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.

A culture change crisis

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.

Driving culture change in the medical field

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.

The progress

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:

• poor patient outcomes,
• poor doctor outcomes, and
• have much wider organisational effects than previously realised.

Culture change is difficult

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.

What junior doctors can do to help drive the change

How do we speak up when we’re junior?

• Congeniality: friendly concern, interest, and support. The people who have behaved badly towards junior doctors today are likely to have been treated this way themselves. People may not be malicious, but not know any better. Things are done this way because they have always been done this way. What we need to stop is intergenerational transmission, which is also seen in domestic violence and sexual abuse. When we report, we need to describe behaviours rather than people.
• Collegiality: companionship and cooperation between colleagues who share responsibility. The advocacy inquiry model is used in workplace conflict settings, especially in the business world. Learn more about this model in the section below.
• Courage: mental or moral strength to venture, persevere and withstand danger, fear or difficulty. There is a tension between feeling fear and doing it anyway, and a junior doctor’s personal safety. Speak up using the advocacy inquiry model (above) if you can, but only when you feel it is personally safe to do so. It is hoped that as the culture changes and hospital reporting systems are better established, junior doctors will feel safer in speaking up. Until this is achieved, personal safety should be considered.

The advocacy inquiry model

It is a four-step model in which we:

1. Describe the behaviour.
   • Example: ‘I’m curious that my attempt to chase the scan for Mrs. Smith to correct an earlier error will reflect negatively on my term reference.’
2. State the concern.
   • Example: ‘I’m concerned that it seems that I am pre-judged no matter how hard I try.’
3. Invite a response or explanation. This may not require words to invite a response or explanation.
4. Conclude. Keep it short and do not expect an epiphany.
   • There is evidence which demonstrates that up to 81% of people will change their behaviour after one feedback session like this.

If you choose not to speak up now, make two resolutions:

1. Stop inter-generational transmission and resolve to behave better in your own personal relations with other people.
2. When you are a leader one day, resolve to speak up on behalf of yourself and the team you lead.

Culture change: what will you do tomorrow?