Bullying is the antithesis of compassion; a way to break others down, to humiliate them and to challenge their sense of their own self-worth and competence. How can this be a way to teach our junior staff to be competent, compassionate and caring and how long must we wait for change?
It has recently been reported that the College of Intensive Care Medicine (CICM) has withdrawn the rights of a major Sydney teaching hospital to train registrars because of alleged bullying.(1)
While this unprecedented withdrawal should be applauded as a move to outlaw bullying in our health service, it appears that it is taking us a long time to learn that bullying is not acceptable. Unfortunately, there is a generational legacy of bullying, teaching by humiliation and even sexual harassment which, while never acceptable, was not effectively challenged.
In a recent statement (1), the Minister for Health Brad Hazzard is quoted as saying:
“I value our medical specialists but they also have to understand that this is the 21st century and there is absolutely not one millimetre of room for a culture of bullying or failure to provide respect to every staff member in the area of service.”
The move to withdraw registrars from Westmead Hospital ICU will inevitably affect the remaining doctors in this vital service by cutting staff numbers, however such a move does not come as a surprise, but was promised by CICM in response to a survey published in 2016 which found significant numbers of ICU staff reported bullying. (2)
All ICU specialists and trainees were surveyed and there was a 50% response rate. 32% reported bullying, 12% discrimination and 3% sexual harassment. 70% of perpetrators were consultants. (3)
In response to allegations of bullying and sexual harassment in surgery, the Royal College of Surgeons not only published an apology but also designed a compulsory learning module which all surgeons, trainees and students must complete.
“Bullying is a real problem for our profession, like it is in the rest of the health sector. It compromises patient safety. Almost half of us have seen it or felt it. Now is the time to build respect and improve patient safety in surgery and deal with discrimination, bullying and sexual harassment.”(4)
In the College of Surgeons website Rhea Liang, a breast surgeon writes:
“There’s been a lot of excusing of that sort of behaviour, of unprofessional behaviours, as long as the surgeon could operate. Because it was hierarchical, people who were not at the top of the pyramid felt unable to speak out.” (4)
“It’s amazing to think that the sorts of behaviours that have been forgiven within the surgical theatre for a long time would be completely inappropriate in any other professional setting.” (4)
Jason Chuen, a vascular surgeon suggests:
“Being a good surgeon means more than just being good, technically. There are some people who believe that if the team fears them, they’ll do what they’re told. If you yell and scream and throw things around, you get what you ask for, not what you might need. People in the team are afraid to speak up. There’s a difference between a compliant team and a high performing team.” (4)
The College of Surgeons has been a leader in encouraging improvements in the culture of Medicine and has offered an example to other colleges. While surgery has long been considered to be an area in need of behavioural change, change is needed across the profession, starting with our medical training.
Despite all the College has done, bullying is still an issue in surgery and the week following the report about Westmead Hospital, the College of Surgeons removed training accreditation from the Cardiothoracic Surgery department of another reputable Sydney hospital.(5)
It is commendable that these Colleges are taking a stand against bullying and I hope that the Medicine of the future will no longer tolerate it at any level. For those who persist in these behaviours, one hopes that they are at last learning that “No” means “No”. While the details have not been made public, such unprecedented action on the part of two Colleges suggests behaviour of a serious nature which could not be dealt with by a simple warning to stop it.
Teaching by humiliation
In 2015 Karen Scott and her colleagues published a pilot survey in which medical student survey had been questioned about their experiences of “teaching by humiliation” and mistreatment in their medical and paediatric rotations. 83% reported witnessing teaching by humiliation in Medicine and 45% in Paediatrics. While there is a significant difference between Medicine and Paediatrics, it is alarming when in the area thought perhaps to be the least abusive, over a third of students reported experiencing or witnessing abusive behaviours. While most of this behaviour could be classified as more subtle abuse such as teachers being nasty, rude or hostile, or belittling or humiliating students, others had experienced yelling, shouting, cursing or swearing. Surprisingly and of great concern, over a third of students considered mistreatment to be useful for learning. (6)
Dr Ranjana Srivastava, writing in The Guardian in response to the decision of the CICM, questioned the hospital’s reassurance that despite the action, there was no problem with the quality of care being provided. She suggested this was disingenuous. She pointed out that many doctors scoffed at the suggestion that any hospital with a culture of bullying could claim its medical care to be faultless. We know that bullying has a very negative impact on both victims and those who witness it, leading at times to anxiety and depression, and even suicidality. We know too that the work of doctors and other staff suffering from mental health disorders is compromised. In a hospital where there is a culture of bullying, and this is unchallenged, patient care suffers.
“Bullying is a deep rooted cultural problem that is perpetrated by those who should know better but get away with behaving badly because they have power and influence.” (7)
How can we expect junior staff to perform at the best of their ability if they if they are affected by abuse?
Can we expect our students to embrace professionalism if what they are witness to in the clinical environment is humiliation, intimidation, harassment and abuse?
Student wellbeing is now considered an integral part of most medical school curriculums. Our demands on students and the way we treat them significantly impacts on their mental health. Little point in teaching them to be resilient if we are at the same time undermining their self-confidence and self-esteem through humiliation and bullying. Little hope of them being the caring doctors we hope for if the role models they witness are bullies. Many students seriously consider dropping out of medical school when they experience the reality of the medical culture, or at the very least choose professional pathways and workplaces where they are less likely to experience abusive behaviours.
We will not ever be able to eradicate work place bullying in Medicine unless we look honestly at how we teach our students, what role modelling they witness and whether they themselves feel cared for.
As a profession, we are learning to be more honest about our own behaviours and how they impact on colleagues, junior staff and students and ultimately on patient care. The tide is turning, if slowly, and disrespect, bullying and sexual harassment are no longer acceptable behaviours.
The more we care for our junior staff, allowing for their growth and development, the more they will mature into caring and respectful senior staff and the more Medicine will become the profession it should truly be, a loving and supporting environment for all of us, staff and patients alike.
Part of the delay in creating culture change in medicine is that healthcare students are taught by those professionals who to varying extents are still caught up in and accept the status quo. I agree that working with the new generation of doctors is vital, so they have different expectations and norms to guide their practice.
Indeed, Fiona, the only thing is that the new generation of doctors has been trained by and is beholden to the old, so they are often still caught up in the ideals and beliefs of the past! But true change is coming… in fact for some, it is already here.