D. William C. Johnston, M.D., FRCSC
Edmonton, AB

Is intimidation present within orthopaedic training programmes in Canada? The answer, I believe, is clearly yes. There has been a great interest in this topic from a variety of sources, including The Canadian Medical Association, The Royal College of Physicians and Surgeons, postgraduate medical education offices, Canadian Association of Residents, and provincial licensing bodies. Many of these organizations have developed guidelines or a code of ethics to cover the area of intimidation, harassment, and discrimination.  

The postgraduate medical offices at Queen's University in Kingston, Ontario has developed a code of behavior for the ethical professor at Queen's. There are sixteen codes, which cover a variety of topics, but intimidation and treatment of students and residents is highlighted.

The Canadian Medial Association's Physician Health and Well-being Policy also notes that it is very important to "have a clear, fair process of preventing and dealing with cases" of intimidation, harassment, and discrimination. Dalhousie Medical School in Halifax has a good document available on the internet that asks the question, "Are you part of the problem? - Break the Cycle." Quotes from residents, such as, "It is part of the job", "I don't like it, but this is the way it has always been", and "It is a necessary part of training", are mentioned.

What is harassment? In brief, intimidation or harassment may include unfair demands upon learners, discrimination based on race, sex, religion, country of origin, verbal abuse, physical abuse or gestures, sexual abuse, reprisals and educational compromise.

Why is intimidation important to recognize and correct? It has been shown to hinder learning, undermine professional confidence, and compromise health care delivery and quality of patient care. It is important to "Break the Cycle". If residents are taught in a way that focuses on learning from intimidation, they will likely teach by intimidation.

There needs to be a clearly accepted process in place to deal with intimidation that should first involve a discussion with the individuals involved. If necessary, this discussion should also include the clinical supervisor, the Programme Director, the Department Head, the Residents' Association, the Postgraduate Medial Education Assistant Dean, Medical Director of the institution, and even the Dean.

A survey of programme directors at Canadian universities was undertaken. Twelve of sixteen have responded (75%). The first question was, "Have there been any episodes reported of intimidation by residents?" Five reported yes. I suspect episodes of intimidation are grossly underreported by residents. Question two asked, "Do you have a formal policy in place with education regarding intimidation?" Eight responded yes. Some of the positive responses outlined a faculty-wide policy but no specific orthopaedic programme involvement. Question three inquired, "Should intimidation be part of orthopaedic residency curriculum?" Seven programme directors said yes it should be. There were a number of very interesting comments made by the programme directors, such as, "Some preceptors had forceful personalities", "We have trouble with one particular staff person", and "If they get taught well, residents feel it is tolerable". Foreign residents had experienced racial intolerance. Some programmes had experienced problems with resident workload being used as an intimidation factor and humiliation in front of peers was also being used.