Bullying – not a disease to watch and wait

Bullying is often first encountered in the playground – whether as a victim, perpetrator, or pupil being taught to treat others with respect and consideration. How then, when we advance from school to higher education, passing examinations, learning complex anatomy, physiology, pharmacology and researching their clinical application, do we fail to remember one of the earliest lessons we were given? Tales of bullying behaviour have been recounted in medical autobiographies with angry outbursts from surgeons throwing scalpels, humiliation of medical students at ward rounds or preventing trainees operating to finish a theatre list faster. One may say ‘back in the day’, but evidence demonstrates that bullying and undermining behaviour remain a prevalent issue.

In 2017, 28% of NHS staff reported bullying, harassment or abuse in the workplace, of which approximately a quarter originated from colleagues. This factor poses numerous harms, primarily to the victim, who may be oblivious to the situation but feel they lack ‘resilience’ or aptitude to be a ‘successful trainee’. This then has repercussions on training and contributes to high burnout rates, endangering the sustainability of the healthcare workforce. Effects on training can manifest as harmful to patient safety, as can a failure to identify or report bullying behaviour, a key finding in the Francis Report of 2013.

However, it’s not all ‘doom and gloom’. Representative bodies in medicine, surgery and subspecialties are making moves to highlight the problem and implement changes to fight bullying behaviour. Among campaigns from the Royal College of Surgeons Edinburgh, the Association of Surgeons in Training, the British Orthopaedic Trainees Association and #ILookLikeASurgeon, just to name a few, there exists a common theme – this is not a battle to be fought by a few. Change needs to come at all levels, from individuals to departments, and from each hospital to national institutions. It is not a disease we can watch and wait, it’s one that requires radical therapy.

What are your thoughts?

Comments (9) Add yours ↓
  1. Culley Carson Professor of Urology

    Bullying is an increasing problem in the SU in the time of social media. People can bully without face to face confrontation. The “cyber-bullying” is especially prevalent in the adolescent and young adult population. Bullying in medical training is a long tradition. From the days of the all powerful surgery chairman who banishes the trainee to the lab for years and years to the surgeon who expels a trainee from the OR for slights during a procedure, trainee bullying has been an unfortunate but common occurrence. At our medical center, all surgeons must sign a contract for behavior in the OR which helps slow these behaviors toward trainees and staff. It is incumbent upon physicians and surgeons in management positions to monitor and control these behaviors in their staff. Only with a change in culture in the OR can we ever expect these bullying behaviors to be controlled.

    May 3, 2018 Reply
  2. Ben Challacombe Consultant Urologist

    You make some good points and clearly we have a long way to go in surgery with the issue of bullying. In theatres i would say things have changed a huge amount over the last 20 years and the days of individual surgeons using verbal and occasionally physical abuse to get their way are thankfully mainly over. The modern theatre culture simply doesn’t stand for this type of behaviour and i like Culley’s suggestion of a contract for surgeons to sign up to. However bullying still exists and is often less obvious than previously and therefore we must all be vigilant and watch out for it. Allowing your team to speak openly and confidentially will allow these issue to be raised and then they must be acted upon to shut down and educate those offending.

    May 3, 2018 Reply
  3. Catherine Lovegrove Academic Junior Doctor

    I agree with both comments above- bullying now can be much more subtle and we have to be aware of that to prevent its propagation. “Unconscious bias” is one example of this.
    It’s great that there are initiatives to identify and tackle the issue and we need the response to come from us all. It’s a sad state of affairs that requires us to contractually sign and explicitly say we will treat others with respect, not tolerate bullying behaviour and create means to broach the issue without prejudice but if it is what it takes then here-here.

    May 4, 2018 Reply
  4. Robyn Webber Consultant urological surgeon

    Catherine’s blog is very timely – bullying in the NHS is an ongoing issue and there are a number of campaigns currently underway to address it and provide support for staff of all disciplines who have been affected. My own involvement has been with the Royal College of Surgeons of Edinburgh #LetsRemoveIt campaign, and having both written some material for their website and delivered a lecture on the campaign a few weeks ago, I have been contacted by a surprising number of people with their own, often distressing, stories to tell. I would agree with Ben however that the culture in theatre has changed significantly in the last 20 years and the concept of a surgeon throwing instruments is shocking and alien to most or all of us in this day and age.

    The effects of bullying can be, in my view underestimated and in the past individuals very often put up with the situation and gained very little sympathy if they tried to discuss it with anyone – it was a case of trying to develop a “thick skin” and just getting on with their job. However, it is now becoming apparent, both from workforce surveys and documents such as the Francis report, that the effects of bullying on the individual can have knock on effects not only on their own well being, but also their ability to do their job, thus becoming a patient safety issue.

    Although there is obviously some way to go until bullying in the NHS is a thing of the past, the various campaigns currently ongoing to highlight its detrimental effects on both affected doctors and the patients they care for, together with the provision of adequate support for bullied individuals are a huge step in the right direction.

    May 5, 2018 Reply
  5. Roger Kirby Professor Roger Kirby

    Bullying still exists in medical training, but hopefully things are now better than they were. The long retired general surgeon John Kirkham once noticed his trainee assistant repeatedly glancing at the clock during a long and difficult surgical procedure. John Kirkham put down his scalpel and stopped operating, he then went over to the wall on which the clock was mounted, took it down and smashed it theatrically onto the floor, shouting: “That will teach you to watch the clock when I am operating!”. I think that constituted bullying, don’t you?

    May 6, 2018 Reply
  6. Vaibhav Modgil Post CCT Andrology Fellow

    There is never a bad time for a blog on bullying.

    We, the medical (and perhaps particularly the surgical) community must do everything in our power to get rid of it. Bullying does not enhance the quality of work a colleague or trainee ever produces. It harms ones emotional health, which in turn affects an individuals self esteem and in turn professional performance.

    Whilst I admire the campaigns and slogans I see around the work place, that alone will not fix an age old issue. I have, thankfully, seen very few instances of instrument throwing, shouting and aggressive behaviour in theatre. Bullying comes of course, in many different formats. The main ingredients used by a bully never really change. Work is simply a more elaborate playground, and the tactics used are often a little more sophisticated. In a profession where there is well established hierarchy, bullying can be even more challenging to stamp out. No one wants to be a ‘problem’ trainee.

    Throughout my career thus far I have been incredibly fortunate to have some wonderful mentors. These are people who I not only admire and look up to on a professional level, but also trust as human beings. Mentorship can make a huge difference to those in training. Whilst educational/clinical supervisors are pivotal in providing professional guidance and ensuring doctors meet critical standards, they are often not given enough time/resources to carry out pastoral duties. It is vital we highlight and find individuals who want to mentor doctors. We cannot assume everyone wants to train/mentor, nor can we assume everyone can.

    I’m not sure we can every completely eradicate bullying. That would mean eradicating bullies; and that’s not possible. What we can do however, is continue to make it far less expectable. Mentorship of junior doctors and genuine buy in from high profile, powerful, and inspirational individuals can play a pivotal role in this.

    May 7, 2018 Reply
  7. Nitin Shrotri Consultant Urologist

    I would like to point out the plight of overseas medical graduates who have been openly bullied by one and all over the years. No one has ever cared for the myriad of overseas Middle Grades who have carried the NHS on their shoulders. They are merely there to be used to the fullest extent and never to “ask for more”. They are deemed untrainable just because they don’t speak the “language” and their “face does not fit”. They are not allowed to hold aspirations. That gets drummed into them. No wonder they have stopped coming here from abroad leaving the NHS on its knees. This is an “elephant in the room” that no one wants to address. Many of these went on to become GPs in the past, who are now coming to retirement leaving a huge void in NHS GP numbers today. There is a shortfall of GPs by 20% in Kent today. We, as a nation, need to be more welcoming to foreigners, allow them to hold aspirations. Refusing to allow them to reach their potential, is bullying, sometimes subtle, sometimes not.

    May 8, 2018 Reply
  8. Peter Rimington Urologist

    I guess I will have to abandon Sir Launcelot Spratt as my hero then.
    It is interesting that bullying has so long been an accepted part of medical life. Believe me, it is not confined to surgery at all. I was talking to a well qualified nurse who has left the NHS to work for a pharma company and she was astounded by the difference in the culture. She said something very sad to me. That everyone in medicine treats everyone else really badly at every level in every aspect. There is so little encouragement or recognition of the work that is done.
    I think we get worn down by the excessive administration to which we are subjected these days and the work becomes tedious leading us to undervalue ourselves, all of us.
    I remember many moons ago doing the train the trainers course (anyone else remember that?) and the message to a newly arrived bombastic South African was, “Praise first, criticise later.” And I think that we should do much more praising in the public arena in theatre, of not just the reg who has done a good job, but the nurse doing the running, the ODP, the porter who was cheerful with the terrified patient on the way to the operating room. And be very sparing with criticism and that in private with sensitivity and trying to get insight into the problems of those who may be struggling for reasons far removed from the work place.
    But Oh! I am going to miss “Gently man, Gently!! You’re not making bread!”

    May 9, 2018 Reply
  9. Mollika Chakravorty Junior doctor

    I know of junior colleagues who have been literally winded by surgeons after making mistakes in the theatre. Fortunately, these stories are rare. I applaud the efforts of the anti-bullying campaigns and in the meantime individuals can do a lot by challenging poor behaviour and listening and supporting colleagues who have fallen victim to bullying.

    I do see a good open culture and creation of friendly learning environments, not only by the crop of surgical trainees rising up the ranks, but also by seniors in all fields I’ve encountered so far. In particular, the best leaders I’ve seen across professions have definitely taken a “praise first, criticise later” approach, creating a good team spirit on the wards and in theatre, and have been excellent role models to have.

    May 9, 2018 Reply

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