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WHAT does it mean to change culture? What does it mean to improve training for medical students and doctors in training?
The medical profession has been going through an earnest time in the past 2 years. In March 2015, Dr Gabrielle McMullin made comments that brought to light the spectre of sexual harassment in the surgical workforce. This broadened a conversation about the wellbeing of doctors in training and medical students, which had begun with the release of a world-first report on the mental health of doctors and medical students by beyondblue.
And it profoundly changed the way in which surgeons manage bad behaviour. The Royal Australasian College of Surgeons (RACS) established an Expert Advisory Group which led to a detailed report on the problem, and finally, an action plan.
Change requires commitment at personal and system-wide levels. In a culture of mutual respect, everyone has responsibilities. This doesn’t minimise the importance of dismantling oppressive systems, but it is a prerequisite for participation in a workforce with high stress, high stakes, and with the lives of patients and the wellbeing of our colleagues on the line.
Every day, when I walk into a room, I must ask myself: does it become safer? This is relevant for the operating theatre, the resuscitation room, the clinic waiting room and the residents’ quarters. In every encounter, do I bring peace?
If we want to make a change that is lasting and robust, we have to make sure everyone knows the rules. I frequently hear from trainees about the bad behaviour of their seniors, and in their voices, a certain incredulity – “I can’t believe he doesn’t know this isn’t okay”.
How do we ensure that everyone knows what professional behaviour looks like? It isn’t obvious, or we wouldn’t have such dramatic rates of bullying, discrimination and sexual harassment. Unprofessional and illegal behaviour are far too common.
It is my privilege to represent the trainees of the RACS, and I recently completed the new RACS e-learning module developed as part of the Building respect and improving patient safety action plan. Crucially, this module will be a CPD requirement for all surgeons. It will also be a requirement for current trainees, and those applying to surgical training in 2017 will have to complete it before applying.
For trainees, this is a major breakthrough, as mandatory training on bullying, discrimination and sexual harassment is something we have called for. Trainees were involved in developing the module, and strengthened its content and approach by doing so. Online learning has limitations and in response to this, a more comprehensive face-to-face course is in the pipeline.
One of the challenges that arises when we mandate training for established clinicians is resistance. It’s common that someone who has been in practice for 20 or 30 years doesn’t really see what the problem is, and doesn’t want to modify their own approaches to their colleagues.
This is why the ongoing advocacy role of RACSTA (the Trainees’ Association of RACS) is so important. We survey our members every 6 months, and will soon be able to share a 5-year analysis of trends in the surgical training experience. The advocacy roles of both the Australian Medical Students’ Association and the Australian Medical Association’s Council of Doctors in Training have been of paramount importance in changing perceptions and driving for change.
One of the emerging challenges in surgical training is that, as consultants are told they must not engage in belittling or discriminatory behaviour, they lose confidence as educators. How does one give feedback when one is frightened of being accused of bullying? Trainees are reporting a concern that the antibullying messages are eclipsing feedback.
Here, too, formal training is required. How to give and receive feedback is a competency that is learned. And it needs to be taught.
Ideally, feedback should be given frequently, not only when a trainee is underperforming or when their career is circling the drain. Feedback needs to be timely and engage the learner. While a growing number of surgeons are undertaking higher degrees in surgical education, most surgical supervisors have no formal teacher-training.
And this is why the Foundation Course for Surgical Educators is so important. It has been developed by the RACS, and is mandatory for anyone training a surgeon.
As a trainee, I feel it’s important to actively seek out and receive feedback in good faith. It’s part of being a professional. As a registrar, I’m responsible for the teaching and training of medical students and residents on my team. Giving them structured regular feedback in a respectful manner is also my professional responsibility. The good news is that like operating, it gets easier and better with practice, and like operating, it’s a genuine privilege.
My hope for my profession is that one day it will be as diverse as the community we serve. But we won’t get there unless we commit to a rigorous self-assessment of our own professionalism.
It starts with the words that come out of our mouths. If anyone in the room could be offended by something, don’t say it. But it goes further than that: if anyone who could be in the room, but isn’t yet, could be offended, don’t say it.
That way, when you have a trainee who is a Muslim woman who wears a hijab, or a medical student who is transgender, they will not meet this wall of awkwardness on their way into the operating theatre, because, all of a sudden, somebody realises they have to change their behaviour. Our conduct should be good enough for the whole community already, so that the medical students and junior doctors entrusted to our care will feel our welcome, and our patients will benefit from the richness that they bring.
Dr Ruth Mitchell is a neurosurgery registrar at the Royal Melbourne Hospital and a PhD candidate at the University of Melbourne. She was the inaugural AMA Doctor in Training of the Year in 2016, noted for her work as the chair of the Royal Australasian College of Surgeons Trainees’ Association and her tireless pursuit of doctors’ wellbeing and high quality medical care, through advocacy, education and research.
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I am a senior specialist doctor who agrees with you 100% Ian ( Hargreaves ). The carrot PLUS, definitely, the stick. Perhaps 6- 12 months
of suspended medical registration, I can almost guarantee you, will be the cure. Sex and money are two of the most important things in
many, many, many men’s lives! All over the Universe! Such men generally have a prior history of sexual indiscretions – within and outside
the medical field. and have got away with them. They are often too arrogant and oblivious to the pain and suffering they cause the victims.
So education alone will not work. I was nearly a victim once.
Wow, well done comment number 4 (registrar), How powerful is the sorry message (very), everyone should have to say that out loud, I like your example of how to “bond”. It’s not the buying coffee, it’s the inherent respect that you are a person who matters that is important. It does matter that you know your work, the theory behind it, and your patients. It does matter that I am looking after your education and know that you are struggling with this aspect, and hence will help you find ways to learn it, with pride in our achievements in this aspect. I will not humiliate you into an embarrassed stressed mess that can no longer think or function unemotionally.
As I wrote in my submission to the RACS EAG: “What is unlikely to work, sadly, is education. Lawyers know the law, but as the EAG Background Briefing points out, have worse statistics for BHD [bullying/harassment/discrimination] than most groups, including surgeons. Smokers know it is bad for them, yet ignore governments and doctors. More paperwork is the last thing we need, and will be no more effective than Neville Chamberlain’s piece of paper.”
The RACS has indeed mandated an online course to make better surgeons, which, when you think about it, is probably as effective as an online course to make taller surgeons. The sad reality is that not one rapist has faced criminal charges (yes, coercing your juniors to sleep with you by threatening their career, is rape), and not one RACS Fellow has been booted out of the College for bullying, harassment, discrimination etc., as a result of the EAG. The response to Gabrielle McMullin’s disclosures has been window-dressing, not profound change.
While I am reluctant to criticise the youthful enthusiasm of trainees like Dr Mitchell, the educational approach is likely to be as effective, to use a neurosurgical analogy, as using an earplug to prevent your mobile phone giving you a glioma. Where the bully is a senior College official, he knows he can literally get away with rape, if not murder, when any inquiry will be supervised by his mates.
What may work is the real stick, rather than the notional carrot: a truly independent Ombudsman who could take anonymous reports, with the ‘high fliers’ on bullying scores to be investigated, counselled, and if necessary, reported to RACS/AHPRA and struck off. Smokers respond to real costs (massive price rises) rather than sober advice from professional doctors. Making bullies face a career-threatening inquiry will be more effective than making them sit in a tutorial where we all agree to be good.
The other issue is the specious association of bad behaviour with incompetence, or ‘patient safety’ concerns. As Bizet said of Gounod, it is possible to be a great artist without being a good man. I have worked with many nice men who were mediocre surgeons, and many bullies and thugs who were technically brilliant. By careful observation during my training, I came to the conclusion that those who threw tantrums, or threw instruments, did not actually get the suture or the drill any quicker than those who asked politely, and they did not do a better anastomosis or internal fixation.
Clearly, the optimal situation is to be a nice person and a good surgeon – I believe the latter can be taught, but I have significant reservations about the former!
I’m not a surgeon, I’m a GP but have been involved in surgery for nearly 30 years, as a student, Intern (In South Africa), resident (UK and Australia) and a registrar. I have experienced bullying but to state that I have had to do operations on my own I was not comfortable with is not true in any of those countries, in fact I found Australia so heavily supervised you hardly ever did any operations yourself unless you had a really supportive consultant. Unfortunately sometimes I had to be pulled up to meet the standard required, for good reason. This is not dealing with machines or some computer work. We deal with patient’s lives here, and most of us I think tend to take it too easy when we start out there. The only way to correct errors is to be told about these, and that doesn’t come easy. Sure, there are different ways of telling someone and one can be polite. Unfortunately I have also been in the position where I have told people off but when instruments are going to get contaminated or patients get injured accidentally whilst under G.A. it is vital to tell people off right there and then. This is the nature of this business we’re in.
Hi Ruth, great article and great initiatives…it is very heartening to read that true change is actually starting to take place.
The culture of medicine would have us believe that change is difficult, if not impossible and that it will take ages, if it happens at all, but that is rubbish. As is all the posturing about how difficult it is to teach an old dog new tricks.
All it takes is a little bit of common sense, decency, respect, humanity, and treating each other as we would like to be treated ourselves…it’s not rocket science!
Bringing love and care back into our own lives and treating each other the same way will infuse the system with the same love and care that is sadly lacking at present…it costs nothing, takes no time and everyone knows how to do it already, so what are we waiting for?!
Thank you Ruth,
As someone who has seen medical students and juniors bullied/harassed, as someone who has observed consultants behaviours- both positive and negative, I’m at a crossroads in thinking you can beat the behaviours.
To the consultant who has yet not woken up-
the ‘when I was going through training’ just shouldn’t apply. When you were going through training you were bullied and harassed, you were overworked and underpayed, you were made to believe that a surgeon wasn’t allowed to have a balanced lifestyle. I’m very sorry to hear that you were hurt by those that should have provided you with a wonderful supportive environment. I’m very sorry to hear that you never spoke up about it then to protect the years of surgical doctors after you. Why do you honestly believe you can treat people well if you yourself have never known what a supportive environment is? I am so very sorry you believe that tough hatred builds stronger surgeons. I’m sorry. This should have never happened to you. When you were in theatre training alone and with no help- you should have had the ability to have a consultant there. You deserved to be taught how to operate safely. You should have had protection. You should never have been left alone to do operations you had never done before or were not competent in.
To the registrar’s who are still fighting these behaviours- I’m sorry. I feel for you. I hope you can find it in your hearts to remember that the bad behaviours you have seen or been subject to are not a reflection on yourself. That those behaviours will not define you and you will never repeat them so as to negatively influence the generation below. You are good hard working people who deserve to be taught in a supportive environment. I’m sorry for all the moments I didn’t realise you were being bullied and you were having to deal with it by yourselves. I’m sorry no one has done anything earlier to protect you.
To the residents, interns and medical students. Wouldn’t it be nice that when the registrar is writing the notes for theatre that the consultant walks with you to get coffee and teaches you a few things along the way? Wouldn’t it be nice if those above you said thank you more often? Wouldn’t it be nice if surgical jobs were actually based on merit and everyone worked hard? Wouldn’t it be nice to be supported, taught and cared for so that everyday you turned up to work you were happy, you were content and could help patients without the behaviours of others getting in the way? I hope you get treated well. I hope you are valued. You should be.
Wouldn’t it be wonderful if consultants, registrars, residents, interns and medical students were all valued and supported? What a change to the patient journey this would make…..
I’ve had things happen to me that should never happen to a junior doctor. As I begin my first year as a registrar I make a promise that I will not repeat these behaviours, I will not tolerate them and I will make it my life goal to be a role model for those above and below me on the hierarchical path to becoming a surgeon.
I hope that those who are leaders in surgery stop being followers and learn to lead the way forward.
I have been inundated with stories from trainees about the sexual harassment that they have been subjected to. One of the worst cases was a female GP trainee in NSW so I think you might have to re think your opinion of the RACGP Linda.
I find the entire situation confusing. As a new “specialist” I’m having to double think my actions on a daily basis. It would make sense to me to ask the medical student to go and get us all coffee, I’ll pay, while I write notes between cases and the registrar reviews the next patient. But if I were male and the student female that would be considered by some as harassment. And when a resident is not up to scratch on a topic (or many, as usually is the case) I’ll suggest they read a particular article and discuss their findings at the next education meeting, but if I’ve asked them to do this too often it’s seen as bullying.
I can’t see how the new “respectful” medical education should look.
You might look at the teacher training and ethical positions of other colleges ag RACGP to get some effective strategies