Foreign Surgery Residents in the U.S. Report Less Bullying, Harassment

Business — Why? Researchers cite different cultural norms and even visa concerns as potential reasons

by
Sophie Putka, Enterprise & Investigative Writer, MedPage Today
January 4, 2023

Foreign international medical graduates (IMGs) working in U.S. general surgery residency programs less frequently reported bullying and sexual harassment, a survey study found.

Foreign IMGs were less likely than North American-born graduates of U.S. or Canadian medical schools (USMGs) to report bullying (53% vs 64%, respectively; OR 0.64, 95% CI 0.49-0.84) and sexual harassment (17.7% vs 34%; OR 0.51, 95% CI 0.37-0.70), findings that seemingly contradict prior data, according to Yue-Yung Hu, MD, MPH, of the Feinberg School of Medicine at Northwestern University in Chicago, and colleagues.

And among the more than 3,000 respondents included, burnout was cited less frequently by foreign IMGs compared with USMGs (25.8% vs 43.4%; OR 0.60, 95% CI 0.44-0.81) as well as by North American-born IMGs (31%) versus USMGs (OR 0.70, 95% CI 0.49-0.99), the researchers wrote in JAMA Surgery.

Previous surveys from Hu and colleagues have pointed to discrimination by race, ethnicity, or gender, and bullying behaviors within general surgery residencies.

“I thought we’d find more [sexual harassment and bullying reported by IMGs], but actually, they tend to report less,” Hu told MedPage Today. “At first I thought that was probably because they tend to be more male — they’re probably not subject to gender discrimination or harassment to the same degree.” But, she continued, even after controlling for gender, they still reported less than their USMG counterparts.

No significant differences between groups were identified in the survey when it came to discrimination due to race or gender, for suicidality, or thoughts of leaving the program.

The results were “surprising,” Hu said. “I don’t have a clean message about it — it’s complicated.”

Researchers offered possible explanations for the seemingly “better” experiences of internationally trained residents, though they noted that “mistreatment and burnout remain common among both groups.”

For starters, while foreign IMGs may have actually experienced less mistreatment, they could also have had different perceptions of mistreatment based on cultural norms or language.

Additionally, “reporting of mistreatment may be affected by social desirability bias and/or concerns surrounding the survey’s ability to preserve anonymity,” wrote Hu and colleagues, adding that foreign IMGs “on visas may be particularly disincentivized from calling negative attention to their employers, on whom they rely to remain in the U.S.”

IMGs may have reported less burnout, the researchers speculated, because of altered expectations after training in other countries, gratitude to train in the U.S. given the many obstacles to doing so, or “survivorship bias, as IMGs with burnout may not attain categorical positions,” the authors wrote.

Hu said the researchers spoke with some IMGs about the potential explanations for the results and received responses such as: “Well, it’s worse where I come from” or “I’m just happy to have made it, and so then I am able to overlook some of the other things.”

“It doesn’t mean that it’s not happening to them, but they have a different framing of it,” said Hu.

She noted that the survey was conducted as part of a larger study called the SECOND trial, which evaluates well-being in residency training at more than 200 programs across the U.S., providing feedback to programs about the data aggregated for an intervention arm. For example, they might report how a program’s rate of burnout among residents compares with others, and then offer suggestions and tools to address the issue at a program level.

For this survey, general surgery residents were in their third to fifth year of residency. Of 6,956 “clinically active” residents who took the survey, the researchers included 3,067 for whom medical graduate status was available. Of those, 9.7% were foreign IMGs, 6.7% were U.S.- or Canadian-born IMGs, and 83.6% were USMGs.

More IMGs were male compared with USMGs (P<0.001): foreign IMGs (74.4%), North American-born IMGs (68.5%), USMGs (57.3%). And more IMGs attended programs in the Northeastern U.S. (44.4% vs 50% vs 28.8%, respectively, P<0.001), while more foreign IMGs were non-white or Hispanic (67.3% vs 38.8% vs 34.5%; P<0.001).

Limitations to the study included recall bias, factors the researchers didn’t measure such as English proficiency, and the exclusion of first- and second-year general surgery residents, who might experience more mistreatment or worse well-being.