Training crisis means more bullying

THE bullying and harassment of junior doctors was perhaps the dominant issue of 2015. Significant efforts are now underway by groups such as the Royal Australian College of Surgeons to address an issue that has been demonstrated to affect up to 50% of trainees.

Anecdotally, I have heard many stories of senior clinicians reaching out to juniors in overt demonstrations of empathy and support. Horror stories from consultants’ own training have been shared with a common theme pervading: as careers progress things do improve.

While it is very difficult to quantify, there is little doubt that bullying has always existed in the medical profession. Publications on bullying and harassment in various forms first appear in the literature in 1988 but as Shem illustrates in The House of God, punishing residencies were an established part of medical training in the 70s.   

Indeed, teaching by humiliation is an art that was unfortunately perfected in hospitals with a sort of Faustian bargain struck. Endure the torment and, eventually, the hazing would finish and a consultant would emerge. Today, this sort of behaviour is rightly deemed completely inappropriate. Yet it clearly persists. 

So why, in 2015, did bullying and harassment erupt as an issue? Is the bullying of today any more sinister and insidious than in the past? Why is it boiling over?

Certainly, today’s trainees are more diverse than they have ever been. Women, international medical graduates and ethnic minorities are all more likely to suffer bullying and harassment. However, it should not be forgotten that anyone can fall victim to it. Indeed, even in homogenous groups, bullies will find victims.

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There is an established dose–response relationship between workplace bullying victimisation and mental health outcomes. Additionally, it is known that those most likely to be bullied and harassed in the hospital setting are juniors. It is therefore logical that the longer a junior doctor remains a trainee, the more likely it is that they will be bullied and, by extension, the greater the toll the bullying will take on their wellbeing. 

Unfortunately for vulnerable juniors training times are longer, and less certain, than ever. In 2014 alone, 1600 applicants to GP and surgical training missed out on places. With an unprecedented number of medical graduates, this backlog is expected to compound in the next few years. By and large, these applicants are cycled back into resident or unaccredited registrar positions of questionable developmental value. This elongates training and means that juniors persist in susceptible positions for longer than ever before.

Further, with such an oversupply of juniors relative to training positions, there is little guarantee that persisting will result in the reward of a training place and subsequent fellowship. This uncertainty compounds any bullying and harassment and drives further negative health outcomes.   

It is therefore clear: the rules of the Faustian bargain have changed, but the downsides of medical training remain.

To date, the response to bullying and harassment has focused on the behaviour of individuals. A zero tolerance policy has been announced, or reiterated, by numerous colleges and there appears to be genuine momentum to generate lasting cultural change. This, of course, should be encouraged. But surely such a complex problem deserves a multipronged approach. With some specialities in Australia now approaching the longest and most inefficient training times in the world perhaps it is time for training reform as well.

Dr Tim Lindsay is an Australian junior doctor and PhD student in the department of surgery, University of Cambridge, UK, supported by the Cambridge Commonwealth Trust.