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THE surgical profession was somewhat broadsided last week when comments made by one of its members at a book launch took on a life of its own.
Vascular surgeon Dr Gabrielle McMullins’s comments laid claim to two problems for Australian women in surgical training: that they can be subject to sexism and sexual harassment and that, if they make a complaint about such behaviour they are out on their own — professionally and personally isolated, and perhaps with no hope of recovery.
The responses in follow-up media reports suggested that there was substance to her claims, although the AMA and the Royal Australasian College of Surgeons immediately condemned her unorthodox advice for trainees that, if approached for sex “probably the safest thing to do in terms of your career is to comply with the request”.
This week in MJA InSight we publish a comment from Melbourne neurosurgeon and chair of the Women in Surgery committee of the RACS, Dr Kate Drummond who reiterates the college’s position that sexual harassment should be dealt with and reported via the appropriate channels.
Importantly, she adds that those in this situation “should be supported through the process of reporting and the subsequent consequences of the report”.
This incident is not first time this year that we have been asked to consider the failings of support systems in medical training. Back in February, media reports about the sudden deaths of four junior doctors, including an ABC Background Briefing investigation, provoked discussion about why junior doctors have high levels of distress and are reluctant to come forward for treatment.
In a commentary written for Crikey, at around the same time, medical educator Dr Kimberly Ivory said the thinking on this topic needed to move beyond individuals, to acknowledge the “dark side” of medical culture. This is where trainees report a learning and working environment that can include “sexual harassment, bullying, humiliation, physical and verbal aggression and discrimination”.
Dr Ivory cited a recent meta-analysis of 51 studies, showing that 59.4% of medical trainees reported experiencing some form of harassment or discrimination during their training. She pointed out that medical education has an “ethical obligation … to support students and trainees to develop their professional identity with integrity”.
Providing support is an underestimated aspect of medical professionalism. It’s a subtheme that flows through many of the articles we publish in MJA InSight. This week, for instance, the author of a comment article candidly requests medical support for the unique and complex set of circumstances that affect families of people who have died from Creutzfeldt–Jakob disease.
In our news section, one story highlights the importance of showing empathy and support to parents who bring children with respiratory tract infections for medical attention, as a backdrop to avoiding unnecessary antibiotic prescriptions. Another story looks at the function of having a registry of people with asplenia or hyposplenia from the patient’s perspective, concluding that what they value most is the personal support it provides.
Despite recognising our need to support patients, it seems that as a group and institutionally we are less adept at supporting each other.
But change may be coming. Some advice for the medical profession came from an unusual source late last week, in the form of an article by former Victorian Chief Police Commissioner Ken Lay published in The Age.
“At times it is very difficult and painful for a proud organisation to accept criticism, particularly when it comes from within. Instinctively it is sometimes easier to deny, to attack the messenger, or to roll out a myriad of ‘best practice’ policies to defend one’s good name”, he wrote.
“Sometimes however, looking in the mirror and reflecting on the ugliness that may be present will make organisations better, people safer, and build community confidence.”
The following day the RACS announced its intention to hold up such a mirror, by convening an independent expert advisory group to deal with concerns of bullying, harassment and discrimination in the health sector.
In making the announcement, college president Professor Michael Grigg concluded: “The College recognises there are problems but is determined to be part of the solution”.
Let’s hope this flags a future where vulnerable young members of our profession can train in a supportive environment, and are no longer out on their own.
Dr Ruth Armstrong is the medical editor of MJA InSight. Find her on Twitter: @DrRuthInSight
I’ve worked in health for 31 years. Bullying was and still is very much an accepted part of the culture. This does’t mean it’s OK. it just mean it is tolerated and sometimes encouraged. The attitude “if you can stand the heat – get out of the kitchen” still revails in some health disciplines.
I’ve seen heath executive repeatedly ignore the evdence of bullying citing miscommunication, cultural differences and even blaming the staff survey tools for asking the wrong questions.
I was a big achiever who thrived until a new manager was threatened by my skills and knowledge and couldn’t take credit for my achievements. Despite me being yelled at in front of others, belittled, socially excluded, the executive didn’t want to know and didn’t want to deal wth it. Their plolicies were all talk. The bullies know this and survive and thrive. I left in order to survive.
“Delayed justice” misunderstands my comment. I was describing one phenomenon that can happen when trainees are put under too much pressure to early. In no way does this deny the culpability of supervisors. As I mentioned, the current influence of individual supervisors on trainees’ careers in some specialties is what drives the potential for abuse of power.
Dr Leaci as a senior Consultant describes bullying as perpetrated in secrecy by junior doctors towards their peers. That does not stack up with the other responses and previous investigation findings where senior supervisors hand down the time-honoured medical tradition of bullying openly and in front of patients, peers and nurses and juniors copy them in their aspiration to become one of the admired ‘tough team’.
The Archbishop of Adelaide has just been summonded to court not for his direct involvement but for his cover-ups of harassment and sexual assaults back in the 70ies leading to ongoing trauma and destruction over years to come. I would not be surprised if in 30 years time any kind of ‘didn’t see, didn’t tackle’ approach will no longer stand with the ones responsible found out and equally held responsible for their omissions, cover-ups and the damage caused under their watch.
Interesting observation Sue Leraci. Sponsors required for success! Yes, that’s why masters/slaves are created. I have always thought the referee requirement should be eradicated in all domains. If selection and progress is based only on point based system who will care to obey the self styled masters? No more referees = no more bullies! True meritocracy will then prevail. Happy to stand corrected.
Over many years of working in public hospitals, I have seen many young trainees – especially in surgical specialties, struggle under the burden to too much responsiblity too soon. Some initially struggle and then flourish, but many cope by becoming – frankly – arrogant and obstructive. Their behaviour towards their juniors can become very different to how they treat their seniors – such that their supervisors may ony become aware when there are complaints. This behaviour has been propagated multi-generationally, and exits in a context where demand for surgical jobs exceeds supply, and sponsors are still required to ensure success. This is a potential “toxic mix”. If supervisors don’t see it, it’s because the bad behaviour isn’t displayed in front of them – for obvious reasons.
Maybe the key is to delay selection into training schemes, and base it on assessments from supervisors throughout the candidates first two years of training, plus of minus a primary exam. If more appropriate people are initially selected for training, there may be less bad behaviour as a result of people being stretched beyond their capacity, and less need to “play up” to the supervisor for career advancement.
Within hospitals, all doctors are either employees or contractors to the organisation – trainees are registered doctors, they don’t “work” for their supervisors – they are junior colleagues. They should treat each other as such, and behaviour should be managed as such.
http://mobile.abc.net.au/news/2014-11-07/canberra-hospital-bullying-claims-teaching-accreditation/5875468
maybe the deniers can take time to visit the above link.
I have endured various forms of bullying and harassment during my fellowship training. It was clear cut proven. Many were racially motivated. Contrary to what is observed by someone it was the exceptional merit, performance and capability of the victims which was lacking in the bullies that motivates them. Same for very many of my colleagues of international background where fellowship is being unfairly denied/delayed. Even after becoming a specialist fighting through the atrocities I faced bullying (threats to life too!) for being meritorous. Better patient outcome is not tolerated by the collectivist bullies. If further proof is needed – I have being through a court process. Both a private hospital group and a collectivist group of doctors were threatening myself and instituted fake disciplinary process and board action for no patient outcome issue. It was only for their personal benefits. I had to endure painful threat phone calls from the said doctors. Writing comments anonymously by anyone doesn’t undervalue the statements – the value of anything resides in its merit and not in its sponsorship!
I supervised a lot of advanced trainees in a RACP programme and also was the coordinator of one training stream for years.
I never heard of any problems either formaly of informally.
As I write this, there are 10 comments already. Only two have the commenter’s actual name. I think this speaks volumes.
In the 20 years or so of practice, I have seen and been subjected to bullying. It’s painful to admit but I may even have been guilty of what could be construed as bullying behaviour myself. Despite my behaviour at these time intending to be playful or joking, in retrospect, the others it was directed at may not have viewed it as such.
It is interesting to note that the initial response of the AMA and the College of Surgeons was that they didn’t believe it was happening and that there were specific processes in place to deal with these issues if they were to arise. This is despite one of the specific criticisms of the whole process was that those who go through the appropriate channels are victimised by the system and end up with worse outcomes as a result. It is telling that the College of Surgeons has, as a secondary response, decided to set up an independent body to look into the issue. One would have thought as doctors we would rely on evidence rather than eminence in our response to any problem, potential or otherwise, that is raised. But that’s not how medicine works now, is it? And therein lies the problem.
Andrew, you did go round with your eyes shut. But you are not alone in this, to the contrary, most Consultants believe that nothing bad can be happening under their watch while most trainees experience or witness significant bullying.
It is of course easier to explain that foul reality away with ‘the juniors not being good enough’ rather than your esteemed colleagues having broken the law and yourself having looked away and failed to support your trainees. Maybe the medical inability to admit guilt and failure has something to do with it and maybe we need some judges to remind us of what is right and what is wrong.
Interesting that as a former director you are one of the only doctors who dare to write in their own name. As long as that does not change you know that the problem has not been resolved.
Perhaps I went around with my eyes shut or was terribly naive but in my 41 year career as trainee and then surgeon, head of unit, surgical supervisor etc., I never came across or heard of any sexual harrassment committed by surgeons. Yes, I did come across ‘bullying’ however this was very infrequent and usually directed at interns or trainees who did not come up to the high standards demanded by some surgeons or who made stupid mistakes (not that you are allowed to call anyone stupid these days). In general surgery each trainee rotates to a new position every six months and is assessed by a new group of surgeons so a bad report by one surgeon who had been denied a ‘blow job’ by his trainee would be overridden by the consensus if this was good. It is not easy to get through surgical training and extremely high standards in medical knowledge, clinical judgement and technical expertise are set as one would hopefully expect. There are a number of trainees who do not measure up to these standards and it would be sad if these trainees blamed the system, sexism or harrassment rather than recognising that they were not up to it and looked at the many other options that are open in medicine.
When you notify a college say about an overt racial discrimination or belittling by a supervisor for no reason, they say it’s an employment problem to be dealt by the hospital administrators. But these bullies are in fact working in tandem with these administrators! Where is going to be the justice for the complainant. I know of scores of internationally trained graduates facing these discrimination and exploitation at the hands of such people holding positions in hospitals and medical boards. Such sinuous passive bullying as opposed to someone being rude is what needs to be addressed. In fact these same elements will use the bullying clause against the victims! They know how to exploit the system – that’s how these elements survive. They will institute false disciplinary actions against the victims to blackmail them. There are so many stories of specialists being exploited by hospital administrators to the extent their normal life is affected. Their demands are more than sexual! It is a sad state of affairs. Of note, these real bullies are generally soft spoken and have a professorial title! Interestingly another such bully I know is a vascular surgeon as well – wonder why this particular specialty produced more of these smooth criminals!!
The Colleges note that there is bullying and harassment because it has become a public issue and threat to their ‘good reputation’, not because they didn’t realise prior. Every investigation and review into the matter has proven it before – but without changing anything as so far the bullying has never been punished, only the complaints about it. Until that changes nothing will change, no matter how many committes and papers.
A subset of population taken from a wider community will exhibit the same distribution of bad persons as in the wider community. So it is not surprising that bullies and crooks exist in the medical fraternity. But what is concerning is that, while they are kept under check by law in the wider community, they run amok uninhibited within the medical community. In fact they occupy positions of power and ruthlessly exploit them. The large majority of medical doctors would not approve of it – if it’s the norm it wouldn’t have been news! But it is the silence of the majority that makes these bad elements powerful. Those elements should be nipped in the bud. Regardless of their prefixes and suffixes, anyone that threatens and bullies should be notified straight to police. We can’t accept an alternative australia within the hospital!
I note that the poll in which I have just voted gives the option of nominating sexual harrassment and bullying as a serious problem in medicine or as a societal issue. In fact it is both. In common with other occupations, and perhaps this applies particularly to the professions, medicine attracts a variety of personality types, including those who are aggressive, arrogant and driven to achieve and who are capable of sexual harrassment. Bullies may therefore actually be more prevalent among the ‘high achievers’ within the profession. This is a problem that needs to be recognised, perhaps particularly at interviews for promotion.
There are some who are very good at exploiting ambiguity and shifting responsibility, reframing themselves as the victim of an accusation of sexual harrassment and using this as an excuse for further discrimination. This contributes to the well recognised ‘no win’ situation for the victim.
Thank you for your comments regarding harassment in the workplace. The woman who reported the harassment is not alone, nor is harrassment or any kind confined to GP training.
We should all be aware that harassment can and does occur in some instances from the very top down, between medical staff, between nursing staff, between administrative staff, and any combination thereof.
I welcome the initiative of the College of Surgeons.
It if often difficult for people subject to any form of harassment to know where to go to report the problem. The notion of “chain of command” is often not sufficient. The protocol for reporting should be promulgated throughout the entire health “industry”.
No one should have to suffer from workplace harassment or discrimination from over zealous, unscrupulous and unethical, unprofessional behaviour of members of the health profession or from allied and support workers in the health system.
I wonder how many of these reported encounters were initially mutual. And how many were initiated by the female. This point never seems to come up in these discussions. I worked for 6 years in UK hospitals in the mid-fifties and encountered a number of possible involvements (no). Maybe it is not always the bloke who is to blame! If I had dilly-dallied would I have the 5 children, 15 grand-children and 5 great-grand- children that I enjoy now?
Maybe we all need to think about this topic more. SO: Suggested title for a student essay or discussion:
“Given that we are nearly all sexually intact and interested / interesting to a widely varying degree, What is sexual harrassment? and what will you do if it happens to you?”
Many of us handle incidents better if we have thought them through in advance.
Thanks for pulling all this together, Ruth and keeping the conversation going. A long, hard reflection is indeed needed and will be therapeutic in the long run.