This is a summary based on a talk on culture change from the 2019 Onthewards Conference with Dr. Rhea Liang. Rhea is a General and Breast Surgeon at the Gold Coast Hospital. Moreover, she’s a surgical educationalist and advocate for women in surgery. She is also Deputy Chair of the Operating with Respect Committee of the Royal Australasian College of Surgeons.
In March 2015, there was a seminal event. A senior surgeon said that for all the trouble it was to speak up, you may as well stay silent about unacceptable behaviour. In other words, it is easier to put up with bullying, discrimination, sexual harassment, and frank sexual assault than it is to bother speaking up.
By September 2015, The Royal Australasian College of Surgeons (RACS) had carried out the largest workforce survey of all surgeons, trainees and international medical graduates (IMGs). The results of unacceptable behaviours were unacceptable.
What is the problem?
49% of fellows, trainees, and IMGs have experienced one or multiple incidents of bullying, discrimination, and sexual harassment. The rates for bullying alone are very high amongst trainees and IMGs. It’s a top-down phenomenon – it’s mainly the behaviour of senior surgeons and consultants. Since the survey run by RACS, other medical colleges and institutions outside of medicine, such as law, have run similar surveys and produced similar results. This suggests the problem is universal; it occurs in hierarchical structures in complex and demanding work environments. This culture has been established for decades, perhaps even centuries.
How are we going to shift this universal, long-standing issue?
Since the survey, RACS has spent $5 million on activities to address the issue. It has developed an online module delivered to every surgeon, trainee and aspiring trainee. This is to ensure all are aware of what constitutes unacceptable behaviour. The online module is mandatory and at the time of Dr. Liang’s presentation, 99% of candidates had completed it. RACS has also developed a face-to-face course to deal with issues relating to unacceptable behaviours for all leadership groups of the college. This course is also mandatory. What’s more, approximately 600 surgeons will complete this face-to-face workshop. That is 1 in 10 surgeons across Australia and New Zealand. At the time of writing, 66% of these surgeons had completed the training.
So how are we doing?
Surveys in Sydney in 2019 demonstrated that we still have a problem. In fact, it is still a problem in every state in every surgical specialty. Emerging research demonstrates that unacceptable behaviours cause:
Why is culture change so hard?
There are several reasons. This is something we’ve never done before, for instance. No specialty has ever tried to perform whole-specialty culture change on a wide scale. We don’t know what ‘ingredients’ are required or what the final outcome is going to look like. Fear of repercussions for the victim is the most frequently mentioned issue, particularly for junior doctors.
“The standard you walk past is the standard you accept.”
But, to ask young doctors to speak up every time they see an example of bad behaviour puts them at risk and introduces them to potential unexpected harm.
How do we speak up when we’re junior?
It is a four-step model in which we:
If you choose not to speak up now, make two resolutions:
Culture change: what will you do tomorrow?