According to the last AHPRA Medical Training Survey, a third of doctors in training had experienced or witnessed bullying, harassment or discrimination in the workplace (1). The person responsible was usually a colleague and concerningly, only a third of those who witnessed or experienced this behaviour reported it. We can’t continue to overlook unprofessional behaviour in our workplace, because doing so is causing harm to ourselves, our patients and the profession.
Medicine is no longer practised by individuals. Instead, we work as part of a multidisciplinary team. And our teams have to be performing at their best if we are to provide the best care to our patients.
The pioneering research on highly functioning teams comes from a longitudinal study at Google where hundreds of employees in their highest performing teams were interviewed to uncover the secret to their success. They discovered that the common feature between these teams was the presence of psychological safety (2).
Psychological safety is the ability to take risks on the team without feeling insecure or embarrassed (3). It might be fostered by individuals speaking up to prevent an adverse event, questioning a senior who is deviating from standard practice or challenging the system to adapt to our community’s needs.
Unprofessional behaviours undermine psychological safety in our healthcare teams. Environments without psychological safety have less learning and this threatens our desire for high-quality medical training (3).
A lack of psychological safety breeds staff dissatisfaction and perpetuates burnout, leading to attrition from the organisation and the medical profession (4). We also expose the next generation of healthcare professionals to the hidden curriculum of accepted behaviours in the hospital propagating a culture of incivility (5).
And it’s not only the health professionals who suffer, because unprofessional behaviour also leads to adverse patient outcomes. Two large studies performed at the Vanderbilt University Medical Center prove this point. Surgeons with higher numbers of patient and co-worker complaints had higher rates of surgical and medical complications as well as malpractice claims (6, 7).
You might be surprised to hear that ninety percent of people rate themselves as above average drivers (8). It’s only when you place dash cameras in their cars and have them watch the footage that their estimation of their driving regresses towards the mean (7).
The team at the Vanderbilt University School of Medicine have thought long and hard about how to promote a culture of professionalism in their institution. Their conclusion was that they had to turn a mirror on unprofessional behaviour. This lead them to pioneer a graded peer-messenger system to feedback lapses in professionalism to healthcare workers (9).
Most of these lapses are addressed with informal conversations by a peer messenger, deemed ‘cup of coffee’ conversations. Ideally the peer is at an equal level of seniority within the organisation and working in a comparable specialty. These conversations aim to shine a light on behaviours identified as being inconsistent with the organisation’s values.
During these cups of coffee, the peer messenger recounts the reported lapse in professionalism in a non-judgemental, non-confrontational way. The goal is not to fix or solve but to inform. After the discussion the clinician has reason to reflect on the behaviour and this frequently leads to self-regulation.
In Vanderbilt’s experience, most health professionals had no issues with professionalism and weren’t identified by the system. Of the smaller number of individuals who had lapses in professionalism, the majority improved after graded interventions (10).
The Vanderbilt team developed a tiered approach for managers to address the minority of those who do have repeated lapses in professionalism. Their experience shows that these interventions often uncover serious underlying medical conditions or psychosocial factors driving their behaviour (9).
There will be challenges to overcome when introducing the Vanderbilt model in the Australian context. Individuals may be reluctant to report unprofessional behaviours for fear of retribution. When introduced into US hospitals, it has taken up to a year for doctors to begin reporting. Presumably this time was needed to develop trust that the system would respond appropriately to lapses in professionalism.
Leaders will need to prioritise having difficult conversations with colleagues. Sometimes the unprofessional behaviours will have been tolerated and normalised for decades. If the feedback is taken poorly, then it could erode relationships or even lead to the individual’s departure from the organisation.
Whilst cultural change will take time, there is something that we can all do in the meantime to promote professionalism. We should make the effort to compliment those who demonstrate exemplary professionalism in the workplace or provide exceptional care to their patients. Positive reinforcement is a powerful tool, and these outstanding individuals deserve to have a cup of coffee too!
As healthcare institutions across Australia are looking to promote professionalism in their organisation, the Vanderbilt model sounds promising. And although the road to implementation won’t be easy, if it stands to improve outcomes for our patients and the wellbeing of our profession, then it’s a road we have to take.