Background: The magnitude of bullying and harassment among psychiatrists is reportedly high, yet no peer-review published studies addressing this issue could be found. Therefore, it was decided to conduct a pilot study to assess the degree of the problem, the types of bullying/harassment and to provide some insights into the situation.
Methods and Principal Findings: Following multiple focus group meetings, a yes/no response type questionnaire was developed to assess the degree and type of bullying and harassment experienced by psychiatrists. Over a 3-month period the questionnaire was administered to a random sample of 60 psychiatrists. 57 out of the 60 psychiatrists reported harassment and bullying. Frequencies of the following response variables are presented in descending order: rumours 40% (n = 24); defamation 20% (n = 12); passing remarks 20% (n = 12); false accusations 15% (n = 9); threats 13.3% (n = 8); verbal abuse 13.3% (n = 8); unjustified complaints 13.3% (n = 8); promotion blocked 13.3% (n = 8); humiliation 13% (n = 8); bad reference given 10% (n = 6); credentials questioned 8.3% (n = 5); physical attacks 5% (n = 3); termination 5% (n = 3); derogatory remarks 1.7% (n = 1) and 1.7% (n = 1) were subjected to personal work. As a result of being subjected to harassment, 66.7% of the psychiatrists did not take any action, whereas 33.3% confronted the person(s) they believed responsible. Asked whether the bullying and harassment caused distress, 18.3% of the psychiatrists did not report any effect, 30% reported mild distress, 40% moderate distress and severe distress was reported by 11.7%.
Conclusions: It was concluded that the magnitude of bullying and harassment among psychiatrists may be quite high, as evidenced by this pilot study. There is a need for extensive systematic studies on this subject and to establish strategies to prevent and address this issue at a national and regulatory level.
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Pakistan produces a large number of doctors every year, especially since the establishment of a number of private sector medical colleges. There are presently 137 790 doctors, which includes 20 557 specialists.1 As in other professions, jealousy occurs among the medical fraternity. Bullying and harassment occur in all organisations, although rates seem to be higher in some healthcare professions.2 Humans are complex beings, who harbour the attributes of jealousy, greed, cunning, self-esteem issues and aggression; all of which are shaped by genetics, psychological make-up and environmental influences. A number of people also suffer from various personality disorders that can cause serious adjustment difficulties in daily interactions and personal communications. Medical professionals are expected to be righteous, sympathetic, kind and to be free of a number of destructive personality traits. They are respected for their role as caregivers and healers and therefore their professional behaviour is required to be exemplary. More so now, greater emphasis is placed on ethical and professional behaviour by regulating authorities such as the General Medical Council of the United Kingdom, in the continuous assessment of “fitness to practice”, which deals with the assessment of professional malpractice, misconduct, mental conditions that in any way limit the ability to practice with safety or any addictions.3 In a developing country such as Pakistan, where morals are taught from childhood through religious training, ethical behaviour from medical professionals is expected at all levels. Unfortunately, the fabric of medical society is being challenged by rampant harassment, which refers to behaviours that are found threatening, offensive, disturbing, unsanctioned by society and bullying, which is the intentional tormenting of others through verbal harassment, physical assault or other more subtle methods of coercion such as manipulation.4 An unofficial report from the Pakistan Medical Association depicts a horrendous picture of harassment among medical professionals. The distribution of such complaints, approximately 200 from Karachi, only gives the distribution as: surgery, 12%; medicine, 16%;, gynaecology and obstetrics, 21%; ear, nose and throat, 11%; ophthalmology, 1%; orthopaedics, 0.5%; dermatology, 0.5%; dental, 5% and psychiatry, 33%. The magnitude of bullying and harassment was quite high among psychiatrists compared with other disciplines. The psychiatric practice pattern in Pakistan is divided between two sectors: public and private. There are a limited number of positions available in institutions in both sectors, but a psychiatrist can start a clinic on his own and settle into private practice. The majority of psychiatrists are concentrated in urban areas and there is an acute shortage of psychiatrists in rural areas. As a result of low educational levels and stigma, the majority of people would prefer alternative practitioners for mental health issues. This pattern is comparable to neighbouring south Asian countries. From personal communication, a group of psychiatrists have narrated harrowing tales about being subjected to verbal abuse, physical attacks, offensive remarks, defamation, questioning of credentials and blocking of promotions, etc. According to them, this attitude of professional colleagues has caused a tremendous amount of mental anguish.4 Discussions about the possible dynamics of this behaviour have introduced theories related to complex human nature, with attributes of jealousy, greed, paranoia, self-esteem problems, psychological make-up, personality traits or disorders, genetic predisposition, influence of upbringing and exposure to non-conducive or threatening environments during developmental stages. The presence of a mental disorder among perpetrators cannot be ruled out. Harassment and bullying can be manifested in various forms including, but not limited to, physical attacks, shouting or swearing, persistent criticism, humiliation, insults, spreading rumours, threats, sabotaging work performance, blocking promotions or appointments and verbal aggression, etc. Perpetrators are known to possess a desire to obtain power, to lack communication skills, to conduct personal vendettas and to follow a “hidden agenda”. Any such behaviour can be a source of perpetual mental anguish, which involves subjecting somebody to severe mental distress, in gross violation of article 5 of the United Nations declaration that states “no one shall be subjected to torture or to cruel inhuman treatment”.
According to Kofi Annan, ex-secretary of the United Nations, “torture is not only the vilest of acts one human being can inflict on another, it is also the most insidious of all human rights violations”.5 Therefore, this declaration should be applied to ameliorate the situation in question. Human rights violations are rampant in Pakistan at all levels but there is a sad irony in the fact that they occur among medical professionals and particularly among psychiatrists who deal with the human psyche. Reportedly, the impact of such mental stress has resulted in posttraumatic stress disorder, depression, anxiety, physical illness, psychoses (rare) and even suicide among victims.6 In Pakistan, there is a paucity of laws to deal with mental torture. Regulatory bodies and professional organisations are not playing effective roles in addressing this issue, which appears to have assumed alarming proportions. There appears to be no systematic study of psychiatrist bullying and harassment in Pakistan. To help assess the magnitude of the problem and gain insight into it, the following pilot study was undertaken. Focus on psychiatry was based on the maximum number of complaints received from this discipline, with a view to taking an example for future studies in the wider disciplines of medicine.
Based on reports, personal communications and the aforementioned complaints to the Pakistan Medical Association, it was supposed that the prevalence of bullying and harassment was high and it was important to assess the magnitude of this problem. As no existing study could be found and no data are available, it was difficult to make an assumption about the prevalence of harassment and bulling experiences of psychiatrists. Despite an extensive search of neighbouring countries with similar backgrounds and situations, no meaningful data related to this issue could be found. Consequently, a pilot study was planned. There are 300 psychiatrists for the whole country in Pakistan and it was decided to select a sample of 20%, ie, 60 psychiatrists, for the scope of the study. The concentration of all these psychiatrists was not uniform in the four provinces in Pakistan. In addition, the number of female psychiatrists is proportionately very low compared with male psychiatrists.
This cross-sectional study was conducted in Pakistan. From the total list of 300 practising psychiatrists, a random sample of 60 was obtained. The selection of the sample was conducted by a person not directly associated nor personally involved with the study. After selection was completed, the psychiatrists were contacted by the study investigator, who explained the purpose of the study and assured confidentiality. Ten psychiatrists refused to participate in the study. Their names were dropped and 10 more were randomly selected from the remaining 240.
A questionnaire was developed through multiple focus groups with psychiatrists in each of the four provinces of Pakistan. This questionnaire was administered to the study psychiatrists and returned by them to the investigator. Relevant demographic information was obtained as well as yes/no responses to a number of variables believed to be representative of bullying and harassment behaviour.
Responses were analyzed using SPSS version 14.0.
Of the 60 randomly selected psychiatrists, 88.3% (n = 53) were men and 11.7% (n = 7) were women. Public sector practice accounted for 71.7% (n = 43) and private practice 28.3% (n = 17) of participants. The number of years in practice since specialisation varied from two to 22, with a mean of 9.95 years.
Ninety-five per cent (n = 57) reported bullying and harassment. Reported frequencies for the 15 variables used to assess bullying and harassment were: rumours 40% (n = 24); defamation 20% (n = 12); passing remarks 20% (n = 12); false accusations 15% (n = 9); threats 13.3% (n = 8); verbal abuse 13.3% (n = 8); unjustified complaints 13.3% (n = 8); promotion blocked 13.3% (n = 8); humiliation 13% (n = 8); bad reference given 10% (n = 6); credentials questioned 8.3% (n = 5); physical attacks 5% (n = 3); termination 5% (n = 3); derogatory remarks 1.7% (n = 1) and subjected to personal work 1.7% (n = 1) (fig 1).
Despite having reported being subjected to harassment, 66.7% (n = 40) of the psychiatrists in the study group reported having taken no action, whereas 33.3% (n = 20) confronted the perpetrator.
Distress associated with bullying and harassment was reported for four categories, no effect to severe; 18.3% (n = 11) of the psychiatrists reported no effect; 30% (n = 18) reported mild distress, 40% (n = 24) experienced moderate distress and 11.7% (n = 7) severe distress. Stress categories were based on subjective descriptions by the individuals affected. Mild distress was perceived when the subjects felt apprehensive and anxious but their professional and/or personal life was not affected. Moderate distress was associated with disturbance in professional and/or personal life, whereas severe distress leads to depression and perpetual anxiety.
Although no psychiatrist reported more than four types of bullying descriptors, 5% (n = 3) marked four options; 25% (n = 15) three; 33.3% (n = 20) two and 31.7% (n = 19) one.
An examination of differences between responses by type of practice yielded no significant difference between public sector practice and private practice (all χ2 non-significant, p>0.05) in the type and number of responses.
An examination of differences in response by gender suggests that only “termination” was different between men and women (χ2 = 11.33, df = 3, p<0.034). Caution should be exercised as only seven of the sample of 60 psychiatrists were women. In addition, following the convention of adjusting p for multiple testing, then only values of p<0.003 should be considered for statistical significance. Accordingly, “termination” was no longer considered statistically significant.
This pilot study is an important step in understanding the magnitude of this problem and is evidenced by the results that 57 of 60 psychiatrists reported bullying and harassment in various forms. It is possible the three psychiatrists who did not report any such incidents may have preferred not to reveal the fact or had not perceived such gestures as harassment.
The number of male psychiatrists outnumbered women but this is a reflection of the proportion of male to female psychiatrists in Pakistan. The unavailability of the possible reflection of responses from women psychiatrists in terms of this issue is a limitation of this pilot study. Given the nature of society and cultural norms of the region, however, women tend to escape because of the low number in the profession, more room for practice, less competition, a low tendency to report complaints and grievances and the avoidance of assuming prominent roles in many instances.
The period since specialisation varied from two to 22 years, which is not an unusual finding as there is a mix of varied experience among psychiatrists in Pakistan, especially in view of the many young psychiatrists who have opted to return to Pakistan and a certain number of new locally qualified psychiatrists.
A majority of the psychiatrists in the study group (71.7%) belonged to the government/public sector. This may be partly due to the fact that the private sector does not hire many psychiatrists because of the low weighting given by the Pakistan Medical and Dental Council (PMDC) to the speciality of psychiatry.
A majority of psychiatrists reported that the spreading of rumours against them is very common in the prevailing medical culture; defamation and passing general uncomplimentary remarks as well as derogatory remarks were reported in high frequencies. False accusations, unjustified complaints lodged to the health authorities, humiliation in public and threats were reported frequently, which is similar to the current general environment in Pakistan, where human rights issues are not addressed appropriately and lawlessness is prevalent.
Many psychiatrists were also subjected to verbal abuse, personal work (some senior psychiatrists would ask the junior working under them to do some personal favours such as writing a letter, visiting an office to collect some documents on their behalf or assisting in some domestic work), bad references, blocking of promotion, termination and even physical attacks (5%). This can also be explained partly by the concept of “feudal psychiatry” in which few self-proclaimed senior psychiatrists have declared their reign in an implicit way.7 There is another trend among psychiatrists in which credentials are questioned. There is the perception of a general sense of superiority among the holders of MRCPsych, who are bent upon nullifying all other qualifications. Although there is propagation by some senior psychiatrists that preference should be given to locally qualified psychiatrists, foreign qualifications still carry weight and are respected.
The majority of the psychiatrists in the study group (66.7%) reported no action being taken against bullies and harassment but 33.3% reported confrontation with the perpetrators. There was a general reluctance or fear expressed by the majority to engage in confrontation with the perpetrators of the bullying and harassment.
The majority of these psychiatrists (70%), however, reported mild to moderate distress because of this harassment, whereas 11.7% expressed severe distress in such a situation. Consequently, there is a need for an exploration of mental health morbidity among the severely affected individuals and it will not be surprising to find disturbing results. Bullying is often an experience that causes the individual to feel isolated, with repercussions for mental and physical health.8 Such behaviour may affect self-esteem, academic progress, personal lives, careers and ultimately patient care.9 In one study,10 37% of junior doctors reported being bullied and experienced at least one bullying behaviour. In Pakistan, professional jealousy impeded the progress of medical practice in general and psychiatric practice in particular.
Some recent examples of debate in academic journals have highlighted the perception of harassment of Pakistani psychiatrists. When the National Health Service in the United Kingdom recruited six psychiatrists from Pakistan under the International Fellowship Scheme, a hue and cry was raised in the form of articles in academic journals condemning this step, with a plea that by such an act the health system of Pakistan would collapse.7 Those who wanted to avail themselves of the opportunity of this recruitment experienced harassment. The relationship of psychiatrists with the pharmaceutical industry was highly condemned.7 The award of membership without examination to distinguished psychiatrists by the Royal College of Psychiatrists was debated in journal articles, and the college was blamed for this policy, which was felt to be wrong, as according to the critics, the psychiatrists thus rewarded did not deserve the prestige.7 This matter caused mental anguish among the psychiatrists, one of whom brought the matter to the law courts with an allegation of defamation. This study reports physical attacks, which is somewhat in line with a report of a professional colleague who committed murder.7 The literature has hinted that perpetrators may have had a personality disorder that had not previously come to attention.11
This study may have limitations due to low sample size, low representation of female psychiatrists and unequal country-wide distribution. The distress categories were based on subjective descriptions rather than the application of a psychological scale. We hope to apply psychological tests in future systematic studies.There is cultural diversity among four provinces of the country, which is not reflected in this study because of the non-uniform distribution of psychiatrists and unequal representation. The results take a broad view of the general scenario, which may be a limitation of this pilot study. The 20% sample was, however, randomly obtained and this percentage is reflective of the general response rate of questionnaires distributed to medical professionals. Apart from the forms of harassment identified in this study, more subtle forms, which at times are difficult to perceive, may be contributing to stress experienced by psychiatrists and other physicians.
The system in Pakistan is such that people are not very open about discussing this issue because of the perceived fear of victimisation. We believe that bullying exists among medical professionals almost everywhere in the world but there are no available visible data. It is our hope that this study will inspire others to conduct such studies in their respective regions. Based on the results, we wish to make a few suggestions as follows.
It is important that awareness of the magnitude of bullying and harassment be raised through media communications.
Professional behaviour should be emphasised through the PMDC.
A “code of ethics” should be put into practice by the regulatory authority (PMDC).
Personality tests and rigorous interviews should be conducted for prospective candidates wishing to enter psychiatry training programmes.
Anti-bullying and harassment policies should be developed by healthcare organisations.
A “medical ombudsman” should be appointed by the government. This concept is worth adopting in a country like Pakistan where professional organisations have failed to address the issue. The legal system in Pakistan is also very complex and it is difficult to get timely justice through the law. The Pakistan Medical Council has remained in turmoil for the past decade and hence an ombudsman can help the system. This concept is not new as many academic medical institutions have appointed an ombudsman.
A system should be in place whereby matters related to promotions in institutions are handled by a committee, which should have a diverse composition of external reviewers, lay persons and persons with legal and ethical backgrounds.
Local credential review committees reporting directly to the regulatory authority of the country should be established.
Reference systems should be from multiple sources.
Threats and physical attacks should be reported to the police directly.
All other issues such as defamation, rumours, subjecting to personal work, unjustified complaints, humiliation, false accusations, verbal abuse and any other form of harassment can be dealt with through the office of the local ombudsman. There are ombudsmen appointed by government, who can deal with a number of issues.
This pilot study suggests that the prevalence of bullying and harassment is quite high in Pakistan and there is a need for systematic studies on this subject.
Ethics approval was obtained from the Ethics Committee of Hamdard University Hospital of Hamdard University, Karachi, Pakistan.
Competing interests: None declared.
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