or incomplete baseline data. A further 146 were excluded for not providing an answer to the question ‘In the last 4 weeks, how often have you felt bullied at work?’. The main dataset contained 1359 responses (online supplemental figure 1).

Survey respondent characteristics

Of the 1359 trainees in our analyses, 73% were male (table 1). Trainees had a mean age of 33.7 years (SD 4.2), most underwent undergraduate training in the UK (76%) and were working full time (96%). The majority of participants were working in a tertiary referral centre for cardiology (59%) and possessed a national training number (94%). Data were available for all local education training boards (online supplemental table 2). Response rates and demographic data were similar across all 4 years.

Table 1

Baseline characteristics of the BJCA survey population

Bullying of cardiology trainees

Bullying in the 4 weeks prior to the survey was reported by 152 trainees (11%). This was broadly similar across the survey years (figure 1). In addition, 431 trainees (32%) reported witnessing bullying while on a cardiology rotation. Bullying was reported in all regions (figure 2, online supplemental table 2). However, there were substantial differences in the rates of bullying between regions.

Figure 1

Bar plot demonstrating the incidence of bullying reported by cardiology trainees within the 4 weeks prior to each survey. Bars represent the percentage of trainees reporting being bullied.

Figure 2

Map of the UK divided into regions. Colours represent percentage of trainees within each region reporting bullying. Darker colours represent higher rates of bullying within the region.

Trainee characteristics associated with bullying

To examine potential characteristics associated with risk of reporting bullying, a univariate logistic regression analysis was undertaken (table 2). Female trainees were significantly more likely to reporting being bullied (OR 1.55, 95% CI 1.08 to 2.21). Trainees who had attended non-UK medical schools were also significantly more likely to report being bullied (European Economic Area (EEA) OR 2.22, 1.31 to 3.76; non-EEA/UK medical school OR 3.16, 2.13 to 4.68). Older trainees were also significantly more likely to report being bullied (OR 1.10, 1.06 to 1.15 per year). However, stage of training and current training location were not significantly associated with a high risk of reporting bullying.

Table 2

Univariable predictors of cardiology trainees reporting having been bullied

Broadly, similar associations were seen when considering those reporting having witnessed bullying on a cardiology rotation (online supplemental table 3). However, those in advanced cardiology training had significantly higher odds of reporting having witnessed bullying (OR 2.14, 1.68 to 2.74). Those who qualified in the EEA and female trainees were significantly more likely to report having witnessed bullying (OR 1.91, 1.30 to 2.81 and OR 1.78, 1.39 to 2.29, respectively).

There were no meaningful changes in the observed associations when we assumed that those who had not provided an answer to whether they had experienced bullying were not bullied (n=1505, online supplemental table 4).

Use of inappropriate language in cardiology

In 2017 and 2020, cardiology trainees were asked if they had experienced sexist, homophobic or racist language in the cardiology department over the preceding year. Sexist language was reported by 7% of trainees (n=43), racist language by 3% (n=17) and homophobic language by 2% (n=10). Women were significantly more likely than men to report sexist language in cardiology departments (14% vs 4%, p<0.001, figure 3). Those who underwent undergraduate medical training outside the UK were significantly more likely to experience racist language (UK 1.5%, EEA 6%, other locations 7%, p=0.006, figure 3).

Figure 3

Bar plot demonstrating the incidence of offensive language heard by cardiology trainees within a year prior to the survey. The left panel is divided by trainee sex. The right panel is divided by location of undergraduate training. Bars represent the percentage of trainees reporting each type of offensive language. Participants limited to those completing the survey in 2017 and 2020 (n=613).

Inappropriate behaviour

In the 2020 survey, cardiology trainees were asked whether they had experienced a range of inappropriate behaviours while on a cardiology rotation from a list provided (figure 4). One-third of cardiology trainees (33%, n=82) reported at least one inappropriate behaviour. The most commonly reported behaviours were a perception of an unfair allocation of training sessions (12%), opinions and views being ignored (12%) and being made to feel worthless/useless (9%). Worryingly, 8% of trainees reported being shouted at or targeted with spontaneous anger. Around three-quarters of trainees reporting inappropriate behaviours did not report being bullied (23%, n=63). Similar rates of inappropriate behaviours were reported by male and female trainees (online supplemental figure 2).

Figure 4

Bar plot demonstrating inappropriate behaviour reported by cardiology trainees divided into those who reported bullying (blue) and those who did not (white). Bars represent the percentage of trainees reporting inappropriate behaviour. Participants limited to those completing the survey in 2020 (n=252).

Who is undertaking bullying?

In 2019 and 2020, cardiology trainees were asked who they had been bullied by (with the ability to select multiple options). Of those reporting having been bullied (n=74), the majority reported being bullied by those from at least two groups (n=54, 71%). Consultant cardiologists were most likely to be identified as a bully (82%, figure 5). Consultants from other specialties were also implicated as commonly bullying trainees (70%). Comparatively, trainees within the same or different hospitals were infrequently cited as bullies (10% and 1%, respectively).

Figure 5

Bar plot demonstrating the job role of those reported to be bullying cardiology trainees. Limited to cardiology trainees who reported being bullied in the 4 weeks prior to each survey. Bars represent the percentage of trainees reporting being bullied who highlighted a member of staff in this role as being responsible. Participants limited to those completing the survey in 2019 and 2020 (n=612).

Qualitative analysis

Many of the respondents used the blank space question to describe examples of bullying that they had witnessed, either directed at themselves or at colleagues. Consultants were reported as the main perpetrators, though registrars and other members of the team were sometimes involved.

Several respondents described being shouted at or ridiculed in front of others. Clinical competence as perceived by the perpetrator was often felt to be the focus. Some described that they had experienced a systematic undermining of their confidence and a lack of support by seniors. Several respondents described how they felt pressured into covering rota gaps.

I felt bullied in a previous job at another trust*. This consisted of a complete lack of supervision and support. I was given unrealistic jobs and then made to feel inadequate when I didn’t achieve them. I was pressured into not taking zero days and study leave. (Female, ST7) *hospital

Discriminatory behaviour was also described, mainly supported with examples of sexism. Respondents discussed the difficulties encountered being female in a predominantly male specialty. This usually included being subject to sexist comments, though several respondents described impacts on the training opportunities provided. Homophobic and racist comments were also cited as examples.

Specific consultant asking nurses not to think too hard as they are women, asking them to make him tea, treating male trainees better than female trainees by refusing entry to lab. (Female, ST3)

Respondents described how being subject to bullying could have a significant emotional impact. This sometimes resulted in them wanting to quit training or having to change supervisors or hospital placements.

I had a very unproductive relationship with my first clinical supervisor which had a huge impact on my mental health and made me feel I should quit. (Female, ST4)

Some respondents talked about how bullying was normalised in the specialty, particularly the ‘cath lab culture’, which was described as ‘macho’ behaviour and use of ‘inappropriate belittling language’. Behaviour was often described as going on unchallenged, including by the respondents themselves, or that nothing changed when the issue was raised. A few respondents described how the problem had been solved following an internal investigation. Others felt that there was a slow change in the culture as people retired and new consultants and staff were appointed.

Not all the comments were completely negative. One respondent highlighted that it could be difficult to distinguish bullying from stress in a high-pressure environment and several said that they had not witnessed bullying recently.

Discussion

In this large and repeated survey of British cardiology trainees, we have shown a persistent and important problem with bullying. One in 10 trainees reports being bullied in the 4 weeks preceding each survey with 3 in 10 reporting having witnessed bullying. Women, older trainees and those who underwent undergraduate medical training outside the UK were much more likely to report being bullied or having witnessed bullying in cardiology. Sexist language was common in cardiology and disproportionately experienced by women. Racist language, while relatively less common, was more likely to be reported by those who underwent undergraduate training outside the UK. Cardiology consultants were the most likely to be reported as being responsible for bullying trainees.

Higher rates of bullying in female trainees and those undertaking undergraduate medical training outside the UK are worrying. Our findings are in line with previous reports demonstrating that women and those from ethnic minority populations were more likely to report bullying.1 7 A survey of 594 junior doctors suggested that women and those from ethnic minority population were both ~60% more likely to report having been bullied.1 However, non-UK surveys have not consistently suggested high rates of bullying in these groups.4 Our survey has also shown that women are more likely to experience sexist language, while those who attended non-UK medical schools are more likely to experience racist language. Cardiology has a low number of women in the specialty,15 and General Medical Council (GMC) data suggest that cardiology has a lower proportion of women completing training (32%) compared with other specialties (47%).16 Higher rates of reported bullying and exposure to sexist language in female trainees risk lowering the credibility and appeal of cardiology as a specialty.

Racist language and bullying of trainees who underwent undergraduate medical training outside of the UK should not be considered acceptable. Currently, cardiology in the UK has a higher proportion of non-white trainees (58%) compared with other specialties (48%).16 However, there is evidence of lower success rates during specialty applications,17 and systemic bias against non-white trainees during medical training and examinations.18 As such, the findings of this study add further, although indirect, evidence of an already objectionable and inappropriate situation.

Consultants have previously been suggested to be the primary practitioners responsible for bullying of doctors in training. Reports examining perceived sources of bullying have suggested that consultants are most likely to be reported as perpetrators.2 3 7 However, Paice and Smith suggested that only ~45% of trainees report being bullied by a consultant.7 In contrast, our results demonstrate that consultants both within and outside of cardiology are perceived bullying trainees.

Our study demonstrates a high proportion of inappropriate behaviours directed at cardiology trainees. This goes some way to address the suggestion that what one trainee perceives as bullying may be considered ‘robust feedback’ by another. While bullying is an inherently subjective experience, these specific behaviours are arguably less subjective and highlight significant broader problems with cardiology as a specialty. That only a minority of those reporting inappropriate behaviours also reported that they had been bullied may suggest a quiescence or acceptance in the trainee psyche, where these specific, negative behaviours are not perceived by the trainee as bullying.

Bullying has been shown to significantly impact trainees. Those subject to bullying are 70% more likely to report serious or potentially serious medical errors.7 Bullied trainees are more likely to take time off work and cease direct patient care than those who are not.4 Furthermore, it is reasonable to consider that bullying of trainees, if witnessed by patients, may reduce patient trust in the service as a whole and those involved as individuals. Loss of patient trust has been associated with worse patient outcomes.19 These factors suggest that addressing bullying of trainees needs to be a priority both to ensure patient safety and to reduce trainee attrition in a time of unprecedented workforce pressures. The impact of not addressing trainee bullying has previously been highlighted as a detrimental factor in the Francis report as part of the Mid Staffordshire NHS Foundation Trust public inquiry.20

Workplace bullying in medicine is undoubtedly a problem in specialties other than cardiology, and the degree to which the prevalence reported here represents a specific problem to be solved, or merely reflects general dissatisfaction may be considered to be an open question. However, the prevalence of bullying in our results is double that found by the GMC training survey in 2018 (5.8%).16 The suggestion that cardiology may have a greater problem with bullying is further supported by data from the 2019 GMC training survey which demonstrated that bullying in cardiology was almost double the average across all medical programmes (12.3% vs 6.9%).21 The voluntary nature of the BJCA survey has led some to suggest that the BJCA survey may overestimate bullying, as those who have experienced bullying are motivated to respond. However, similar levels of bullying reported in the BJCA survey compared with the most recent GMC survey data do not support this. Although it is cardiology trainees reporting high levels of bullying, the fact that non-cardiology consultants were perceived as being responsible for some aspects of bullying by ~70% of those reporting bullying suggests the problem is more widespread. This high figure is particularly concerning given the push towards an increased component of general medicine within cardiology training in response to the Shape of Training report.22

Regional bullying rates are discussed at each Specialist Advisory Committee meeting and region-specific interventions have previously been undertaken in areas with high rates of bullying. However, given the burden of bullying identified within cardiology, it is clear that further national action is required. The BJCA and British Cardiovascular Society are preparing a coordinated national plan to tackle bullying in cardiology trainees.

Limitations

This study has a number of strengths including its large size and wide geographical coverage. However, some limitations must be acknowledged. In particular, this survey was primarily advertised to members of the BJCA. While the majority of cardiology trainees (>90%) are members of this group, some are not and this may have biased our results. We cannot be certain of the response rates for the survey as a proportion of all cardiology trainees as the total number of cardiology trainees with and without national training numbers is not publicly available. As the survey was repeated over a number of years, not all questions were asked each year. The blank space question used for qualitative analysis was not compulsory and represents only a small proportion of total survey respondents. Associations between baseline characteristics and reporting being bullied were undertaken using a univariable approach. The authors felt there was insufficient power to reliably consider a multivariable analysis. However, a univariable analysis prevents clear delineation of the independent relevance of the associations identified. This study was undertaken as a complete case analysis to deal with participants with missing variables which may have led to bias in the associations reported as participants with missing variables are unlikely to be missing completely at random.

Conclusions

Bullying in cardiology is common and disproportionately affects female trainees and those who went to medical school outside the UK (figure 6). In addition to bullying, trainees report a significant rate of inappropriate language and behaviour. Given the significant wider implications associated with bullying, this is an issue that requires significant attention in the immediate future.

Figure 6

Central illustration of the findings from this study. EEA, European Economic Area.

Key messages

What is already known on this subject?

  • Doctors are commonly subjected to bullying behaviour which can detrimentally affect patient outcomes.

What might this study add?

  • One in 10 UK cardiology trainees reports having experienced bullying.

  • Bullying is more commonly reported in women and those who attended medical school outside the UK.

How might this impact on clinical practice?

  • High levels of bullying of cardiology trainees may result in lower morale and potentially worsen patient outcomes.

Data availability statement

Data are available upon reasonable request.

Ethics statements

Patient consent for publication

Ethics approval

This study reports the results of a survey of participants collected voluntarily as part of the routine activities of the British Junior Cardiologists' Association.

Acknowledgments

The authors would like to thank Mrs Sarah Brown (Cardiology Specialist Advisory Committee lay representative) for her help in considering the broader implications of trainee bullying on patients and the public, and Mr Azeem Ahmad for his assistance administering the survey. We would like to thank the local British Junior Cardiologists’ Association trainee representatives for their help in disseminating the survey to trainees in their regions. We would like to thank Miss Lily Moore for her assistance in developing the central illustration (Figure 6) for this manuscript.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Contributors CFC, AJ, HCS and CA were involved in the development of the survey and acquisition of survey data. CFC, CA, AC and SR developed the analysis plan. CFC undertook statistical analysis. AM undertook qualitative analysis. All authors were involved in the interpretation of data and results. All authors contributed to the preparation, critical review and approved the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Map disclaimer The depiction of boundaries on this map does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. This map is provided without any warranty of any kind, either express or implied.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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