Bullying: The Most Destructive Phenomenon Plaguing Medical Culture

Knowing what’s right doesn’t mean

much unless you do what’s right

– Theodore Roosevelt

Bullying in Medicine

Workplace bullying and harassment have been described as the ‘most destructive phenomenon plaguing medical culture’. (1) Safework Australia defines workplace bullying as: repeated and unreasonable behaviour directed towards a worker or a group of workers that can lead to physical or psychological harm. (2) This behaviour demonstrates non-compliance with Australian work law as per Work Health and Safety 2011 regarding quality and safety regulations affirmed to provide all workers and trainees with safe work environments free from such harms. (2)

Recent headlines in the media, detailing a culture of bullying and harassment within the medical profession, sparked a considerable focus on the implications of nonconformity with workplace quality and safety regulations on staff and students. (1,3) Reports from the Australian Senate have revealed that these concerning behaviours contribute to a substantial problem across all regions and various specialties within the medical field. (4) The significance of this unethical conduct remaining unrestrained has been shown to have broad consequences among medical professionals, junior doctors and medical students as well as patient safety and to society in general. (1,4,5) For example, workplace bullying has been linked to the alarming incline of suicide and suicide attempts among medical students due to compacting stress, anxiety and burnout associated with such an all consuming academic degree. (6-8) Despite this well recognised consequence, the misconduct continues. The unspoken acceptance of ongoing mistreatment of students within medicine is extremely unethical. (1,9) This essay aims to explore the impact to medical student’s professional development, when observing this behaviour exhibited by clinical placement supervisors.

The Australian Medical Association express that ‘all doctors (and students) have the right to train and practice in a safe workplace free from bulling and harassment’. (4,9) However, they also acknowledge that the hierarchical nature of medicine seems to have stemmed the perfect breeding ground for an ongoingly accepted degree of bullying and harassment during medical training, partially due to the inherent power imbalance between medical students, junior doctors and senior medical staff. (4,8) Students are particularly vulnerable to observing and experiencing bullying as they are often not given guidance on reporting procedures or advised by senior students and staff against reporting for fear of negatively impacting upon their future career and professional reputation as a result. (1,4,10) Furthermore, students are often not covered by hospital policies during their training and believe because of this no meaningful positive outcome will result from reporting observed or endured bullying or harassment. (4) All of which reinforces the acceptance of this behaviour as part of their chosen career path with little nonconformity from students. (10)

The unforgivingly competitive environment of medical training has incontrovertibly contributed to widespread institutionalised bullying and harassment within the profession. In an environment where students are under constant pressure to perform exceedingly for grades, placements and professional positions, it is certainly understandable that many feel defined by their test scores and curriculum vitae. This creates a sense of depersonalisation which could potentially lead to or contribute to increasing depression among medical school cohorts. (1,11) Students report low levels of peer support and camaraderie within cohorts and fear reaching out when struggling in these circumstances. Concerned their classmates see this weakness as a strategic advantage for themselves. (1,11) Students also report instances when observing peers intentionally undermine each other in front of supervising medical staff to better their own reputation. These issues stem largely from the lack of policing as well as reinforcement from similarly observed behaviours in the work place by senior staff. (4,8) Overtime these behaviours become pervasive and largely ignored, accepted as the norm within the profession and allowed to perpetuate from student culture to professional culture and vice versa. Allowing this level of unprofessional behaviour to remain authoritative is detrimental to the ongoing professional development of all medical practitioners and medical students alike. (4,6)

Professionalism

Paradoxically, society upholds an assurance that medical practitioners and trainee doctors will act with a high degree of professionalism. Surveys have shown that doctors are the most trusted professionals in society. (12) Professionalism is a term used to describe the societal expectations and characteristics of a professional. (9,12,13) Professional behaviour in medicine encompasses attributes including: competency, respect, morally upright and ethically sound, evidence based and altruistic service to the public. (9,13) These professional virtues are critically important for doctors and compromising these ethos results in unsafe working and learning environments, reduced job satisfaction among practitioners and the loss of proficient care. The repercussions of which are detrimental to both medicine as a whole and the general public. (9,12,13)

Medical students receive majority of their structured professional education and training during their preclinical years. (1,4,14) During this training it is imperative to integrate the importance of the attributes, as previously mentioned, future doctors need to develop in order to become proficient medical professionals. However, it may be challenging for a student learning within a hospital (during placement or clinical years), emerged in an institutionalized culture of unprofessional behaviour, to be able to act as ethically educated in their preclinical curriculum. Research suggests in these circumstances students are more likely to follow the behaviour exhibited by their peers, supervisors and role models (the hidden medical curriculum). (1,4,14) Students describe this experience as “trying to win a game no one ever taught them the rules to”. (1,4) This results from an underlying cultural belief in medicine that bullying, and harassment of junior doctors and students is a rite of passage and something always done in the ‘old days’ that has remained largely unchallenged. A large-scale cultural change therefore needs to be mandated to ensure safe working and learning environments within medicine. (1,4,15)

Example scenario

A 2nd year medical student was at Newspeak Hospital on a placement to the respiratory ward. They were particularly interested in going into respiratory medicine and working at this hospital and wanted to make a good impression with supervising staff. The medical student was asked to shadow an intern and watched them take a detailed history from a patient on the ward. Afterward the senior physician came to get an update on the intern’s patient and asked the medical student somewhat patronisingly “Did my intern forget anything in their history today?” to which the medical student said, “Yes actually, they forgot to ask about a smoking history”. The senior doctor turned angrily to the intern and said, “How does a medical student know how to take a better medical history than you do, maybe you should go back to medical school!” then turned to the medical student and said, “Keep up the good work, we wouldn’t want any more useless interns around here in the future!”

The above example shows a lack of respect for the intern’s well-being and ability to learn from this situation. The senior doctor fails to use constructive feedback to help educate and support the learning of the intern. This behaviour depicts a significant deviation from the standard of professionalism outlined by the AMA. (4,13) Observing this behaviour as a medical student who is eager to win the admiration of senior staff could have a multitude of impacts. For example, the student could find the last comment a reinforcement of their behaviour instilling a competitive and self-serving mentality in which undermining peers can help get you ahead, further perpetuating this type of behaviour into the next generation of future doctors. (4,16,17) Or alternatively the student might have felt horrible guilt for the impact to the intern resulting from their honesty and developed a fear of entering the hospitals hierarchy and being exposed to the same scrutiny and pressure to constantly perform to avoid disappointing senior staff, leading to negative mental health such as anxiety or burnout. (16,17)

Impact to medical students

When might it be ethically justifiable for students to observe unprofessional behaviour?

In the above scenario it is unlikely a student would feel it’s their place to stand up for the intern against the senior doctor or express witnessing unprofessional behaviour to their school or the hospital. In the past it has been unheard of for a medical student to show nonconformity to this behaviour out of fear for their career opportunities dictated mainly by recommendations and word of mouth from such senior physicians. Thus silence and agreeance seems like the only way to survive the ordeal. (4,18) Some students witnessing this behaviour who are also in great admiration of the physician may fail to recognise this behaviour as “bullying” and internally normalize it as part of the job or attribute it to something else. (16,17) This makes it very difficult to differentiate the unprofessionalism as unethical or a deviation from the ethos and professional characteristics deemed necessary for a doctor and impact the student’s judgement on how to act as a future doctor in similar scenarios themselves. (4,9,10)

Impact on learning and professional development

In general, study’s reveal that established humiliation techniques used by senior doctors and nurses when training medical students have proven to have negative impacts on learning overall, thus presenting no justifiable reason to continue with its practice within medical training. (1,4,11) In regard to development of professionalism, it is seen that role modelling and mentorship is the most effective way for students to develop these skills ongoingly and that didactic approaches used in medical school curriculums are far less effective in teaching student’s these life-long career skills. (1,11) Learning environments which unsuccessfully promote trust and support and are populated with those with low integrity are failing the next generation of impressionable students. Students confess witnessing real-world mentors treating themselves, other staff and patients unprofessionally instils negative values and propagates unprofessional behaviours despite preclinical education. (10-12)

Conclusion

It would be reasonable to conclude that professionalism training in medical school cannot be detached from the quality of the learning environment and thus institutionalised bullying remains rife throughout the profession. Medical schools would benefit from further understanding and acknowledging the “hidden curriculum” and working towards mentoring students with how to deal with this overarching culture of unprofessionalism throughout their career instead of relying on isolated role play and vignettes used in didactic teaching. (11,12) Ongoing professional education throughout clinical years in real life learning environments, promoting trustworthy mentors and strong policing of bullying would potentially instil in the next generation of students that unprofessional behaviour is toxic to themselves, their peers and their patients. (1,11,12) Student’s choosing to go into medicine altruistically sacrifice a lot of their lives to be able to make a positive impact in society, they should not have to sacrifice mental health enduring unsafe working environments as a reward for their hard work. Students can be the stop to this perpetual cycle if given the right support. (1,4)

References:

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