Resident Intimidation

1. Resident Intimidation Seemal R. Desai, MD Vice-Chair, AMA-RFS Governing Council Honolulu, Hawaii Interim Meeting

2. Introduction • Overview of Intimidation • AMA-RFS recognition of the issue • History of graduate medical education • Recent changes in GME • Is intimidation an issue? • Consequences of intimidation • Proposed solutions

3. Intimidation • Definition -- attempt to frighten by acting in a dominating manor with the goal of making people do what the intimidator wants. • Behavioral trait – present in everyone • Behavioral theorists suggest it is seen in children as a consequence of being intimidated by others

4. AMA-RFS • Section within the AMA • Approx. 25,000 resident and fellow members • 76 State and specialty societies • Annual and Interim Assemblies

5. AMA-RFS • Member Connect Survey – • 688 Residents and Fellows responded • Identified four issues of importance • Medical Liability • Educational Loan Debt • Uninsured • Intimidation • Over 75% of residents think it is important that the AMA address the issue of intimidation

6. Member Connect Survey • Prevalence • Resident members asked if they have experienced: • Non-physical harm threatened • Pressure to report work hours inaccurately • Sexual Harassment • Physical Harm Threatened • 25% have had non-physical harm threatened • 22% have been pressured to report inaccurate duty hours

7. Perpetrators

8. Member Connect Survey • Reporting – • 68% of residents believe they would know how to report intimidation • 50% responded they would not be comfortable reporting intimidation to their residency program

9. Reporting

10. History of Graduate Medical Education • 1914 – CMEH approved list of hospitals for internship • 1923 – CMEH approved list for GME • 1928 – Essentials of Approved Residencies and Fellowships – set standards • 1953 – RRC was developed • 1981 – LCGME became the ACGME • Now 26 RRC’s, TYRC, IRC

11. 1914 2006 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 Trend in Graduate Medical Education Standardization of Medical Education

12. 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 Trend in Graduate Medical Education Standardization of Medical Education 1914 2006 Learners Teachers Learners Teachers Learners Teachers

13. 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 Trend in Graduate Medical Education Standardization of Medical Education 1914 2006 Learners Teachers Learners Teachers Learners Teachers Educational Values

14. 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 Trend in Graduate Medical Education Standardization of Medical Education 1914 2006 Learners Teachers Learners Teachers Learners Teachers Educational Values Generation Gap Conflict

15. Sir William Osler • Father of Medical Education • Established the sleep-in residency program • Residencies were open-ended and had a long tenure • Residents led restricted and almost monastic lifestyle • System spans the generations • May now be obsolete

16. Generations • Traditionalists • Baby Boomers • Generation X • Generation Y

17. Generations • Traditional or Silent Generation 1925-1945 • Term was title of Nov 5, 1951 cover of Time • Raised during the post-war depression • Faith in institutions, government, business, family, or church • William Manchester commented: • Withdrawn, cautious, unimaginative, indifferent • Respect authority • Subscribe to a top-down model of authority • Included: Johnny Carson, Sandra Day O’Connor, Clint Eastwood, Neil Armstrong

18. Generations • Baby Boomer 1946-1964 • Born during economic prosperity post WWII • First generation that had advanced degrees • Vietnam War • Idealistic leaders that succeed by leading in the worst of times • Political leaders today • It is estimated that the Boom Generation will hold a plurality in Congress until 2015, the White House until 2021, and will have a majority in the Supreme Court from 2010 to 2030.

19. Generations • Generation X 1961-1981 • Term popularized by Coupland’s 1991 novel “Generation X…” described the loss of the icons of the baby boomer generation • Jane Deverson – coined term in a text where she described this gen. “sleeps together before marriage, don’t believe in God, dislike the Queen, and don’t respect parents” • Skeptical, raised during recession and downsizing • More concerned with work-life balance than boomers • Self driven, learners, skilled individuals

20. Generations • Generation Y – 1977-2003 • Technology driven • Tolerant of multiculturalism • Customizing of everything • Typically received positive affirmation from parents • Expect the same affirmation by teachers • Insist on a work-life balance

21. Why is there a problem now? • More Intimidation or Less Tolerance? • Sentinel Events • ACGME Core Competencies • 2003 Residency Work Hour Reforms • Diversification of the workplace • Is medicine the only industry affected? • Military • Corporate workplace

22. Institute for Safe Medication Practices • Survey published in March, 2004 • 2095 staff from different hospitals • >80% felt mild intimidation • 48% suffered strong verbal abuse • 43% experienced threatening body language • 4% physically abused

23. Patient Care Dishonesty Reporting Patient data Fear to act Congested communication Compromises in patient care Individual Relationship injuries Depression Fatigue Resignation or Transfer Perpetuation of cycle Consequences of Intimidation

24. Solutions • Education • Identification • Enforcement

25. Education • Education Goals • Diversity Training • Behavioral Training • Generation Gap Training • Forum • Medical School • Workshops/Seminars • On-line curriculum

26. Identification • Natural History of Reporting • Fear of consequences • Doubt of anonymity • Whistleblower • Monitoring mechanisms • Exit interviews • Ombudsman program • Hotline for reporting intimidation

27. Enforcement • Benign Enforcement • Resident-Faculty Compact • Faculty-Resident Compact • Ombudsman Program • Punitive Enforcement • Requires identification of a systems problem • Labor intensive

28. Summary • 75% of AMA-RFS members rank intimidation as a top issues for residents • Generation Gaps create conflict that lends itself to intimidation • The consequences of intimidation are destructive to education and patient care • Solutions to intimidation involve a multidirectional approach including: education, identification, and enforcement

29. Contact Information Seemal Desai, MD Vice-Chair, AMA-RFS Governing Council The University of Alabama Birmingham seemald@yahoo.com