On the surgical approaches to bad behaviour

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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