Prevalence and Associated Factors of Bullying Among Medical Residents A Systematic Review and Meta Analysis
Prevalence and Associated Factors of Bullying Among Medical Residents A Systematic Review and Meta Analysis
DOI: 10.1002/1348-9585.12418
REVIEW ARTICLE
1
Unidad de Medicina Familiar Número
7, Instituto Mexicano del Seguro Social, Abstract
San Pedro Garza García, Nuevo León, Objective: To assess the prevalence of bullying in medical residents and its as-
Mexico
2
sociated factors.
Facultad de Medicina, Universidad
Autónoma de Nuevo León, Monterrey,
Methods: In this systematic review and meta-analysis, articles from MEDLINE,
Nuevo León, Mexico EMBASE, Scopus, PsycInfo, Cochrane databases, and Web of Science were
3
Plataforma INVEST Medicina UANL- searched. Published and unpublished cross- sectional studies were included.
KER Unit Mayo Clinic (KER Unit
Cochrane's Q test and I2 statistics were used to assess the existence of heteroge-
México), Universidad Autónoma de
Nuevo León, Monterrey, Nuevo León, neity. Subgroup analysis and sensitivity analysis were performed on evidence of
Mexico heterogeneity. Egger's test and funnel plots were performed to investigate publi-
4
Knowledge and Evaluation Research cation bias.
Unit, Mayo Clinic, Rochester,
Minnesota, USA
Results: A total of 13 cross-sectional studies with a total of 44 566 study partici-
5
Unidad de Medicina Familiar Número pants from different medical residencies were analyzed. The overall prevalence
64, Instituto Mexicano del Seguro of bullying was 51% (95% CI 36–66). Furthermore, female residents and residents
Social, Santa Catarina, Nuevo León,
that belong to a minority group had higher odds of experiencing bullying com-
Mexico
pared to their peers.
Correspondence Conclusion: A high prevalence of bullying in medical residents exists around the
Neri Alejandro Álvarez Villalobos,
world. There is a need for education, dissemination, and more effective interven-
Unidad de Medicina Familiar Número
7, Instituto Mexicano del Seguro Social, tions among the residents and authorities about bullying to build and promote
Blvd. Diaz Ordaz y, Maria Cantú S/N, adequate behaviors and diminish bullying prevalence.
Zona Industrial, 66217 San Pedro Garza
García, NL, Mexico.
KEYWORDS
Email: [email protected];
[email protected] bullying, interprofessional relations, medical residencies, meta-analysis, prevalence
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any
medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2023 The Authors. Journal of Occupational Health published by John Wiley & Sons Australia, Ltd on behalf of The Japan Society for Occupational Health.
perpetrator.5–7 Lastly, the condition of whether the behav- and the broader healthcare system that mistreatment
ior should be considered negative or not depends on the and intimidation are an unavoidable part of medical
victim's perception, not on the perpetrator's intention. training.20,21,24–27
Healthcare providers and medical students are a spe- The medical hierarchic environment is filled with pres-
cial population when it comes to bullying. Studies have sure, where the difference in knowledge leads to an un-
found that medical students experience mistreatment balanced power dynamic. Bullying is a very well-known
during their education at twice the rate of students in problem around the world and identifying the factors that
other fields.8 Prevalence of bullying in this community foster its prevalence in the medical profession is essential,
has been reported in primary studies before. All these especially among medical residents. Medical residents
studies have a wide difference in the reported prevalence, are special because of the inherent nature of their work.
ranging from 30% to 95%.1,2,4,9–13 Medical residents are not really students since their work
Bullying can have consequences, including emotional is sometimes on par with the work of a medical attending.
distress, work absenteeism, and physical and psycholog- Yet, they are not medical specialists either, since they are
ical harm to the victims.6,12,14,15 These effects not only still being trained in their respective specialties. As a re-
affect the victims of bullying in the medical community sult, medical residents occupy a somewhat ambiguous role
but also can directly and/or indirectly affect patient care, within the healthcare system. Therefore, this systematic re-
ultimately compromising patients' health.11,16–19 view and meta-analysis aim to assess and review the differ-
Attitudes in the healthcare workforce can make it dif- ent studies conducted so far on the prevalence of bullying
ficult to identify and address instances of bullying and in medical residents and its associated factors around the
can perpetuate a culture of fear and hostility within med- world.
ical education. In addition, the hierarchical nature of the
healthcare system can make it challenging for victims of
bullying to come forward and report their experiences 2 | MATERIALS AND METHO D S
without fear of reprisal or retaliation.20,21 Despite these
challenges, it is essential to continue working toward a The systematic review and meta-analysis were conducted
culture of respect, support, and safety in medical educa- according to the Preferred Reporting Items for Systematic
tion in order to promote the well-being of healthcare pro- Reviews and Meta-Analyses (PRISMA) checklist and the
viders and ensure the highest quality of care for patients. guidelines from the Cochrane Handbook for Systematic
Considering the reports of bullying in the healthcare Reviews of Interventions (Table S1).28,29 The study was
workforce and the impact it has on patients' health, some registered in the International Prospective Register of
research teams have made progress on raising awareness, Systematic Reviews (PROSPERO) with the registration
expanding our knowledge regarding bullying, and even number CRD42022333170.
giving some recommended courses of action. Fnais et al.
reported on the most common form of harassment, which
was verbal and academic, and the most common form 2.1 | Databases and search strategy
of discrimination, which was due to race and gender.22
Although the definition for harassment and discrimina- A comprehensive electronic literature search was per-
tion is essentially different from any proposed bullying formed by an experienced librarian from inception up to
definition, it highlighted the continued issue medical February 10, 2022. The search was conducted in multiple
education is facing. Laisy and Ahmad, after qualitatively electronic databases including MEDLINE, Embase, Web
assessing literature, explored some risk factors and out- of Sciences, Scopus, Cochrane databases, and PsycInfo.
comes of bullying as well as issued some recommenda- Both published and unpublished articles from the gray
tions to reduce bullying in healthcare, although the impact literature were also searched. The articles that reported
of the proposed interventions is yet to be measured.18 the prevalence of bullying and associated factors were in-
Samsudin et al. also assessed qualitatively the risk factors cluded in the final analysis. No language, study setting,
and outcomes of bullying, concluding that more evidence or time frame restrictions were applied. No studies were
is needed to better understand this phenomenon.23 Even excluded based on the risk of bias assessment.
still with these advances in the bullying research field, no The search terms used were [(“Bullying” AND “preva-
quantitative assessment has been performed regarding lence”) AND ((postgraduate AND “medical students”) OR
bullying in medical residents. residents OR postgraduate OR “medical residency” OR
Education, awareness, and overall eradication of bul- “post-graduate training” OR specialty OR medical specialty
lying in medical education have been challenging. One of OR “medical residency programs”)]. The tailored search
the main obstacles is the belief among clinical teachers strategy for the used databases can be found in Table S2.
ÁLVAREZ VILLALOBOS et al. | 3 of 13
2.2 | Searching and eligibility of studies measured with either a bullying scale or a bullying ques-
tionnaire. Factors associated with bullying were extracted
Retrieved articles were exported to EndNote reference soft- as reported by the authors of the included studies, includ-
ware version 9 citation manager where they were dedupli- ing but not limiting to medical specialty, race or ethnicity
cated using the native deduplication function within the of the subjects, source of bullying, acts of bullying, and
software, followed by a manual review.30 The remaining psychological outcomes like burnout.
studies were then imported into a systematic review soft-
ware (Distiller SR), where we screened the studies in two
phases: the title and abstract phase and the full-text phase. 2.5 | Quality assessment
Articles included in both phases were evaluated indepen-
dently and by two reviewers. Studies included by at least Two authors independently assessed the quality of each
one reviewer in the abstract screening phase were consid- studies using the AXIS tool to evaluate the risk of bias for
ered for full-text screening, this was done to increase sensi- cross-sectional studies.31 The studies were assessed for
bility in the included records for full-text screening. During methodological quality, comparability, and the outcome
the full- text screening, agreement of inclusion between of statistical analysis using established evaluation criteria.
both reviewers was required for the study to be selected. A predefined score of 17 of 20 for high-quality studies was
Disagreements at any phase were resolved by consensus. A set by the research team. Discrepancies between evalua-
pilot was made before each phase, and the chance adjusted tors during the quality appraisal process were resolved by
inter-rater agreement was estimated at the calibration and internal discussion and, if no agreement was reached, a
conduction of each phase by Kappa statistic. A Kappa statis- third author settled the discrepancies.
tic of >0.70 was set as an appropriate inter-rater agreement.
Data extracted included the author's name, publication
year, country where the study was conducted, medical spe- 2.6 | Data processing and analysis
cialty of the subjects, sample size, study subjects (medical res-
idents by Post Graduate Year [PGY]), race or ethnicity of the The data extracted from the identified articles were re-
subjects (as reported in the publication), objective of the study, corded in a Microsoft Excel spreadsheet and cleaned for
reported prevalence of bullying, the instrument used to eval- analysis. Numeric data were reported using measures of
uate bullying, most common source of perpetrators reported, central tendency and dispersion, while categorical data
and other factor associated with the presence of bullying. were reported as frequencies and percentages. We esti-
mated the prevalence of bullying in medical residents using
a binomial–normal model for meta-analysis of prevalence
2.3 | Eligibility criteria via the generalized linear mixed model.32 Prevalence es-
timates were reported as binomial proportions with 95%
Due to prevalence being a condition reported at a spe- confidence intervals (CIs). The heterogeneity of the studies
cific timeframe, only published and unpublished cross- was assessed using Cochrane's Q-test and I2 with its cor-
sectional studies were included. Articles that evaluated responding p-value. A statistical test with a p value of less
bullying using a validated questionnaire, or used a ques- than .10 was considered significant for heterogeneity.29
tionnaire with a specific question addressing bullying or The values defined as the demarcation of low, moderate,
provided a definition for bullying that included a per- and high heterogeneity were 25%, 50%, and 75% respec-
sistent negative behavior rather than isolated incidents, tively.33 A fixed-effects model was applied when there was
with a power imbalance between the victim and the per- low heterogeneity and a random-effects model was used
petrator, were included. Furthermore, articles without when heterogeneity was moderate or high. A subgroup
full text and not reporting the prevalence of bullying were analysis based on PGY was planned a priori; nevertheless,
excluded. All authors independently assessed the eligibil- the amount of included studies that reported PGY was not
ity of the articles to be considered in the final analysis. enough to do a proper analysis. All analysis was performed
in R statistical software version 4.2.2 and p values less than
0.05 were considered statistically significant.
2.4 | Outcome measurement of the study
After title and abstract screenings, 733 articles were ex- The most frequently included medical residency
cluded, leaving 58 articles to assess for eligibility. Of those was of surgical nature, with nine studies including
articles, 13 were included in the qualitative and quantita- them9,34–36,38–40,42,44 and seven studies conducted only
tive synthesis. Figure 1 provides a visual representation of in surgical specialties without including any other
the literature screening process. specialty.34–36,38–40,44 Interestingly, none of the studies co-
incided with the definition of bullying, but shared com-
mon points like the need of being a repetitive behavior
3.1 | Characteristics of the studies and that causes a negative impact. Of the included studies, six
study participants did not directly provide a definition.35–37,39,41,44 The rest of
the studies' characteristics can be seen in Table 1.
We analyzed 13 cross-sectional studies, which included a
total of 44 566 participants. Of the included articles, eight
were from the United States,9,16,34–39 one from Australia,40 3.2 | Prevalence of bullying
one from Australia and New Zealand,41 one from India,42
one from Pakistan,43 and a multi-country study that in- The overall pooled prevalence of bullying in medical resi-
cluded several Latin American countries.44 dents was 51% (95% CI 36–66; Figure 2).
Identification
Record excluded
Records screened
N = 733
N = 791
Abstract screening (N = 733)
No bullying (N=26)
Could not separate medical residents
from the rest (N=6)
No medical residents (N=9)
Incorrect study design (N=2)
No total prevalence reported (N=2)
FIGURE 1 PRISMA flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
ÁLVAREZ VILLALOBOS et al. | 5 of 13
3.3 | Heterogeneity and publication bias on female residents by professors than on male residents
(44% vs. 15%; p = .002; Yates correction p = .005).
This systematic review and meta-analysis detected high Only three articles specified the most common bul-
heterogeneity (I2 = 100%; p < .001). A preplanned sensi- lying acts.34,36,43 Two studies coincided in that the two
tivity analysis was performed by recalculating the pooled most common acts were being repeatedly reminded of
effects while omitting one study at a time (leave-one-out errors or mistakes and being shouted at the second most
method). The studies by Hussain et al.,43 Kemper and common. They differed in the third most reported act;
Schwartz37 and Ayyala et al.16 showed a possible influ- Zhang et al. mentioned withholding important infor-
ence in the overall pooled proportion. This influence mation while Heiderscheit et al. mentioned persistent
could be due to the abstract nature of bullying, along criticism of work or effort. It is worth mentioning that
with the subjectivity and heterogeneity of its definition. Heiderscheit et al. reported that the sources of discrim-
The full leave-one-out sensitivity analysis can be seen in ination were similar for medical residents that are part
Figure S1. A funnel plot was performed to visually evalu- of the LGBTQ+ community and non-LGBTQ+ residents.
ate publication bias (Figure S2). Although the visual Hussain et al. reported that their most common form of
inspection of the funnel plot might show asymmetry, bullying was verbal, with 26% of doctors being disturbed
Egger's test did not indicate the presence of funnel plot because of repeated inappropriate jokes about them.
asymmetry (p = .5820).
3.4.2 | Bullying source and acts Two studies associated bullying or any mistreatment as
a risk factor for medical residents for burnout.35,37 Chia
Eight of the included studies asked participants to identify et al. reported an OR of 3.09 (95% CI, 1.78–5.39) while
the most common perpetrators of bullying, with attending Kemper and Schwartz reported an adjusted OR of 1.8
physicians being mentioned as one of the most frequent (95% CI, 1.62–2.42).32,34,35,37 Additionally, Kemper also re-
sources in all of the studies and as the main perpetrators ported that in the frequency of mistreatment, each higher
in four studies.9,34,36,40 In the work presented by Kemper “dose” of mistreatment was associated with an adjusted
and Schwartz, the most common source of bullying was OR of 3.01 (95% CI, 2.06–4.40).
clinical staff (nursing, therapy).37 The only study that re-
ported co-residents as the number one perpetrator (42%)
was the one by De la Cerda-Vargas et al.,44 which focused 3.5 | Quality assessment
on neurosurgery residents. The former also reported a dif-
ference between bullying perpetrators depending on the Only one39 of the included articles met the prespecified
sex of the victim, bullying was more frequently inflicted criteria for high quality with the AXIS tool. The median
6 of 13 | ÁLVAREZ VILLALOBOS et al.
Participants
Total participants
Author (year), (medical specialty/ According to their
Region residency) residency year, n (%) Race/ethnicity % Study objective
Zhang et al. 6264 (General surgery) NR Non-Hispanic White Examine prevalence, types,
(2020)34 15.9% Minorities/other sources, and factors associated
United States 21% with bullying reported by US
general surgery residents
Chia et al. 564 (Vascular surgery) PGY1: 65 (11.5) White 54% Inform initiatives to improve
(2022)35 PGY2–3: 140 (24.8) Asian 24.1% wellness by assessing the
United States PGY4–5: 111 (19.7) Hispanic/Latino 4.7% prevalence of hazards in
PGY6–7: 248 (44) Black 4.3% vascular training and the
Other 7.1% rates of wellness outcomes
Prefer not to say 5.8%
Heiderscheit et al. 6381 (General surgery) PGY1: 1585 (24.83) Asian, Native Hawaiian, Determine the national
(2021)36 PGY2–3: 2535 (39.72) or Pacific Islander prevalence of mistreatment
United States PGY4–5: 2261 (35.43) 18.03% and poor well-being for
Black or African LGBTQ+ surgery residents
American 5.08% compared with their
White 67.44% non-LGBTQ+ peers
Other or prefer not to say
12%
Kemper and 1956 (Pediatrics) NR African American 4% (1) Describe the prevalence of
Schwartz Asian 16% bullying, discrimination,
(2020)37 Caucasian 66% sexual harassment, and
United States Hispanic/Latino 4% physical violence; (2) Assess
Other/mixed/prefer not to the epidemiology of these
answer 10% experiences; and (3) analyze
the relationship between
them and burnout
Pei et al. (2019)38 180 (Surgery) NR NR Evaluate the incidence of
United States bullying acts experienced by
surgeons in the US
Ayyala et al. 21 212 (Internal NR NR Describe the prevalence of
(2019)16 medicine) bullying among internal
United States medicine trainees
De la Cerda- 111 (Neurosurgery) PGY1: 17 (15.3) NR NR
Vargas et al. PGY2: 19 (17.1)
(2022)44 PGY3: 34 (30.6)
Latin America PGY4: 21 (18.9)
PGY5: 18 (16.2)
PGY6+: 2 (1.8)
Ling et al. 370 (General surgery) NR NR Determine the extent and nature
(2016)40 of workplace bullying among
Australia general surgery trainees and
consultants in Australia
Chadaga et al. 1791 (16 Different PGY1: 389 (22) White 63% Deliver an estimated of bullying
(2016)9 residencies) PGY2–8: 1367 (76) Other ethnic groups 30% among residents and fellows
United States Prefer not to say 35 (2) Prefer not to say 7% in the US graduate medical
education system and to
explore its prevalence within
unique subgroups
ÁLVAREZ VILLALOBOS et al. | 7 of 13
Bullying prevalence
Instrument was developed from validated 307 (36.2) 498 (49.2) 373 (30) NR 14
instruments by a multidisciplinary
committee of qualitative researchers,
surgical faculty, and trainees
A survey through the Association of 371 (19) 274 (20) 95 (16) Clinical staff (60%) 13
Pediatric Program Directors' longitudinal Family members of
educational assessment research patients (54%)
network Faculty (43%)
Fellow resident/colleague
(28%)
NAQ-R 71 (39.9) NR NR NR 7
Survey developed based on previous surveys 84 (75) 23 (92) 60 (69.76) Other residents (42%) 14
focused on mistreatment, discrimination, Patients and their relatives
and burnout in residents with surgical (28%)
training Managers and bosses
(23%)
(Continues)
8 of 13 | ÁLVAREZ VILLALOBOS et al.
T A B L E 1 (Continued)
Participants
Total participants
Author (year), (medical specialty/ According to their
Region residency) residency year, n (%) Race/ethnicity % Study objective
Bairy et al. 174 (Different NR NR Determine the prevalence of
(2007)42 residencies) persistent and serious
India bullying among junior
doctors, identify its sources
and determine if any
personality trait pointed
toward being a “bully”
Hussain and 246 (Different NA NA Determine prevalence of
Rahim residencies) bullying among postgraduate
(2014)43 medical trainees in tertiary
Pakistan care hospitals in Peshawar
Brajcich et al. 5574 (Surgery) PGY1: 1377 (24.4) White 66.3% To undertake a national
(2021)39 PGY2–3: 2295 (40.3) Black 5% evaluation of the association
United States PGY4–5: 2029 (35.6) Asian 17.7% of resident unions with
Other 10.1% well-being and working
Prefer not to say 4.9% conditions among residents
Downey et al. 417 (Anesthesiologist) NA NA To investigate levels of stress,
(2021)41 anxiety, and depression, and
Australia and to identify factors
New Zealand exacerbating or relieving
stress in anesthesia trainees
Note: Senior registrars are medical doctors that have completed their postgraduate training and are undergoing further training under supervision of a
consultant or specialist. Junior registrars have the same characteristics as senior registrars, with the difference being that junior registrars have recently
completed their undergraduate medical education. Adding up percentages might not result in 100% because of rounding.
Abbreviations: NR, not reported; PGY, postgraduate year; S-NAQ: The Short-Negative Act Questionnaire.
Bullying prevalence
A questionnaire based on basic five types of 204 (89.02%) NA NA Senior registrars (20%) 8
bullying according to Rayner and Hoel6 Junior registrars (18%)
Fellow colleagues (17%)
Nurses (16%)
Professors (11%)
Survey adapted from previous surveys 3735 (67%) NA NA NA 18
following the American Board of Surgery
of the AXIS scores was 14 (interquartile range 12.5–16). considered high since bullying in any workplace should
A detailed report on the quality assessment is reported in be nonexistent.
Table S3. It is worth noting that the problem of bullying in the
medical environment starts during undergraduate edu-
cation, as medical students are more likely to experience
4 | DI S C USSION inappropriate treatment compared to students in other de-
gree programs.8 While previous studies have explored the
In this systematic review and meta-analysis, the pooled prevalence of bullying in medical students and residents,
prevalence of bullying in medical residents is 51%, which this study provides a specific focus on medical residents
likely resides between 36% and 66% with 95% confidence, across various specialties.46–52 However, the lack of con-
which indicates that there is a high prevalence of bullying sensus among experts regarding the definition of bullying,
among medical residents in the world. This high preva- which is often used interchangeably with terms like dis-
lence might be due to an absence of bullying prevention crimination or harassment, highlights the need for further
programs in teaching hospitals, limited to non-existent research in this area. Overall, the findings of this study
media coverage of bullying in medical residents, and/or a suggest that addressing bullying in medical residency pro-
lack of a consistent definition of bullying. grams should be a priority, and effective interventions and
Bullying in the general workforce has been estimated preventative measures need to be developed.
at a prevalence of 38%.45 Prevalence of bullying in the The included studies identified several associating
medical workforce has been reported at 25%.19 Medical factors of bullying. Among the associated factors, being
student's prevalence of bullying has been reported as well, a woman was reported as a risk factor to experience bul-
with prevalences from 46.4% to 59.4%.22,46 Although com- lying, which follows the results of other studies.53–55
paring numerically the prevalence of bullying sounds like Regarding the most common perpetrators, studies seem
a logical process, all of the reported prevalence should be to differ in their reports. A study done in the general
10 of 13 | ÁLVAREZ VILLALOBOS et al.
healthcare workforce of Greece reported that the most this review. All included studies in this systematic review
common source of bullying was colleagues of the same and meta- analysis were cross- sectional studies, which
hierarchy (66.7%) followed by superiors (58.7%).56 Even if may limit the generation of a causal-effect link between
they are not the most common, workers that have a su- independent and dependent variables. There also has been
perior hierarchy in the healthcare workforce, like attend- a reported difficulty to compare data across countries, es-
ing physicians, are repeatedly reported as one of the most pecially when comparing data from countries that have
common source which goes along with the generational a different language.8,61 Another limitation is the quality
misunderstandings that harsh treatment is an essential of the included studies. Only one of the included studies
part of medical education. reached the prespecified score for high quality, with do-
The two most common acts of bullying were being re- mains with the lowest scores being related to addressing
peatedly reminded of errors or mistakes and being shouted non-respondents and justifying the sample size. The final
at, both of which can be categorized as verbal bullying. results should be interpreted cautiously and only after
Verbal aggression or verbal bullying has been reported as grasping the risk of bias assessment.
the most common acts of bullying in the medical work- The preferred instrument, identified in this review, to
place, although the specific acts vary.11 measure bullying in medical residents was the NAQ with
Throughout bullying research, a wide variety of terms its variations. This questionnaire was not specifically de-
to describe negative interactions in the workplace have signed for medical residents. As mentioned before, med-
been used by researches, some of which not only describe ical residents are a special kind of population since their
bullying behaviors but also different constructs like dis- responsibilities land on student-like responsibilities and
crimination.23 Discrimination is the differential treatment teacher/attending- like responsibilities, and evaluating
or unequal access to opportunities based on certain char- them with a nonspecific questionnaire might yield un-
acteristics, and, although discrimination has a different veracious results. Future research should focus in either
definition from bullying, it can lead to bullying behaviors. designing a questionnaire specifically for medical resi-
Zhang et al.'s study which is reported that minorities ex- dents or validating an existing one. Furthermore, future
perience bullying more frequently is an example of this studies should focus on clearly establishing risk factors
phenomenon.34 for bullying so that specific effective interventions can be
Bullying is associated with medical burnout. Burnout designed. Although there has been heterogeneity in the
has been reported as a prevalent condition in the health- reports, there is no doubt that bullying is present during
care area, especially after the COVID-19 pandemic, with a medical residency worldwide.
pooled prevalence of 41% (95% CI 20.7–61.3).57 Although
there are several factors that can influence burnout in
healthcare, bullying was identified as a factor on two of 5 | CONC LUSION
the included studies.
Our study falls in line with the Joint Commission's This systematic review and meta-analysis found that the
Sentinel Event Alert, which stated that intimidation prevalence of bullying among medical residents is high,
and disruptive behaviors in healthcare are not rare.58 with an overall prevalence of 51%. The findings suggest
Furthermore, this phenomenon creates an unhealthy and, that bullying is a significant issue in medical residency
sometimes, hostile environment reinforcing the need for programs and highlights the need for interventions to pre-
healthcare professionals to focus on this issue. vent and address bullying in this setting. Further research
The rapid technological and social progress that has is needed to identify the factors contributing to bullying
taken place in the last century have allowed us to live with and to develop effective strategies to prevent and address
more freedom and at a higher standard than before.26 Of this problem.
course, this advancement also reflects in the medical field;
healthcare professionals with more experience in their AUTHOR CONTRIBUTIONS
respective fields might look that the habits of new resi- Neri Alejandro Álvarez Villalobos, Gabriela Guadalupe
dents with contempt. This, along with the generational Elizondo Omaña, and Humberto De León Gutiérrez
misunderstandings and the belief that harsh treatment is designed the study and run the literature search. Same
an essential part of medical education contribute to the authors acquired data, screened records, extracted data,
ongoing uphill challenge of eradicating bullying in the and assessed the risk of bias. Neri Alejandro Álvarez
medical community.25,59,60 Villalobos, Humberto De León Gutiérrez, Fernando
To the knowledge of the authors, this article is the first Gerardo Ruiz Hernandez, Francisco Javier Carranza
one to provide a pooled prevalence of bullying in all medi- Guzmán, and Héctor Alejandro Vaquera Alfaro did
cal residencies in the world. There are some limitations to statistical analyses and wrote the report. All authors
ÁLVAREZ VILLALOBOS et al. | 11 of 13
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