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A NATIONAL survey that highlights disgruntlement among junior doctors about aspects of their training program, including bullying, is a timely call to colleges to get their house in order, says a trainee representative.
Dr Michael Bonning, chair of the AMA’s Council of Doctors in Training and co-author of its 2010 Specialist Trainees Survey, said that with the impending increase in graduating medical students vying to enter postgraduate training, the survey would give colleges insight into how they could improve their programs.
The inaugural survey, reported in this week’s MJA, found that while colleges rated well in many areas such as selection and access to supervision, several areas elicited negative feedback, including the capacity of trainees to raise concerns without fear of recrimination. (1)
A mere 11% of trainees agreed or strongly agreed that their college responded in a timely and appropriate manner to cases of bullying and harassment, 16% said there was appropriate remediation for unsuccessful candidates and the same proportion said there was an effective appeals process.
Training costs were also called into question, with only 23% agreeing or strongly agreeing that training was good value for money.
“… 40% of respondents reported that the cost of their training program had caused them financial hardship”, the authors said. “Ensuring reasonable costs for training and assessment is integral to minimising the adverse consequences of study debt.”
The 55-item online self-report survey was available to all 10 649 hospital-based vocational trainees although only those on the AMA database received an email about it. There were 538 respondents from 18 disciplines.
The researchers said the bullying and harassment finding was of concern.
“Trainees are at risk because distinctions between workplace and training supervisors can be blurred”, they said. “It is critical that colleges have well defined and transparent processes for dealing with these matters, which are the responsibility of educators as well as employers.”
Dr Bonning said bullying could take several forms, including belittling of junior staff.
“There are ingrained cultural problems in the way in which more senior doctors treat more junior doctors, [including] unreasonable work requirements”, he said.
Problems were often not resolved because colleges rarely had a strong presence in hospitals.
“What we find is that the college’s representatives are the same people who are sometimes the ones handing out the treatment deemed as bullying”, Dr Bonning said.
Dr John Quinn, executive director for surgical affairs at the Royal Australasian College of Surgeons, said his college attempted to tackle bullying and harassment head on. The college had developed a booklet on the issue, which was distributed to all fellows and trainees and posted on the college website.
Dr Quinn said trainees were represented at all levels of the college, even on the governing council, and the college would continue to strive to improve satisfaction rates.
A fair and effective appeals process was a condition of the college’s regular accreditation by the Australian Medical Council.
A spokesperson from the Royal Australasian College of Physicians also said the college had made progress in supporting trainees, including improving procedures to promote transparency and procedural fairness.
Measures to further improve arrangements at the RACP included the implementation of the Code of Conduct and programs covering bullying and harassment. In 2012, the RACP will develop the “trainee in difficulty” program to further support trainees.
Dr Bonning said the single largest increase in vocational training numbers ever in Australia would occur over the next 5 years, putting increased pressure on training programs.
The AMA plans to repeat the survey every 4 years.
In a joint editorial, MJA editor Dr Annette Katelaris and guest editor Dr Christine Jorm said the dual role of junior doctors as both hospital employees and trainees of colleges created problems over who was responsible for them. (2)
– Cathy Saunders
Posted 4 October 2011
Since leaving (being bullied out) of my training in a prestigious surgical field, after months of tears, panic attacks and chest pains I have slowly recovered from the bullying I suffered. It’s interesting how some consultants would judge me and be overtly condescending, but ignore the many occasions were my diagnoses were correct or contradicted theirs. I’ve just finished G.P training to find in my travels, several ex surgeons, orthopaedic surgeons, ED trainees who were also treated very badly. These are good people who were willing to put up with the appalling lifestyle in some of these specialties but were just bullied by the narcissistic consultants that float up in the hospital stratosphere. I’m sure if the survey was completed by more trainees the truth behind the ill treatment of trainees in many specialties will be in the open. The assessment process has got to be more transparent and there needs to be focus on skills and clinical decision making and not be based on how much brown nosing one can do to get through.
The lack of respondents to this survey is simply due to the fact that it was not well publicised. We must change the environment where individuals feel they can behave badly and still get away with it.
They must be told that the game is up. The trainee community, patients and the hospital community will not tolerate such practices any longer.
More public scrutiny is required. Also, by limiting the length of time in office held by these individuals we can curtail their power base. It is very important that all high-stake processes within medical colleges be objective, fair, transparent and repeaetable to facilitate timely reviews and/or appeals of college decisions. The rhetoric of policy statements published by colleges is often not acted out in practice. There must be a process for challenging deviations from policies without fear of recriminations.
I call for this survey to be repeated on-line via this Blog. Maybe The Age and The Australian newspapers can lend support by publishing the launch date of the survey and the submission deadline. . It would be very interesting to see the results of the second survey.
The initiative of running this survey is commendable but we need a larger sample size to give more credibility to the findings.
I read with interest the observation that it is often the heads of units in public hospitals who perpetuate bullying behavior of hospital trainees.
The recent article “The unholy trio of bullying, cronyism and narcisism at work” talks about how individuals can abuse their position power by ganging up with their colleagues to bully their victims. It is critical that we have a forum for “outing” such bullying and “mobbing” behaviour. Australia now has legislation to prevent bullying. What we need is a forum to ensure trainees have the support they need when they suffer bullying and mobbing behaviors from those who abuse their position power. The issue of trainees fearing to speak up because of possible recriminations from the head of unit who are acting more like a Godfather or Mafia head must stop.
I would like to see more trainees use this blog to highlight bullying behavior in public hospitals.
More work needs to be done indeed, the question is by whom.
Further research would be helpful, but action would help even more, action to change a well known system where the old boys bullies still remain untouchable.
To disquaify the 538 doctors in advanced training taking the time and effort to report to an AMA questionnaire as ‘disgruntled’ just because they dare to raise the topic bullying seems to confirm the very same problem.
Espeically given that the Colleges got high markings on most other questions, unlikely finding in ‘disgruntled staff who ‘are just not good enough’.
Maybe it’s the Colleges that need to wake up to a new generation of doctors that expect accountability, fairness and justice rather than the old boys club mentality.
Many years ago, when I was on the active staff at the Royal Adelaide Hospital in a visiting capacity and also the convenor for neurosciences topic teaching in the Adelaide University undergraduate course, visiting medical officers were personally involved in quite intensive postgraduate teaching and examining as well as clinical work.
Such non-clinical activities were readily and appropriately accommodated within fairly ‘elastic’ guidelines applying to ‘visiting sessions’. The then standard ‘5 session’ employment contract catered for a reasonable amount of research, personal education and teaching time – in addition to direct patient contact time.
Since the late 1980s, rules for ‘visiting sessions’ have changed progressively to ‘contracted hours’, focused towards direct patient care activities. As a result of this there has probably been an erosion of the wider role of the teaching hospital consultant operating in what should be a lively clinical and academic environment. It is likely that the shift towards administrative separation of ‘clinical’ versus ‘education & research’ in hospital budgets is one of a number of factors contributing to postgraduate malaise: an administratively attractive (that is cost saving) rigidity that sees clinicians being employed for strictly clinical duties and ‘academics’, employed through the university system, carrying prime responsibility for teaching.
It isn’t black and white and there are ‘points’ on all sides but I think such changes in emphasis over time are real, and underlie some of the problems being experienced by present generation of post-grads seeking the support they need for their examinations, publications etc – and which I received from my seniors in my young days – to ascend specialist career paths.
Likewise, I do not condone bullying; as a ‘baby-boomer’ who has gone through training ‘in the bad-old days’ the current
generation can honestly be re-assured that things are infinitely better than they used to be from EVERY point of view…
As Sir Winston Churchill once said to a graduating class at a British University: “Never, never, never, never … give up!!!”
The training programs are poorly run and the trainings are non-validated. If the 50-90% trainees fail their exams the training has a problem. Somehow we accept this fail rate under the disguise of “rigorous training program”. But if in the army 50% of the army recruits can’t pass the final exam there will be an outcry of waste of public money. If a car company produces cars that do not pass QC 50% of the time the company will fold. It is in the interest of the specialist colleges to fail their trainees, and also in the interest of the society as well. What better way to save money in the health care system when you have senior registrars competent at consultant levels performing competent work when the society is paying them registrar rates? If the implication of failing exams is that the trainees are incompetent, then where are all the misdiagnosises and dead patients? We are not seeing many, because they are competent, they are just not passing exams.
I have always found it strange that most medicos have an element of humanitarianism in them when it comes to looking after their patients but this does not extend to colleagues, both senior and junior. Many forget about the asymmetry of power that exists in the relationship. While I’m not all for the tail wagging the dog, I think a better balance can and should be achieved. The work is difficult as it is without dealing with the egos. To quote Gandhi: “Be the change that you want to see in the world”. Let’s hope when you have completed your training you action these words.
Bullying and unrealistic expectations combines uncomfortably in hospital medical practice for new graduates. Many many times crying colleagues have needed support over registrar and consultant behavior – behavior that has entirely centered around an exercise of power rather than any real problems in performance. It’s a culture that sadly still thrives with those on the receiving end having no power to make any complaint. How do you complain when the person responsible for getting a person on to a training program is the person doing the bullying? The only comfort I have ever been able to offer colleagues and med students is “it’s a game, it’s an exercise in power, don’t take any of it to heart, they do it to everyone”. I have often wondered is that really the best we can do?
This survey, albeit very poorly constructed and responded to should be received with some dismay by all members of our profession as a warning that we are not doing our job well at all. There are obviously significant numbers of trainees who have grievances, receive poor supervision and training, and who should become the trainers of the future. I don’t believe the profession has moved with the rest of society in regard to quality of lifestyle, methods of teaching and most importantly with humanity. I am about to retire, and I hope the specialists I have trained will do the same for the following generations, with enthusiasm and caring, keeping in mind that the most important thing is the patient’s wellbeing!
That said, it will be very important for the profession to ensure that it improves this aspect, otherwise various government agencies will take over the training and assessment of doctors and the colleges will be locked out of any standard setting processes. Do we want the bureaucrats setting the standard of care our patients receive?
This survey is merely a scratch of the surface of the sometimes archaic way we try to teach. We need to engage with educationalists to sort out how we improve the methods we use, and how we can progress medical education in this country.
Bravo to the respondents for letting us know that we have problems, and now let’s move onto the next phase of correcting those.
While I agree this is a small (5% of the target population) response rate, there is a need to listen to claims of a serious nature, particularly those of bullying, harassment and lack of support. The stress on trainees can be enormous. Every year there are a number of suicides in this group.
If this survey is not accepted because of its poor validity, it is time a better survey was performed. As a profession we cannot go on ignoring problems within our ranks, it debases our standing in the community.
It would also be very interesting to see if issues were reported differently in different training programs. I hope more detailed results will be provided to the colleges.
Since I read this I need to share with you my experiences: I am from Mexico; when I studied Medicine we suffered bullying and we were molested
A 5% response rate means that this survey is no more rigorous than the surveys the online newspapers carry out. The aggrieved and the more internet connected can be expected to be disproportionately represented. Who knows what other biases there are.
All we can conclude is, like so many second rate presentations at meetings: “More work needs to be done!”
Reading these responses as well as my own above brings a few things to mind. (1) The surgical consultant who looked at a “trainee” who had just stated “In my opinion …”, and retorted with “You don’t have opinions, and if you do, we give them to you.” And (2) when I asked a registrar in one of the surgical disciplines if he had discussed this case with his consultant, he said, “Hell no, I don’t know where my consultant is to be contacted. He’s probably fishing on XXX Bay.” and (3) when another response at another time to the same question was “Hell, no. I want to get onto the training programme next year.”
I’m glad I got through my training and have now got my FRACS and have a successful practice. However the training did definitely leave me with a very bitter taste, and if I did not have to be part of RACS I would leave the college. From the long hours, financial strain of the exuberant fees to the difficult bosses. I have not wanted to engage with the college at all since I finished. I think that this is wrong and I’m sure I’m not the only one.
I find it fascinating that it is the individuals fault if they become a ‘senior registrar with 2 left hands’. I have noticed several occasions when surgical consultants have little interest in their registrars. Failing to address the issue of ‘2 left hands’ has to be a lack of overseeing which is probably intended to be done by each and every surgical consultant that a registrar works with, by them feeding back to a supervising person. This is an issue in its own right. Furthermore, there seems to be a serious lack of interest in registrar training on behalf of some of today’s consultants, on occasions not knowing the names of their registrars even, and yet the very same consultants are quick to claim that today’s registrars are less dedicated or devoted to duty/care. Perhaps setting a good example might be a good place to start.
538 respondent out of 10 649 trainees hardly makes this data “rigorous” or representative
In Reply to Alex Crandon: You make an interesting point, however I disagree with your allegation that present day trainees do not have the devotion to care or duty as trainees in years gone by. The professional workforce is changing and its no longer reasonable to judge today’s workforce by yesterday’s standards. Perhaps its not that trainees are less dedicated, but that the shape of the medical workforce has evolved, and both the colleges and older members of the workforce must come to terms with this?
An interesting article but one that needs to be interpreted in the light of present day training. While I cetainly would not condone bullying it needs to be realised that many of the present day trainees do not have the devotion to care/duty that we did when at the same point in our training. Many current trainees want to work “office hours”. Furthermore as trainers we are acutely aware that there are candidates getting through the training system who are not up to scratch technically, especially in surgery where we sometimes see senior registrars with two left hands. Unfortunately gone are the days when you could take the candidate aside and tell them frankly they don’t have the ability and need to move on. Why are they gone? Because trainers are not wanting to get tied up in allogations of bullying, racism and the like; so they are allowed through. In the end it is the patients and the system that suffers.
Personally the system needs to be more rigorous but without the bullying – there is a difference.
I cant blame them given the attitude of us longer admitted fellows when we use words like ‘junior’ or call them trainees (with the implication that we are trainers). After all they are not medical students but qualified fellow doctors furthering their abilities.
I strongly believe that Colleges have far too much influence on the profession unreasonably. That is one issue.
The second however concerns my experience with the examining process of one particular College. I failed one part of the final exams consistently (the only unscrutinsed part incidentally). I sought remedial interviews with the College examiners in Melbourne. They siad they could not and did not and did not wish to do this. Further, they said that this was impossible in any case, as all exam papers were destroyed before results were announced. In my view this should be actionable. Transparency?
This contrasts with the College of the same disciplne in the UK which REQUIRES remedial interviewing after a small certain number of failures.
Needless to say, after several attempts, which bore no relation to my ability in the discipline, I stopped battering my head against a brick wall. Despite formally removing from the College, not one official contacted me to ask for feedback.
The proffered attempt to help was quite useless – go and see your local hospital supervisor of training. When I did so, the answer was, hell, I have no idea why the college would ask that, and what they would be looking for. No-one tells us these things.
re graduate numbers and positions available. Can someone please inform me how many medical gradutes we have produced in the last five years, and how many training positions are available to teach them ? My next question is how much does the influx of overseas graduates affect available positions?