Table 1

Summary of studies investigating bullying in academic medicine

Author (year), countryStudy designSettingDefinition of academic bullyingTargetPerpetratorSource of biasRisk of bias
Huber et al (2020), USA18SurveyAcademic and non-academic hospitalsData not providedResidentsConsultant (83.0%) and resident (63.0%)Inadequate sample sizeLow
Hammoud et al (2020), USA22SurveyAcademic hospitalsStudy-based graduation questionnaireResidents and medical studentsFor resident victims: consultant (58.7%), resident (27.9%), nurses (26.4%), other employees (10.2%) and administration (5.4%)
For medical student victims: consultant (66.4%), resident (50.9%), nurses (22.4%), other employees (13.8%), administration (5.2%) and students (12.0%)
Low response rateLow
Balch Samora et al (2020), USA28SurveyAcademic hospitalsA behaviour that a reasonable person would expect might victimise, humiliate, undermine or threaten a person to whom the behaviour is directedResidents, fellows and consultantsMultiple*Inappropriate statistical analysis and low response rateModerate
Brown et al (2020), Canada65SurveyAcademic hospitalsGender-based discrimination included belittling remarks, inappropriate comments and jokes, denial of opportunities, and behaviours that are perceived as hostile or humiliatingResidentsNurses, consultants and residentsInadequate sample size, analysis not conducted in full coverage of the sample, inappropriate identification of bullying and low response rateHigh
Zhang et al (2020), USA29SurveyAcademic and non-academic hospitalsNAQ† usedResidentsConsultants, co-residents, nurses and administratorsStudy subjects not described in detailsLow
Lind et al (2020), USA26Before–afterAcademicPublic belittlement or humiliation; physical harm; denied opportunities for training or rewards, or receiving lower evaluations or grades, based solely on gender; and being subjected to racially or ethnically offensive remarksMedical studentsData not providedUnblinded outcome assessors, small sample size, high loss to follow-up and analysis of change score not appliedHigh
Colenbrander et al (2020), Australia64SurveyAcademic hospitalsData not providedMedical studentsData not providedInadequate sample size, analysis plan, data analysis coverage and unreliable measurement of bullyingHigh
Iqbal et al (2020), Pakistan68SurveyAcademic and non-academic hospitalsNAQ† usedConsultantsData not providedInadequate sample size and statistical analysisModerate
Elghazally and Atallah (2020), Egypt63SurveyAcademicBehaviour that is intended to cause physical or psychological damage due to the imbalance of power, strength or status between the aggressor and the victimMedical studentsProfessors (30.1%), students (51.2%) and staff (18.7%)NoneLow
Raj et al (2020), USA19SurveyAcademicHarassment defined as unwanted sexual advances, subtle bribery to engage in sexual behaviour, threats to engage in sexual behaviour or coercive advances*ConsultantsData not providedNoneLow
Kemper and Schwartz (2020), USA17SurveyAcademic and non-academic hospitalsData not providedResidentsFaculty (43.0%), clinical staff (60.0%), resident (28.0%), medical student (3.0%) and admin (9.0%)NoneLow
Stasenko et al (2020), USA16SurveyAcademic and non-academic hospitalsHarassment is defined as an unwelcome sexual advances or other forms of physical and verbal aggression that is sexual in natureConsultants and fellowsData not providedLow response rateLow
Afkhamzadeh et al (2019), Iran75SurveyAcademic hospitalsPhysical or verbal violence, or bullyingMedical students and consultantsData not providedNoneLow
Wolfman and Parikh (2019), USA32SurveyAcademic and non-academic hospitalsRepeated negative actions and practices that are carried out as a deliberate act or unconsciously; these behaviours cause humiliation, offence and distress to the targetResidentsData not providedInappropriate sampling frame, and identification of bullying condition, low response rateHigh
Chowdhury et al (2019), USA31SurveyAcademic and non-academic hospitalsNAQ† usedResidentsData not providedInadequate sample size, description of subjects and setting and low response rateHigh
Ayyala et al (2019), USA30SurveyAcademic and non-academic hospitalsHarassment that occurs repeatedly (>once) by an individual in a position of greater powerResidentsData not providedInappropriate methods of bullying identificationLow
Hu et al (2019), USA27SurveyAcademic and non-academic hospitalsDiscrimination and harassment on the basis of gender, race, or pregnancy or childcareResidentsConsultants (52.4%), admin (1.1%), co-residents (20.2%) and nurses (7.9%)NoneLow
Brown et al (2019), International69SurveyAcademic and non-academic hospitalsData not providedResidents or fellow and consultantData not providedInappropriate methods of bullying identification and low response rateModerate
Zurayk et al (2019), USA25SurveyAcademic and non-academic clinicsStudy-based sexual experience questionnaireConsultants and residentsResidents (60.0%), lecturers (33.0%), professors (44.0%), nurses (10.0%) and hospital staff (29.0%)Inadequate sample size, inappropriate sample frameModerate
Castillo-Angeles et al (2019), USA23Before–afterAcademic hospitalStudy-based abuse sensitivity questionnaireResidentsData not providedSmall sample size, inadequate blinding of outcome assessors and loss to follow-upHigh
Kappy et al (2019), USA21Before–afterAcademic hospitalHarassment; discrimination; humiliation; physical punishment; and the use of grading and other forms of assessment in a punitive mannerMedical studentsConsultant, co-resident and nurseIntervention and outcomes not well definedModerate
D’Agostino et al (2019), USA20SurveyAcademic and non-academic hospitalsAbuse or harassment particularly of a sexual typeResidents, fellows and attendingConsultants (64.5%), co-resident (38.7%), ancillary staff (25.8%)Inappropriate methods of bullying identification, inadequate statistical analysis plan and low response rateHigh
Chung et al (2018), USA33SurveyAcademicFeeling of intimidation, dehumanisation, or threat to grade, or career advancementMedical studentsAttending physician (68.4%), resident (26.3%) and nurse (10.5%)Inappropriate sample methods, non-validated method of bullying identificationHigh
Kemp et al (2018), USA34SurveyAcademic hospitalDisrespect for the dignity of others that interferes with the learning processResidents, consultants and fellowsData not providedInadequate statistical analysis plan and low response rateModerate
Benmore et al (2018), England42Before–afterAcademic hospital*Data not providedResidentsSenior consultantsInsufficient enrolment, inadequate sample size, no blinding of outcome assessors, high loss to follow-up, lack of statistical analysis or ITS designHigh
Duru et al (2018), Turkey46SurveyAcademic hospitalData not providedConsultants, researchers, administrators, nursesSpecific occupations of bullies not specifiedInappropriate sampling and inadequate sample sizeModerate
Chambers et al (2018), New Zealand47SurveyAcademic and non-academic hospitalsData not providedSpecialist consultantsPrimarily men. Senior medical staff (52.5%), non-clinical managers (31.8%) and clinical leaders (24.9%)Low response rateLow
House et al (2018), USA24Before–afterAcademic hospitalData not providedMedical studentsFaculty most frequently were the source of bullying followed by residents. Exact breakdown not specifiedInsufficient enrolment, inadequate sample size, no blinding of outcome assessors, outcomes not clearly described, lack of statistical analysis, individual-level analysis or ITS designHigh
Kulaylat et al (2017), USA5SurveyAcademic hospitalVerbal abuse, specialty-choice discrimination, non-educational tasks, withholding/denying learning opportunities, neglect and gender/racial insensitivityMedical studentsFaculty (57.0%), residents, fellows (49.0%) and nurses (33.0%)Inappropriate sampling, inadequate sample size, classification bias, and non-validated identification or measurement of bullyingHigh
Malinauskiene et al (2017), Lithuania6SurveyAcademic hospitalsData not providedFamily consultantsSupervisor (25.3%), colleague (9.8%), subordinate (2.9%)Inappropriate sampling, inadequate sample size and coverage biasModerate
Chrysafi et al (2017), Greece70SurveyAcademic and non-academic hospitalsData not providedConsultantsSurgeons most frequently followed by internal medicine consultants, then radiologists/laboratory consultantsLow response rate and coverage biasModerate
Kapoor et al (2016), India58SurveyAcademic hospitalData not providedMedical studentsData not providedInappropriate sampling and inadequate description of study populationModerate
Chadaga et al (2016), USA14SurveyAcademic hospitalsNAQ† usedResidents and fellowsConsultants (29.0%), nurses (27.0%), patients (23.0%), peers (19.0%)Low response rate, inadequate sample size and coverage biasModerate
Llewellyn et al (2016), Australia62SurveyAcademic hospitalsData not providedResidentsSenior medical staff: (58.3%) in 2015, (60.6%) in 2016
Non-medical staff: (33.2%) 2015, (33.9%) 2016 Manager: (5.2%) in 2015, (1.2%) in 2016
Junior resident: (3.3%) in 2015, (4.3%) in 2016
Low response rate, biased sampling, coverage and classification biasHigh
Rouse et al (2016), USA36SurveyAcademic clinicsNAQ usedFamily medicine consultantsData not providedLow response rateLow
Shabazz et al (2016), UK43SurveyAcademic and non-academic hospitalsBelittle and undermine an individual’s work; undermining an individual’s integrity; persistent and unjustified criticism and monitoring of work; freezing out, ignoring or excluding and continual undervaluing of an individual’s effortGynaecology consultantsSenior consultants (50.9%), junior consultants (22.3%), medical director (4.5%)Low response rate and classification bias Moderate
Peres et al (2016), Brazil59SurveyAcademic hospitalData not providedMedical studentsData not providedLow response rate and classification biasModerate
Ling et al (2016), Australia49SurveyAcademic hospitalsNAQ usedGeneral surgery residents and consultantsFor trainee victims: staff surgeon (48.0%), trainee surgeon (13.0%), admin (13.0%), nurses (11.0%), other consultants (6.0%)
For consultant victims: (31.0%) staff surgeons, (28.0%) admin, (13.0%) other consultants, (11.0%) nurses, other (10.0%), trainees
(4.0%)
Low response rateLow
Kulaylat et al (2016), USA37Before–afterAcademic hospitalData not providedMedical studentsFaculty (57.0%), residents/fellows (49.0%) and nurses (33.0%)Inadequate sample size, no blinding of outcome assessorsModerate
Ahmadipour and Vafadar (2016), Iran50SurveyAcademic hospitalBeing assigned tasks as punishment, being threatened with an unjustly bad score or failureMedical students, interns and residentsData not providedInadequate sample sizeLow
Jagsi et al (2016), USA38SurveyAcademic hospitalData not providedConsultants who won a career advancement awardData not providedInadequate sampling frame and classification biasModerate
Crebbin et al (2015), Australia and New Zealand72SurveyAcademic hospitalsData not providedResidents, fellows and consultantsSurgical consultants (50.0%), other medical consultants (24.0%) and nursing staff (26.0%)Low response rateLow
Cresswell et al (2016), UK44Before–afterAcademic hospitalData not providedResidentsData not providedInsufficient description of study purpose, inadequate enrolment and sample size, no blinding of outcome assessors, outcomes not clearly described, lack of statistical analysis or ITS design and high loss to follow-upHigh
Loerbroks et al (2015), Germany51SurveyAcademic hospitalsData not providedResidentsData not providedNoneLow
Malinauskiene and Bernotaite (2014), Lithuania73SurveyNon-academic clinicsNAQ usedFamily medicine consultantsBullying from patients (11.8%), from colleagues by (8.4%), from superiors by (26.6%)NoneLow
Mavis et al (2014), USA15SurveyAcademic hospitalsMistreatment either intentional or unintentional occurs when behaviour shows disrespect for the dignity of others and unreasonably interferes with the learning processMedical studentsClinical faculty in the hospital (31.0%) residents/interns (28.0%), nurses (11.0%)Low response rate, inadequate description of study population and statistical analysisModerate
Oser et al (2014), USA13SurveyAcademic hospitalData not providedMedical studentsResidents>clerkship faculty>other attendings>other students>preceptors =nursesNoneLow
Oku et al (2014), Nigeria4SurveyAcademic hospitalData not providedMedical studentsMedical students (23.7%), consultants (21.7%), lecturers
(17.5%), consultants (16.5%), nurses (16.5%), other staff (4.1%)
NoneLow
Gan and Snell (2014), Canada60SurveyAcademic hospitalData not providedMedical studentsConsultantsLow response rate, inappropriate sampling, small sample size and classification biasHigh
Fried et al (2015), USA3Before–afterAcademic hospitalPower mistreatment defined as made to feel intimidated, dehumanised, or had a threat made about a recommendation, your grade, or your careerMedical studentsResidents (49.7%), clinical faculty (36.9%), preclinical faculty (7.9%)NoneLow
Al-Shafaee et al (2013), Oman48SurveyAcademic hospitalsBeing coerced into carrying out personal services unrelated to the expected role of interns and instances in which interns were excluded from reasonable learning opportunities offered to others, or threatened with failure or poor evaluations for reasons unrelated to academic performanceResidentsInternal medicine (60.3%), surgery (29.0%), paediatrics (15.5%), specialists (51.7%), consultants (50.0%), residents (12.1%), nurses (24.1%)Inappropriate sampling, inadequate sample size, inadequate description of study population and coverage biasHigh
Owoaje et al (2012), Nigeria52SurveyAcademic hospitalData not providedMedical studentsConsultants (69.1%), residents/fellows (52.4%), other students (15.7%), nurses (7.8%), laboratory technicians (4.1%)Low response rateLow
Askew et al (2012), Australia66SurveyAcademic and non-academic hospitalsData not providedConsultantsConsultants (44.0%), managers (27.0%), patients (15.0%), nurses/midwives (4.0%), junior consultants (1.0%)Low response rateLow
Meloni and Austin (2011), Australia53Before–afterAcademic hospitalData not providedHospital employeesData not providedLack of blinding of outcome assessors, high loss to follow-up, lack of statistical analysis or ITS design, and unit of analysis not clearly describedHigh
Dikmetas et al (2011), Turkey61SurveyAcademic hospitalData not providedResidentsSurgeons>internistsLow response rateModerate
Eriksen et al (2011), Norway67SurveyAcademic hospitalNAQ usedHospital employeesColleagues; specific occupations not describedLow response rate, inappropriate sampling and inadequate statistical analysisModerate
Imran et al (2010), Pakistan54SurveyAcademic hospitalsThreats to professional status, threats to personal standing, isolation, overwork and destabilisationResidentsConsultantsInappropriate sampling, classification and coverage biasModerate
Ogunsemi et al (2010), Nigeria55SurveyAcademic hospitalData not providedResidentsAdministrative staff (58.0%), from the hospital chief executive (41.4%), from patient relatives (40.4%), nurses (32.7%), residents (30.0%), patients (20.0%)Inadequate sample sizeLow
Best et al (2010), USA39Before–afterAcademic hospitalData not providedUnspecifiedData not providedStudy purpose not clearly described, insufficient enrolment, no blinding of outcome assessors, lack of statistical or individual-level analysis or ITS designHigh
Nagata-Kobayashi et al (2009), Japan56SurveyAcademic hospitalsAssigned you tasks as punishment; threatened to fail you unfairly in residency; competed maliciously or unfairly with you; made negative remarks to you about becoming a consultant or pursuing a career in medicineResidentsSurgery (27.6%), internal medicine (21.4%), emergency medicine (11.5%), anaesthesia (11.3%), consultants (34.1%), patients (21.7%), nurses (17.2%)Low response rateLow
Scott et al (2008), New Zealand1SurveyAcademic hospitalA threat to professional status and personal standing, isolation, enforced overwork, destabilisationResidentsConsultants (30.0%), nurses (30.0%), patients (25.0%), radiologists (8.0%), residents/fellows (7.0%)Low response rate, inadequate sample size and description of study populationModerate
Gadit and Mugford (2007), Pakistan71SurveyAcademic and non-academic hospitalsData not providedConsultantsSenior colleaguesInadequate sample sizeLow
Shrier et al (2007), USA40SurveyAcademic and non-academic hospitalsData not providedConsultantsColleagues (24.0%), patients (19.0%), teachers (18.0%), supervisors (15.0%)Inappropriate sampling, inadequate sample size and coverage biasModerate
Cheema et al (2005), Ireland45SurveyAcademic hospitalsData not providedResidentsSenior residents (51.0%–70.0%), nursing staff (47.0%–59.0%), administration (15.0%–16.0%), colleagues (12.0%–13.0%)Low response rateLow
Rautio et al (2005), Finland57SurveyAcademic hospitalData not providedMedical studentsLecturers (27.9%), research/senior research fellows (27.7%), professors (16.6%), associate professors (13.6%)Low response rate, inappropriate sampling, inadequate sample size and coverage biasHigh
Wear and Aultman (2005), USA35SurveyAcademic hospitalData not providedMedical studentsGeneral surgeons and obstetriciansLow response rate, inappropriate sampling, inadequate sample size, classification and lack of validated measurement toolHigh
Carr et al (2000), USA41SurveyAcademic hospitalsData not providedConsultantsSuperiors and colleaguesNoneLow
Quine (1999), UK8SurveyNon-academic clinicsData not providedConsultants54.0% greater seniority, 34.0% same seniority, 12.0% less senior; 49.0% of bullies older than victimsNoneLow
  • Academic hospitals/clinics were defined as teaching hospitals/clinics with a university affiliation.

  • *Regarding sexual harassment: the most common sources were attending surgeons (69% overall, 71% women, 18% men); trainees (46% overall, 47% women, 9% men); attending non-surgical (22%, 22% women, 18% men); other allied health professionals (16%, 15% women, 36% men); nursing (14%, 12% women, 73% men); admin staff (4%, 2% women, 36% men). Regarding harassing behaviours: the most common sources were attending orthopaedic surgeons (76% overall, 75% women, 86% men); trainees (30%, 32% women, 14% men); attending physicians; non-surgical (eg, anaesthesiologist, internist) (20%, 21% women, 11% men); nursing staff (18%,18% women, 20% men); administration staff (13%, 12% women, 17% men); and other allied health professionals (9%, 10% women, 9% men).

  • †The NAQ is a validated tool for assessing the prevalence of workplace bullying.

  • ITS, interrupted time series; NAQ, Negative Acts Questionnaire.