Residency training can be stressful. Some stress is expected and is part of the steep professional and personal learning curve that residents must negotiate prior to commencing independent medical practice. Sometimes stress can arise unexpectedly in the midst of learning and clinical work and can threaten personal and professional wellbeing [^1-3]. Stress can take many forms. While some stress can stimulate learning (a student or resident recognizing a knowledge gap at the point of care, and then taking steps to address this), other stress can be potentially impairing (a learner receiving voluminous emotionally charged and non-constructive critique). The shadow side of stress may take the form of intimidation, harassment or discrimination (IHD).

The College of Family Physicians of Canada (CFPC) recognizes the importance of the learning environment to medical education, the stressors embedded in residency training, and considers this "an important and often overlooked component of a training program" [⁴]. The Standards for Accreditation of Residency Programs of the CFPC state: "a supportive learning environment requires respect for learners, a respect for their learning objectives and a willingness to help them achieve those objectives" [⁴]. Furthermore, these CFPC standards require "that resources are available to meet the health and safety needs of residents and, in particular, to recognize and provide counselling for stress-related problems among residents" [⁴].

There is substantial literature documenting the prevalence of IHD in the medical education environment [^5-19]. Studies have been conducted on abuse across residency disciplines [²⁰] and sexual harassment within a family medicine residency program [²¹]; however, concerns surrounding IHD have not yet been explored in-depth in Canadian family medicine residency programs. IHD has been reported by medical students and residents to range between 40-93% in Canada, the USA, the UK, Israel, Japan [^8-11,²⁰,^22-25]. The most commonly encountered unwanted behaviours were persistent attempts to belittle and undermine the work of the trainee or to humiliate the trainee in front of colleagues [⁸,²⁶]. Some believe that belittling residents is a "salutary rite of passage" [²⁷] and that intimidation and harassment is potentially an effective educational tool [²⁸].

Experiences of IHD are often not reported usually due to fear of retaliation [²³], especially if the perpetrator is also responsible for in-training evaluation. Residents may choose to deal with IHD incidents informally or alone, fearing the consequences of making the offender aware of reported concerns and risking further IHD, if ongoing interaction with that individual is likely. Younger or less mature residents may hold themselves responsible for their own victimization.

Experiences of intimidation and harassment can cause psychological concerns, creating distress and dissatisfaction in the training environment [¹,²⁹]. IHD has been found to affect the health of those in training resulting in poor morale and motivation, poor patient care, lower career satisfaction, and mental health problems [¹,²,^8-10,³⁰,³¹]. Depressed residents were more than six times as likely to make errors in medication as compared to their non-depressed colleagues [³].

The impetus for our study was threefold: experiential, opportunistic, and quality driven. Firstly, while a family medicine residency program director, one of the authors (RC) became aware of isolated instances of IHD experienced by family medicine residents. This generated two haunting questions: What was actually happening within the program? What would it take to find out? Secondly, the groundbreaking survey work on resident wellbeing by a psychiatry colleague revealed disturbing results regarding resident stress and resident perceptions of harassment and intimidation [¹,⁹]. It was evident that data on IHD among family medicine residents in Canada is scarce and there was no literature comparing IHD between Canadian and IMG family medicine residents. Finally, the pan Canadian work on accreditation and the issue of IHD in postgraduate medical education was being increasingly recognized [³²]. Therefore, as part of a sustained and provincial family medicine residency program quality improvement process, it became necessary to formally explore IHD issues in our family medicine settings to provide the evidence-base for any needed action.

The purpose of our study was to examine the frequency, type, source, and basis of intimidation, harassment or discrimination (IHD) during residency training as experienced by Alberta family medicine graduates.

A total of 242 (64.2%) of 377 graduates responded to the survey. The questions on IHD were completed by 235 (97.1%) respondents. The average age of the respondents was 34.6 (SD = 5.3) years, 53.2% were females, and 16.6% were international medical graduates (Table 1).

This study exploring IHD within a Canadian family medicine residency program setting reveals that perceptions of IHD are prevalent among family medicine graduates. Although the overall prevalence of IHD in our study (44.7%) is at the lower end of that reported in the literature [¹,¹¹,²⁰,³⁵], clearly any occurrence of IHD is of concern. Our finding that inappropriate verbal comments were the most frequent type of IHD is consistent with the published literature [¹¹]. The study also provides new information on the comparison of IHD between Canadian and IMG family medicine graduates. While the two groups demonstrate a similar prevalence of IHD, a greater proportion of IMGs perceive ethnicity, culture, or language to be the basis of IHD and Canadian graduates tend to identify gender as the basis of IHD.

The primary sources of IHD during family medicine residency training appear to be external to the discipline of family medicine: specialist physicians, hospital nurses and specialty residents. This finding is consistent with another study that reported abuse during clerkship rotations to be most prevalent on surgical rotations [³⁶]. Within the hospital setting, there is a traditional power structure and hierarchy in which family medicine residents may be at the lower end of the resident pecking order and, in a values-challenged system, possibly less deserving of respect [⁶,¹⁰,¹³]. Predominant perpetrators of mistreatment in medical education settings have been reported to be consultants, supervisors, instructors, physicians, colleagues, nurses, allied health personnel, and sometimes patients [⁶,²⁰,³⁷]. Some may use teaching as a forum to humiliate, rather than to constructively challenge and critique [⁸,²²,²⁶].

The finding that there are perpetrators from within the discipline of family medicine is also of great concern, particularly when these individuals are entrusted with teaching residents and influence local family medicine culture or practice. There is substantial room and need for constructive dialogue and conjoint behaviourally-based problem solving on matters of IHD, both within and external to family medicine.

Gender and ethnicity were cited as the most frequent perceived basis for IHD, with more females citing gender and more IMGs citing ethnicity, culture, and language. The gender differences may arise from biological or cultural differences in the perception, specific identification, and recollection of an IHD event. In some medical environments, there may be a perceived or real "boys club" mentality wherein female residents need to "prove" themselves. Some studies reveal significant differences in the degree of sexual discrimination and sexual harassment across specialties in American medical schools [⁶,³⁸]. Power differentials may exist between female residents and male physicians or experienced nurses. Females may perceive that the consequences of reporting IHD is worse than the IHD itself, for the rewards of being labelled a "troublemaker" are few. We propose that "work as punishment" (i.e. being given additional work duties), experienced by more males than females, is a more aggressive type of IHD compared to the passive-aggressive removal of privileges (i.e. being subtly excluded from procedural skill learning opportunities) experienced by more females.

Given the many challenges that IMGs experience in workforce integration in Canada, it is reassuring that no significant difference exists in the proportion of Canadian and IMG graduates who experienced IHD in our setting. We speculate that, at the time of the survey, perhaps significant Albertan and pan-Canadian IMG focused efforts were beginning to bring about change at the point of learning and care [³⁹]. The greater proportion of IMGs perceiving ethnicity, culture or language to be the basis of IHD is not surprising, although disturbing given both Canada's reputation as a tolerant and multi-cultural society, the Canadian Charter of Rights and Freedoms, and the societal thrust towards equity in education. Family medicine residency programs need to be cognizant of IHD experiences by IMGs and proactively formulate a constructive and robust educational response.

Our study findings reveal that that older graduates are less likely to report IHD than their younger colleagues. It is unknown whether older graduates truly experience less unwanted behaviours or whether with increasing age and maturity, perceptions and/or interpretations change. Behaviour that may be perceived as a form of IHD by a younger graduate may be "taken in stride," discounted or ignored by one who is older. It is also possible that perpetrators of IHD may be more likely to target younger individuals. Further research examining the relationship between age and IHD using qualitative methods may help to elucidate these findings.

Our finding that only slightly more than half (54.4%) of family medicine graduates knew about the process to address IHD in residency training is not reassuring. This may partially explain why official grievance avenues are under utilized [²¹]. In both family medicine training programs and in the postgraduate medical education and university systems in which residency training is embedded, there are policies and programs to foster an educational environment that is both conducive to learning and explicitly supportive of the well-being of learners. Consequently, it is prudent to communicate within training programs that prevention [²¹] is the preferred strategy. Efforts by residency programs to monitor resident well-being are recommended as well-being may be a good indicator of progress in eradicating IHD.

The impact of IHD on the graduates in this study is unknown. Consequently, future research on how family medicine residents cope with IHD would be beneficial especially in understanding what type of support mechanisms should be provided. Evidence suggests that male students who are abused are more likely to perpetuate mistreatment, even toward patients [⁴⁰]. Whether residents in our study who were intimidated or harassed went on to intimidate others is unknown and may be worthy of investigation.

Is more IHD policy needed? We doubt it. Quinn [⁴¹] asserts that the connection between law, policies and everyday practice is "contradictory and incomplete". It appears that the real policy challenge is meaningful and enlightened implementation at the point of learning and care. Educators addressing IHD issues recognize the power differential and hierarchical systems that can make it difficult for a learner to directly attempt to address a personally-directed IHD. It is agonizing to challenge a superior if that same individual is the one who will be completing the end of rotation evaluation. What is difficult at the level of an individual learner must be addressed by educators, local educational structures, and those in authority. While solutions to IHD issues were not the focus of the current study, promoting both a healthy learning environment and physician wellness could be a constructive contextual approach in facilitating preventative efforts.

Perceptions of IHD are prevalent among graduates who have completed family medicine residency training in Alberta. The most frequent type of IHD experienced was in the form of inappropriate verbal comments. The primary sources of IHD during family medicine residency training appear to be external to the discipline of family medicine. This study provides new information on the comparison of IHD between Canadian and IMG family medicine graduates, with a greater proportion of IMGs perceiving ethnicity, culture, or language to be the basis of IHD. Residency programs and the educational systems in which they are embedded should both explicitly recognize and robustly address any IHD concerns while actively promoting prevention, with an emphasis on personal and professional well being and a supportive learning environment.

We declare we have no competing interests.

RAC was the principal investigator and was involved in all aspects of the study including study design, questionnaire development, interpretation of the study findings, and manuscript preparation. OS contributed to the development of the study design, questionnaire development, ethics application, interpretation of study findings, and manuscript preparation. WW participated in the study design, questionnaire development, conducted the data analysis and contributed to manuscript preparation. FC conducted the literature review and provided assistance during the implementation phase and contributed to manuscript preparation. CH provided project management expertise in all phases of the study and contributed to data interpretation and manuscript preparation. All the authors contributed to critical revisions and approved the final version of the manuscript.

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1472-6920/11/88/prepub

This project was jointly funded by the Alberta Rural Physician Action Plan (RPAP), Alberta International Medical Graduate (AIMG) Program, Capital Health (Edmonton), and Calgary Health Region. Mr. Henry Sun designed the web-based questionnaire format. Dr. Marianna Hofmeister completed an initial literature review.

We wish to acknowledge the many educational strengths of the family medicine residency training programs at the University of Alberta and Calgary that have been identified through regular program monitoring and the external residency program accreditation process. Their sustained program and departmental commitment to quality assurance via rigorous in depth inquiry and their willingness to directly address identified issues is admirable.