Memories of being humiliated and belittled by senior clinicians have never left me. My failed attempts to answer increasingly difficult questions in front of my colleagues whilst being “taught” on daily wards rounds. The condescending comments as the inevitable occurred. Not revealing the embarrassment I felt or my sense of relief when the focus moved onto someone else. But I never felt bullied. Maybe it was my lack of awareness of bullying, my acceptance of this method of teaching or that my experience was not one of exclusion but more a rite of passage. If I reflect, was I a victim of bullying?
Bullying is a major problem in our hospitals. Awareness of the incidence of bullying and its impact on young doctors has increased in the public consciousness through recent media reports. Surveys from a number of the vocational colleges have highlighted a concerning culture of bullying behaviours (1,2).
Junior doctors may be at a higher risk of being bullied and less likely to report bullying behaviour due to fears about negatively impacting their chances of acceptance into vocational training programs. Close to half of the residents and fellows (48%) in the United States graduate medical education system reported being subjected to bullying (3). The most frequently reported bullying behaviours were:
In my role as the NSW Chair of Prevocational Training Council, I recorded with my colleague, Dr Ros Crampton, a short three-minute video on unacceptable behaviour in medicine and would encourage you to watch it.
The video is titled “Unacceptable behaviour in medicine” rather than “Bullying in medicine”. So why do we not call it bullying if that is what the problem is? There is definitely a time and a place to name bullying. Bullying behaviour tends to be repeated over time or occurs as part of a pattern of behaviour. Unacceptable behaviour can be an isolated event.
Language is important; once the bully word is mentioned, those accused will typically become defensive. Denial, blaming, or allegations of the trainee’s poor performance often ensue. This limits the opportunity for prompt resolution of the issue. As bullying is usually the result of repetitive episodes of unacceptable behaviour the early reporting of events and ensuring that health organisations address the problem in a timely and proportionate manner should reduce the incidence of bullying in our workplace.
Unacceptable behaviour is not always black or white; it takes the action of one individual and the perception of another. Context is important. Many senior clinicians may be surprised that others perceive what they see as teaching, feedback or direction as unacceptable behaviour. Most doctors if questioned would accept that their behaviour or actions have been unacceptable at times. I would like to say that I am an exception. But I am not.
Unfortunately, my early experiences of teaching influenced my teaching practices. Teaching at my morning handover too frequently involves a barrage of GWITs (Guess What I am Thinking) questions (but without the demeaning comments). The value and effects of pimping of medical students and junior doctors in medical education has received recent scrutiny in the medical education literature (4).
Many clinicians would value the opportunity to reflect on, explain, clarify or in many cases apologise for their unacceptable behaviour. It is for this group of doctors that this video is particularly directed towards. Educating about the negative consequences of bullying and disrespectful behaviours is supported as a strategy to reduce the incidence of bullying in the workplace (5). Alternative strategies are required for those that are less insightful into their behaviours.
As a junior doctor, it is important to be able to identify situations involving unacceptable professional behaviour. There is evidence that junior medical staff may choose to either ignore or accept certain behaviours as normal when in fact they are not.
A complaint that we hear quite often from some senior medical staff is that doctors in training don’t understand the difference between being provided with constructive criticism or feedback and being bullied.
The following are legitimate and reasonable behaviours:
Recognising what behaviours are legitimate or unacceptable is a necessary step to reduce bullying behaviour. As a junior doctor you need to understand that the problem is with the bully and not with you. Their behaviour is not okay and should not be pardoned because of their position or expertise.
To speak up, report or act about unacceptable behaviour is difficult for a junior doctor. But silence allows unacceptable behaviour to continue in our hospitals. Silence exists because junior doctors may not know how to report or are concerned about the risk of repercussions in reporting. Fear of retaliation and a lack of confidence in our hospitals to adequately and appropriately handle reports of unacceptable behaviour can also contribute to ongoing mistreatment (6). We need to empower junior doctors to speak up. The video describes a number of avenues to report unacceptable behavior.
In my experience, your Directors of Prevocational Education and Training (DPET) or Directors of Clinical Training are good first options. Irrespective of whom you report your concerns to the bullying claim needs be taken seriously, handled promptly and confidentially and appropriate action taken.
Junior doctors should be applauded when they speak up but shouldn’t carry the burden of changing the entrenched culture of medicine around how we treat our colleagues.
Unfortunately, there is a need for better literature to assist us in addressing the bullying issue in medicine. But what evidence there is points to the idea that by engaging the bystanders or observers of bullying behaviour in the problem we are most likely to see a change in culture. Indeed, this makes sense when you think about it. The bully is often lacking insight that they are being a bully. The bullied individual is feeling disempowered. But the bystander at least has an opportunity to act (or not).
This is also more easily said than done. We are talking here about what’s called a “difficult conversation” something that most of us would like to avoid if possible and often find, well “difficult”. There are some promising developments in terms of training programs that give doctors the confidence and skills to engage in difficult conversations rather than avoid them.
To those senior colleagues who may be reading this blog, it is up to you to stand up and to speak out on unacceptable behaviour. Senior clinicians need to model collegiality and respectful communication to develop a culture that is better, kinder and more respectful to everyone.
Jax*, a junior registrar, is in my office to discuss Read More..
How graded assertiveness can help you James talks to Sarah Read More..