Workplace mistreatment, in the form of intimidation, harassment, and discrimination, remains prevalent within medicine. Various studies have quantified levels of perceived mistreatment amongst learners and faculty between 30 and 85% [5, 10,11,12]. Physicians work in an immersive environment, often interacting with patients, allied health professionals, nurses, administrative staff, and other physicians. As such, understanding the interpersonal dynamics of mistreatment is imperative when the goal is to cultivate solutions that lead to positive change. Within OHNS, there is a lack of data characterizing the source, nature, and overall prevalence of mistreatment. This survey study aimed to quantify mistreatment and understand how it manifests within OHNS, a crucial first step in addressing this ubiquitous problem.

Canadian OHNS physicians surveyed in our study experienced workplace mistreatment at a mean rate of 47.6%. Both faculty and trainees were affected by mistreatment, but trainees to a greater degree. OHNS faculty were the most common source of intimidation and harassment towards both trainees and other faculty members. Patients and their families were the most common sources of discrimination. Moreover, overall mistreatment was experienced at a greater rate by females—with gender being the most common perceived reason for mistreatment. Other factors associated with mistreatment include non-White ethnicity and junior faculty status.

The hierarchical structure of medicine and a lack of diversity are historical factors that have contributed to mistreatment in the clinical setting [10, 13]. Several respondents alluded to the “toxic” hierarchical culture of medicine as one that allows mistreatment to remain prevalent (Table 3). In recent years, medicine, as a structural entity, is challenging the historical reliance on “dysfunctional” hierarchies and moving towards “functional” hierarchies which rely on an inclusive environment to improve education, learner well-being, and patient safety [10]. Moreover, dysfunctional hierarchies often reinforce an exclusionary culture that may shame those speaking out about mistreatment [7].

Despite a majority of institutions having mistreatment policies and resources available, there was a discrepancy between the number of people experiencing mistreatment and those utilizing the available resources. Overwhelmingly, the principal reason preventing utilization of resources was due to fear of retribution and breach of confidentiality. Given the relatively small size of OHNS departments, it can be inherently challenging to protect anonymity (Table 3). Furthermore, trainees believed that their ability to secure future employment could be compromised, especially considering the largest source of intimidation and harassment was OHNS faculty. Several of the trainees who reported mistreatment and consulted resources described being met with blame or inaction. Hesitancy in accessing program-based resources may be addressed with a third-party ombudsman tasked with addressing mistreatment concerns—such as the newly formed Office of Learner Experience at our institution. Such structural entities that establish mistreatment policies and anonymized reporting mechanisms are a crucial first step. Awareness of these resources, culture change through strong leadership, and accountability are essential to fostering a safe and supportive work and training environment.

Nearly half of all faculty experiencing mistreatment reported it as coming from another faculty member. This finding highlights that mistreatment extends beyond residency and underscores the importance of an accountable support system. There was also a significant portion of mistreatment coming from patients and patients’ families. Though complete prevention is difficult, several mitigation strategies have been suggested to better prepare trainees and faculty when faced with difficult patient encounters. These include formal team debriefing sessions, cultural competency education, awareness of the chain of command for escalation, creation of multidisciplinary task forces focused on education efforts and policy changes, as well as mistreatment surveys, such as the one executed herein, for longitudinal tracking [14, 15].

There are several limitations to this study. Given the need for respondents to reflect on events of the past year, there is an element of recall bias. Moreover, as this survey contained the words “mistreatment” and “discrimination” in the title, it is possible that that those who experienced mistreatment were more likely to answer the survey, therefore overestimating the rates of mistreatment we observed. A second limitation is the low response rate of 39.1%. Although this rate is on par with other national surveys within the profession (20–40%), our results should be interpreted with caution due to participation bias [16,17,18]. Moreover, the relatively low number of respondents and overall homogeneity in particular demographic categories prohibit more robust statistical analysis, which may have provided some important insights. Finally, as the survey was disseminated by our study team based out of the University of Toronto, there is a possibility of bias towards respondents from the University of Toronto over other institutions in Canada.