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Prevalence of Harassment and Discrimination Among 1996 Medical School Graduates: A Survey of Eight US Schools
R. S. Mangus;
C. E. Hawkins;
M. J. Miller
Oregon Health Sciences University School of Medicine
JAMA. 1998;280:851-854.
Context.—Harassing and discriminating behaviors on the part of instructors or supervisors are known to affect the quality of work performed by medical students, influence their career decisions, and have other undetermined long-term consequences.
Objective.—To assess the prevalence and forms of harassment and discrimination experienced by 1996 medical school graduates.
Design.—A self-administered survey of harassment and discrimination mailed to graduating medical students.
Setting and Participants.—A total of 1001 graduating medical students at 8 US medical schools (4 public and 4 private), chosen from each of the 4 regions designated by the Association of American Medical Colleges for geographic categorization.
Outcome Measure.—The number of reported experiences of various forms of harassment and discrimination while attending medical school.
Results.—Of 1001 surveys, 548 (55%) were returned. Overall, 46% of the students reported experiencing some form of harassment and 41% some form of discrimination from instructors or supervisors while attending medical school. Nonsexual verbal harassment was reported by 41%; sexual verbal harassment was reported by 10%. Discrimination based on gender was reported by 29% of students; discrimination based on race was reported by 12%.
Conclusions.—Harassment and discrimination of medical students by instructors and supervisors continue to occur frequently, and new approaches are needed to address these problems.
Harassment and discrimination adversely affect performance, productivity, and learning in professional and academic settings.1-9 Definitions of harassment and discrimination vary across legal and lay usage. In 1991, Lenhart and and Evans10 defined harassment as verbal or physical conduct that creates an intimidating, hostile work or learning environment in which submission to such conduct is a condition of one's professional training. The same group defined discrimination as those behaviors, actions, interactions, and policies that adversely affect one's work because of disparate treatment, disparate impact, or the creation of a hostile or intimidating work or learning environment.10 Common forms of discrimination include those based on gender, age, religion, ethnicity, and race.
Abusive experiences are known to have a negative effect on the attitudes, behaviors, and learning capability of medical students.11-12 Recent reports indicate that between 72% and 99% of senior students experience some form of harassment from instructors, peers, patients, or staff during medical school.7-9,13-15 However, the majority of these studies were conducted at single institutions using small sample sizes. The prevalence of discrimination among medical students in academic settings is not as well documented. This multicenter survey assesses the prevalence and forms of harassment and discrimination experienced by a large sample (n=548) of 1996 medical school graduates.
Methods
A questionnaire was distributed to 1001 graduating medical students at 8 US medical schools (4 public, 4 private), 2 schools in each of the 4 regions used by the Association of American Medical Colleges (AAMC) for geographic categorization. Schools were chosen for inclusion by convenience and willingness to participate, not by a strict, randomization scheme. Questionnaires and return envelopes were placed in students' school mailboxes and were returned independently. Individual follow-up was not possible. The questionnaire was institutionally developed and contained sections taken from the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System questionnaire.
Two questions assessed the subjective experiences of harassment and discrimination (Table 1 and Table 2). To characterize their experiences of harassment (verbal, physical, or sexual) and discrimination (gender, age, racial, or religious), respondents were asked to choose as many responses as were applicable. Students were not given a definition or examples of either harassment or discrimination. The questionnaire as a whole was not conclusively assessed for reliability and validity. Data were collected from April to June of 1996. Analyses were conducted using SPSS (Version 6.1, SPSS, Inc). Nonparametric tests were used for group comparisons.
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Table 1.—Number (Percent) of Respondents Reporting Each Form of Harassment*
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Table 2.—Number (Percent) of Respondents Reporting Each Form of Discrimination*
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Results
A total of 1001 questionnaires were mailed and 548 (55%) returned. Response rates from the individual schools ranged from 44% to 69%. Students from public and private universities comprised 61% and 39% of the sample, respectively. The sample included a smaller proportion of female students than male students (44% and 56%, respectively) and fewer nonwhite racial/ethnic groups than whites (27% and 73%, respectively) (Table 1). Respondents' ages ranged from 23 to 47, the median age being 26 years (mean, 27.5 years).
Among respondents, 46% reported experiencing some form of harassment while enrolled in medical school (Table 1); nonsexual verbal harassment was most commonly reported (41%). Female students were significantly more likely than male students to report any form of harassment (54% and 39%, respectively; P<.001), nonsexual verbal harassment (46% and 36%, respectively; P=.02), and sexual verbal harassment (20% and 2%, respectively; P<.00001). Sexual harassment of any form was reported by 10% of students and by more women than men (21% and 2%, respectively; P <.00001).
A total of 41% of students reported experiencing some form of discrimination during medical school. Female students reported experiencing discrimination more often than male students (52% and 33%, respectively; P<.00001). Nonwhite racial/ethnic groups (blacks, Asians, and Hispanics) reported more discrimination than did whites (74%, 44%, 50%, and 39%, respectively; P=.04) (Table 2). Female students were significantly more likely than male students to report gender discrimination (47% and 14%, respectively; P <.00001). Nonwhite racial/ethnic groups (blacks 68%, Asians 28%, Hispanics 40%) were significantly more likely to report racial discrimination than were whites (3%; P<.00001). Discrimination because of age was significantly more likely to be reported by the oldest age group (29 years and older) (P=.02) and discrimination because of religion was significantly more likely to be reported by male students than by female students (6.8% and 2.1%, respectively; P=.01).
Comment
Many cross-sectional studies have been conducted over the past 15 years to assess the prevalence of medical student harassment. In 1990, the AAMC added questions about harassment and discrimination to their annual graduation questionnaire. Between 1990 and 1992, 5 separate studies reported the prevalence of medical student harassment to be greater than 70%.7-9,13-14 Unfortunately, the majority of published studies do not provide a complete representation of US medical students. Most were conducted at single institutions with small sample sizes and/or poor return rates.7-9,13, 15
An exception to this is the AAMC questionnaire, which was completed in 1996 by more than 80% of graduating medical students nationwide. The questionnaire results showed that 48% of the 13168 respondents experienced at least one episode of mistreatment while in medical school.16 This finding is comparable to the 46% prevalence of medical student harassment reported here for the same graduating class. This similarity in prevalence could be due to the geographically varied multicenter survey strategy employed in both the AAMC questionnaire and in this study. The demographic composition of this survey's respondents (and that af respondents to the AAMC questionnaire) were comparable with the distribution of US medical students by age, gender, race, and attendance at private or public schools.
The occurrence of harassment or discrimination has been assessed in previous questionnaires by providing examples of interactions between medical students and people with whom they interact. These interactions are then categorized by type of harassment (verbal, sexual, or physical) or discrimination (gender-, racial-, or age-related). This objective determination of "harassment" and "discrimination" has been used to facilitate study comparisons. In the present study, rather than provide researcher-imposed constructs of harassment and discrimination, students determined whether they had experienced harassment and discrimination according to their personal understanding of these terms. This may provide a more comprehensive assessment of harassment and discrimination, although it limits comparability with previous studies. The use of only 2 questions in this study decreases the sensitivity and specificity of the measurement instrument; however, prior studies may inflate the measured prevalence of student experiences of harassment and discrimination through extensive questioning.
Results of the subgroup analysis from this study were similar to those of previous studies. Women were more likely than men to report any form of verbal, physical, or sexual harassment and any form of discrimination. These findings support the results of Komaromy and colleagues,17 who assessed the prevalence and sources of sexual harassment in 1993 among 133 internal medicine residents. That study found that women were more likely than men to report experiencing sexual harassment from attending physicians, fellows, or other residents; men were more likely to report sexual harassment from patients, nurses, and other staff members.17
The use of a self-report survey carries with it many of the inherent limitations of a cross-sectional study, including recall bias and reporting errors. This study had a 45% non-response rate that introduces a bias of unknown quantity. Finally, results from this study may not be strictly comparable to those previously published because of its unique question format. Despite these limitations, this study demonstrates a continued high prevalence of harassment and discrimination experienced by medical students.
Sexual harassment remains an important issue that medical institutions must address—one in every 5 female medical students reports experiencing sexual harassment from an instructor or supervisor at least once during medical school. Discrimination based on gender and race are also vitally important areas for concern at medical institutions.
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