Bullying and harassment of trainees: An unspoken emergency?

Knowing what's right doesn't mean much unless you do what's right Earlier this year, vascular surgeon Gabrielle McMullin issued some startling advice to female surgical trainees: acquiesce to the sexual advances of your male colleagues, or risk compromising your career.1 The comments might have been controversial, but they were successful in exposing a silent epidemic of bullying and harassment in medicine. McMullin's thinly veiled entreaty for action has resulted in unprecedented media attention, including an investigation by Four Corners2 and articles in major newspapers.3, 4 In response, the Royal Australasian College of Surgeons (RACS) has commissioned an Expert Advisory Group to report on discrimination, bullying and sexual harassment,5 the Australian Medical Association (AMA) has convened a high-level roundtable6 and the New Zealand Resident Doctors' Association has instituted meetings with the Ministry of Health, union representatives and health professionals.7 But will any of these interventions secure lasting reform? This article explores the susceptibility of emergency medicine (EM) trainees to bullying and harassment, and distils stakeholder opinions on a destructive phenomenon plaguing medical culture. Workplace bullying can be regarded as any recurrent interpersonal interaction that comprises intimidation, harassment, aggression, victimisation, emotional abuse or psychological mistreatment.8 It can take many forms, including threats to professional status, isolation, overwork and destabilisation.9 Although a perpetrator might be motivated by a desire to improve performance, intentions are irrelevant. Medical associations have stated that bullying includes any degrading or offensive behaviour that undermines the confidence and self-esteem of the recipient.10, 11 Both bullying and harassment are legally prohibited in workplaces in Australia and New Zealand (NZ).11-13 Evidence suggests that bullying is profoundly gendered.14, 15 Different types of workplace bullying are directed towards men and women, with women more likely to experience gender incivility.8, 14, 16 Bullying and harassment in medicine appear to be as ‘old as the profession itself’.3 A 2014 meta-analysis of 51 studies across multiple disciplines and countries revealed that 59.6% of trainees have experienced bullying. Consultants are the most frequent source, and female trainees and those from ethnic minorities are at higher risk.17 Australasian figures are comparable.18-20 A 2008 study of NZ trainees found a rate of 50%,19 and an Australian survey from the same period revealed that 25% of all doctors had been bullied in the previous year.20 Beyond Blue's 2013 National Mental Health Survey of Doctors and Medical Students reported that 4.5% of doctors and 2.5% of medical students felt stressed as a result of bullying.21 Specialties associated with poor clinical supervision, long hours and sleep deprivation appear to be at higher risk.22 Although much of the media attention has focused on whistleblowers within surgical specialties, such as Caroline Tan23 and Stephen Bolsin,24, 25 EM is not immune.22, 26-29 Up to 98% of EM trainees in the United States have experienced an episode of bullying or harassment, although this figure includes abuse by patients.26, 27 In the United Kingdom, a 2009 study of 33 329 trainees found that EM followed obstetrics and gynaecology and surgery as the third highest risk specialty.22 The 2014 iteration of the same survey also rated EM poorly for undermining and lack of a supportive environment.28 Differences in EM practice between countries mean these rates might not reflect those in Australasia. Although there are no published data on bullying and harassment in Australian EM, a recent NZ survey found that junior doctors experienced or witnessed 73 instances of intimidating behavior in the ED within the past 2 years. The reported rate compares favourably with many surgical disciplines, but worse than most non-procedural specialties.29 Alana Killen, former Chief Executive Officer of ACEM, believes that EM is ‘at the lower end of the spectrum’ in its susceptibility to destructive behaviours. ‘During my time at ACEM, I saw very few documented examples of bullying and harassment, however I think it is fair to say that this situation does exist in some hospitals and often goes unreported’ (written communication, July 2015). Although bullying and harassment impairs trainee health and well-being, there are secondary effects on education, productivity, staff retention and patient safety.10, 20, 22, 30 Danika Thiemt, ACEM trainee and Chair of the AMA Council of Doctors-in-Training, believes these negative impacts result from an ‘erosion of confidence, skills and initiative’ (written communication, June 2015). The ED is an unpredictable and volatile environment that combines high decision density, time pressure, rapid patient turnover and significant supervision requirements. It is also a complex milieu of interactions between individuals and disciplines. Exchanges between consultants, registrars, interns, medical students, nurses, allied health practitioners, laboratory personnel and clerks can all take place during the care of a single patient and might involve multiple communication modalities. It is conceivable how bullying and harassment might surface under these conditions. Viet Tran, Chair of the ACEM Trainee Committee, contends that a common source of bullying is inpatient units. ‘ED residents, in particular, can be intimidated by inpatient registrars and consultants when making referrals. The ED is in the unfortunate position of creating work for everyone else, which makes us vulnerable’ (written communication, July 2015). Nurses can also be a source of bullying, particularly for junior doctors.19, 26 So too can patients,26, 31 a fact highlighted by ACEM's recent work on alcohol-related presentations.32 Despite this, Thiemt feels that EM possesses many protective factors, including a training pathway that facilitates ‘work-life balance and flexibility’. Killen maintains there is also ‘a culture of equity’. ‘Staff in EDs rely heavily on each other, and (from my observation) respect the skills and expertise of their colleagues which tends to favour a more collaborative and equitable workplace’. Diana Egerton-Warburton, Chair of ACEM's Public Health Committee, agrees. ‘High service delivery requirements in ED means trainees are in demand and a valued resource. Training networks, in my experience, will go out of their way to provide a safe supportive environment, including mentor programs’. The evidence supports this view. Studies have identified variables that predict workplace bullying, including excessive workload, role ambiguity, role conflict, lack of support from co-workers and a competitive work climate.8 Although some of these elements are common to all specialties, they are not characteristic of EM. A major barrier to reform is that trainees are reluctant to report instances of bullying and harassment.10, 11, 22 This reflects concerns regarding potential impact on assessment, training and job prospects, because ‘the people they want to complain against have absolute control over their careers’.4 Thiemt says a major factor is that ‘those who supervise doctors in training (DiTs) are often responsible for assessment and in some cases, the employment of the same DiTs’. There are also concerns regarding stigmatisation (a perception of being ‘weak’) as well as the confidentiality of human resource (HR) processes.10, 11, 29 The depth of mistrust is illustrated by the reluctance of bullied EM trainees to contribute to this article. Despite attempts to include their perspectives, none were willing to go on record because of confidentiality concerns and the risk of marginalisation. James Lawler, President of the Australian Medical Students' Association, suggests that reporting inappropriate behavior must be normalised, so that issues can be addressed efficiently and effectively. ‘Part of the problem has to be that we're struggling to identify and deal with the minor incidents of bullying and discrimination properly’. In many cases, he feels that ‘the narrative should have been stopped early on when a certain staff member made inappropriate comments during ward rounds, or intimidated a new staff member or student’. Thiemt also feels that HR processes do not align with contemporary training models. ‘Doctors in training are not typically in one location long enough for existing HR systems to work effectively in a timely manner. They are also often answering to an external body, such as a training college’. In the accompanying article, Tran has provided practical advice for trainees in recognising and responding to bullying and harassment.33 His recommendations affirm that the integrity of reporting systems is paramount. Hospitals in the UK have attempted to address this by establishing bullying hotlines, enabling immediate and confidential notification of intimidating behaviour as well as early investigation of allegations.28 Ombudsman models, injury prevention strategies and a ‘zero tolerance’ approach have also been proposed.4, 22, 30, 34 Like others,3, 4, 34, 35 Lawler maintains that the definitive solution lies in cultural change across the profession. ‘There isn't one leader in particular who can stand at the top of this hierarchy and speak to the rest, so it needs to come from a range of doctors – but it can't be expected that changes in attitude will simply “trickle up” ’. The RACS Expert Advisory Group has itself acknowledged that, ‘what is required is not only a change of behaviour; it is a change of the beliefs of individuals, and a change of the culture of the group and organisation’.12 Experience from overseas suggests this takes time but can be achieved with targeted interventions. A recent General Medical Council report describes how one department was able to transform its handover routine from an exercise in intimidation into an effective learning process.28 Thiemt agrees that ‘workplaces should strive to encourage honest and open lines of communication, and develop “no-fault” reporting systems’. However, more importantly, ‘Heads of department need to be aware of typical bullying and harassment behaviours that perpetuate an unhealthy culture and develop strategies to change these behaviours’. Supervisors must also be careful to ensure that feedback, assessment and performance management processes do not involve intimidation or humiliation. Markwell et al. have specifically addressed this issue in their accompanying article.36 ACEM has policies on discrimination and harassment, as well as a code of conduct and procedures for addressing allegations of bullying against any member of the College.37-39 However, policy manuals alone are unlikely to address underlying cultural issues. AMA survey data suggests that only 30% of trainees believe their college has clear and accessible bullying and harassment policies.40 Only 12% agreed that their college responds to reports in a timely and appropriate manner, but the survey was undertaken prior to RACS implementing its high-profile investigation.5, 12 As part of the solution, the AMA has proposed an annual national survey of trainees that measures trends in training quality, well-being and workplace practices.40 Other commentators, including Killen, suggest that colleges need to take a more active role in demonstrating leadership and driving reform. ‘Historically, Colleges have tended to delegate this responsibility to the hospitals by claiming it is a workplace issue. Although hospitals are the employers and therefore have a duty of care, Colleges set the standard for the Fellows as far as professional skills and expertise are concerned. It could be argued that it is time for Colleges to take a more proactive role in setting standards for behaviour of their Fellows’. Despite evidence that trainees are frequently subjected to bullying, studies suggest they can also be perpetrators of intimidating behaviour towards medical students and junior doctors.19, 20, 26 Similarly, consultants can be bullied by more senior doctors and administrators.18 Killen also notes that there have been a few incidents where ACEM staff have ‘reported feeling bullied by fellows’. These observations support the theory that bullying is learned and, in a ‘culture of abuse’, all clinicians are potentially susceptible to destructive behaviours.12 They also affirm the role of colleges in promoting professionalism, and supporting members to develop effective teaching, supervision and leadership skills. Training workshops focused on bullying and harassment have been developed by overseas colleges specifically for this purpose.41 Killen believes the new ACEM curriculum will better equip clinicians to address destructive workplace practices: ‘The revised curriculum places far greater emphasis on non-medical domains … the Professionalism domain incorporates such things as ethics, code of conduct, professional relationships and workplace challenges’. It remains to be seen whether any of this dialogue will have a meaningful impact on the prevalence of bullying and harassment. As a next step, the profession needs to address some uncomfortable truths about its tacit tolerance of intimidating and destructive behaviours. EM has capably led major professional reforms, and bullying and harassment is another area where it can demonstrate leadership and advocacy. The current environment creates an opportunity for intervention; the question is whether the EM community will remain complicit, or champion a new era of workplace civility. All authors are section editors for Emergency Medicine Australasia.