Reviewed: Dane Chalkley, Tessa Davis
Irony – when the literal meaning is the exact opposite of the intended meaning.
This blog is aimed at those of you that have recently started as a registrar. Your new role includes increasing clinical responsibilities and supervision, studying for college exams and working on a research project in your “free time” whilst trying to achieve that elusive work-life balance.
With such a key transition, it is critical that you affirm to your peers your new more senior role. It is also important that you acknowledge your increasing responsibilities and initiate some efforts to reduce your workload.
Bullying is undoubtedly bad. However, in this blog, I will let you in on some secrets to the dark art of bullying that will reduce your workload without a junior doctor ever noticing they were bullied.
The simplest introduction to the dark art of bullying is when you are asked for a consult. This immediately provides you with the upper hand as the doctor is requesting you to do something for them and their patient.
The phone consult is ideal for those of you wanting to dip your toe into the murky waters of bullying in medicine. Medical school and junior doctor training have effectively eroded your empathy, but some registrars will still find face-to-face bullying initially uncomfortable until their skills are honed.
Is the consult actually somebody else’s job? This is the first step. Irrespective of the consult, there will be always a chance that it could be someone else’s work. Depending on your hospital, it may require asking the doctor requesting the consult to go back to all the admissions over the past 20 years to see if they have been admitted under another consultant, to recheck the roster or to otherwise delay the consult until it becomes your colleagues’ job. This is time-consuming for the referring doctor, but even if it is only infrequently successful, it is an efficient use of their time to reduce your workload.
Frequent interrupting is the easiest technique to create a sense of unease in junior doctors. It is important that you don’t allow the junior doctor to get into a rhythm and this is achieved by asking lots of questions from the start. Interrupt the presenting complaint with a quick, ‘What’s the medical record number?’ This will throw them off very early while also signaling that you’ll be tapping on a computer without really listening. It is always important to ask a number of questions that the junior doctor will not know the answer to. This creates a sense of failure in the junior doctor and increases the gratitude that they will bestow upon you for seeing their patient.
Silent treatment. This is a more advanced technique. It involves not saying anything until the doctor requesting the consult thinks that you are either asleep or have hung up on them. This will instill in them a feeling that you are so unimpressed or bored with the consult and that they aren’t worth listening to. All without saying a word – efficient and effective.
The referral may sound completely reasonable, but a really good way to undermine the confidence of the junior doctor is to insist on a more senior review before you grant access to your prowess. “Have you discussed this with your senior?” is a solid opener but a, “perhaps your senior should see them first and call me back if you still want me to” is a real self-worth destroyer. Save this for 16.45 on a Friday and then pop off for your weekend without handing over. That’s where this strategy excels.
Feel free to not answer your pager – perhaps leave it unfathomably far away from you, wait for the third one, answer but state you’re in a meeting and can’t talk now. You know they’ll be champing at the bit when you finally return to them to impart wisdom. At this point techniques 1-4 can be maxed out with the preceding junior’s anticipation sealing the deal.
The beauty of the face-to-face interaction is that you are able to combine verbal and non-verbal communication cues.
Strategies that I have found effective include a shrug, a shake of the head, eye-rolling, turning your back on the person speaking to you or turning around and doing another job. Why make eye contact at all?
Choice of body position is worth considering; looming over the seated junior or slumping further into a chair for the standing opponent are excellent strategies. ‘You’re lower than me’ or ‘this is my territory’ are what you are showing here.
Whichever strategy, it is important that the person asking for help somehow feels ignored or worthless.
As with most of medicine, this written guide is only a start and is aimed at the novice practitioner. It will be with further experience and learning from your senior consultants that you will become an expert in the dark art of bullying. Once you are aware of some of the secrets, you will identify how many of them have been integrated into routine medical care. The sardonic smile, raised eyebrow or peering over your lowered spectacles are all examples of subtle signs that you may not even of been consciously aware of.
Rest assured that although some of the strategies may be difficult to implement initially, it becomes easier over time. By the time you are a consultant, you will be unaware that you are even doing so.
Hopefully, most of you noted the irony in the blog. This was my attempt to highlight a serious issue within medicine. I am not suggesting that asking questions when you receive a consult is not good medical practice. To the contrary, it assists you to prioritise your workload, clarifies the reason for the consult and ensures that the necessary information is available to address the question you are being asked.
But many of us have used the strategies described at some stage. I know I have. Typically, justified by the pressure of time or we fall into the trap of adopting these types of behaviours when we are hungry/angry/late/tired or feel uncomfortable or uncertain in our roles. Regrettable, sometimes it is because we are having a bad day and we want someone else to know about it.
Sadly, I see the impact on junior doctors every day. Following a request for a consult, senior review or referral for admission, junior doctors describe feeling stupid or worthless. They often don’t know why. It is unacceptable to make a junior feel shit for doing their job. Don’t underestimate the harm you may cause. The impact is cumulative and just as damaging as other forms of unacceptable behaviour in medicine that we more commonly associate with bullying.
The culture around requesting a consult is so endemic in medicine that junior doctors frequently blame themselves when they face such responses. Doctors feel they “deserve” to be treated this way if they don’t have all the information, they call at an inconvenient time or just because. Junior doctors don’t deserve this. Requesting a consult is a difficult skill and as a junior doctor they deserve appropriate and timely feedback provided in a supportive way.
We have developed an onthewards consult guide to assist junior doctors with the task of requesting a consult. But it is to the receiver of a consult or a referral that this blog is directed towards, as without you we can’t create a culture of communication between colleagues that is respectful and kind.