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HEALTH care is increasingly complex. Objective peer review, constructive feedback and robust debate are essential to continually improve the quality of patient care.
But doctors don’t always disagree well. One of the contributing factors to bullying in medicine is the complex interplay of different personality types in very stressful situations. Some doctors have personality traits that predispose them to having interpersonal conflict and being unable to see the view from the perspective of others.
For all these reasons, we must become as expert in communicating and managing inevitable conflict as we are in our clinical knowledge and skills.
In this challenging environment, it is critical to understand what constitutes bullying and what doesn’t. Routine performance review, justified criticism of suboptimal clinical management, or an occasional short temper due to sleep deprivation are clearly not bullying.
For an effective complaint of bullying to be made, one must document repetitive verbal abuse, threats or yelling; unjustified criticism; physical or mental intimidation; behaviour such as excluding, ignoring, isolating or belittling; giving people impossible tasks or timeframes; deliberately withholding information that is vital for effective work performance; spreading false rumours or lies or back-stabbing.
In an ideal world, bullying wouldn’t exist, but if it occurred, it would be dealt with quickly and effectively with an optimal human resources intervention, as recommended by the Fair Work Commission (here and here). In a formal complaint process, a senior member of staff would meet with the complainant, alleged perpetrator and witnesses separately to ascertain the facts and to take appropriate action.
Unfortunately, we live in a less than ideal world. Sometimes, the bully and their target are brought together for mediation at the outset, which is inappropriate if the perpetrators’ behaviour has been abusive. At these meetings, bullies may deny bad behaviour and question the competence, mental stability or integrity of their victim, which adds to the trauma. Alternatively, a mediation may appear to resolve issues, but the whistle blower is later “punished” by the perpetrator.
Most people know that bullying is unlawful. To avoid being held to account, bullies often conduct their abuse privately or in subtle repetitive ways that are difficult to document. Unless there is written or other evidence of bullying, it can be difficult for a complainant to prove damaging behaviour without witnesses. But others may prefer to stay neutral for fear of career damage. Bullying thrives in environments where good doctors say nothing.
How can we respond early to bullying before it becomes harmful and without being unfairly accused of being sensitive or vexatious?
I have learnt to use a harm minimisation approach if I am targeted by a bully. It helps to speak privately to the most senior person I can trust and say something like:
“May I speak to you confidentially? I have noticed these unacceptable behaviours in X. I am not going to make a formal complaint, I can deal with them, but I am concerned that someone else will. Please talk to X privately to make them aware of the impact of their behaviour. These behaviours need to stop.”
The most senior person may be another doctor, a medical director, a human resources or practice manager, a chief executive officer or a board member. It must be someone who can influence change.
Then, here is the important part: I remain objective when my trusted senior confidant tries to dismiss my concerns. I pre-empt their resistance, which usually comes in the form of questions such as this:
“Are you being oversensitive? Did you do anything to provoke this behaviour? Can’t you stand up for yourself? Why has no-one else made a complaint about this?”
Or comments such as:
“You need to muscle up. I would never let that happen to me. I have never seen those behaviours.”
And so on. I respond professionally to ensure action is taken with statements such as this:
“I am very tolerant but I will not tolerate these negative behaviours because they are harmful to other doctors, staff and patients. As I said, I will not make a complaint but someone else will. Do we want that to occur on our watch?”
X’s behaviour usually stops with a quiet word from my colleague. Next week, I will write about what to do if it doesn’t.
Medical workplace bullying: we don’t want anyone to get hurt, we just want it to stop.
Clinical Professor Leanne Rowe AM, GP and co-author of Every doctor: healthier doctors = healthier patients
If this article has raised issues for you, help is available at:
Doctors’ Health Advisory Service (http://dhas.org.au):
NSW and ACT … 02 9437 6552
NT and SA … 08 8366 0250
Queensland … 07 3833 4352
Tasmania and Victoria … 03 9280 8712 http://www.vdhp.org.au
WA … 08 9321 3098
New Zealand … 0800 471 2654
Medical Benevolent Society (https://www.mbansw.org.au/)
AMA lists of GPs willing to see junior doctors (https://www.doctorportal.com.au/doctorshealth/)
Lifeline on 13 11 14
beyondblue on 1300 224 636
beyondblue Doctors’ health website: https://www.beyondblue.org.au/about-us/our-work-in-improving-workplace-mental-health/health-services-program
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless that is so stated.
Fifteen years ago, i worked in a rural vic town hospital. I was told by a senior review doctor I wasn’t doing my job. There was only two IMGs covering after hours, busyEd, two wards, theatre and a day hospital.
I kept notes on my days for this person, proving there was no lunch, tea breaks, toilet breaks. This independent reviewer disappeared without feedback or reason. The next four years continued with lots of unpaid overtime and being mistreated was an everyday occurrence. I am thankful to have managed patient care to the best of my ability, and moved on to different pastures, but wll never forget the introduction to australian medicine
Obvious cases are easy. Where this whole area gets tricky, is when someone’s feeling of discomfort is perceived as being bullied, from a statement delivered under stress by a person consumed with fear for his patient’s life. Sometimes stress overrides one’s natural courtesy. It is exacerbated by a junior’s inability to see the whole picture (e.g. he/she was kept awake by ICU phone calls overnight, plus the brain tumour op of your favourite patient starts in 1/2 hour).
Certain RMOs are truly difficult to deal with. E.g. I had trouble with an older female RMO who was in tears almost every day. She was obviously having problems, but refused discussion or support. Yet during a tutorial, couldn’t handle my technique of trying to lead her to an answer, rather than giving it to her. She delivered a volatile charge that I was teaching by humiliation, and deplored the look of disgust on my face (I’d just come out of hospital, and had a sudden tendinitic pain course up my calf, but she didn’t know that!). No appropriate discussion – just a letter complaining of being inapropriate. This is the set of case that makes mentoring fragile personalities difficult for consultants. (I’ve spared you the multiple mis instructions and deceit in the letter!)
A typical mis construction occurred in the article by Dr Elizabeth Millikan in “Doctor” magazine last year, when the only example of bullying was a consultant being terse.
It seems to me that there are 3 main reasons bullying is overcalled: a) I readiness for work stress b) difficulties when some female RMOs face male culture (e.g. more expectation of a competitive environment, a brusquer communication style (e.g. monosyllabic instructions re doing a procedure); and c) failure to appreciate consultant stress. There are added difficulties with some millennial issues exaggerating and supporting what has been called infantilism such as the concepts of microaggressions and safe spaces. And one must feel sympathy for women who are or have been, deeply hurt by men.
I think more data should be collected and discussed. It would be interesting/helpful to analyse who complains about what and if there are gender biases. In general, women have been culturally raised to “go tell the teacher”, while men find failure to stand up for oneself almost cowardly. This impacts on how the complainant is regarded, and to claim that there’s a power dynamic making this impossible is often wrong: many powerful men (mostly) would take a shine to such spirited individuals.
There’s a ready PhD here, provided the sampling isn’t biased.
Personally, it seems that RMOs from large families (I.e. not so precious), girls who have a strong supportive bond with their father, those who’ve knocked around in the University of Life, and those who’ve experienced the discipline and uncertain outcomes of competitive sport are less likely to feel bullied.
Further could be said re the inherent psychological differences between men & women; and before anyone rabbits on about “toxic culture”, why don’t you document the multiple occasions where juniors are being appropriately mentored?
I have been a victim of bullying in a south Australia hospital . An environment of protectionism and cover ups upon cover ups of inappropriate practices . When issues were raised they were merely swept under the carpet . No one wishes to address the elephant in the room . In the end I was labeled a “trouble maker “ and rumours spread . Junior staff would confide in me about their grievances and I felt compelled to raise safety issues . Registrars unsupervised in Procedure rooms . Numerous unsafe practices which wouldn’t be considered appropraie in any hospital in good standing. The system was broken and refused to be changed . In the end they suggested that the would not renew my contract. I left broken. Saddened .
Many of the accounts of workplace bullying I hear from both inside and outside medicine (like the ones shared here) are totally appalling. I am stunned by people who think they are entitled to treat other human beings the way they do.
However I am grateful to you Leanne for defining the things that do not constitute bullying as there is sometimes a tendency to categorise single incidents or simple personality clashes as bullying and that does not help the cases of people who have experienced really serious bullying.
Thankyou for the excellent article – I look forward to the next one.
A common theme has emerged in the anonymous comments here and in social media. A victim makes a legitimate complaint which the bully denies, and a prolonged complaints process is handled poorly by senior people and/or an external investigation. The victim leaves due to continuing bullying but their painful memories of the abuse linger for decades.
How is it possible that endemic bullying persists in medicine despite a recent Senate inquiry, viral social media awareness campaigns, doctor education, incident reporting and other initiatives to improve mutual respect and medical culture over the last few years? Why would doctors continue to bully others, refuse to accept they have a problem, and risk damaging their reputation, position, career or in a recent case, their accreditation? Why do bystanders stay silent when the evidence is clear and the abuse continues?
My MJA Insight article on 11 Mar will discuss these issues and invite your feedback. Thankyou to the doctors who commented above. Your input into this discussion is very important. Medical workplace bullying. We only want it to stop.
Over 20 years ago, when I was an intern at the Royal Adelaide Hospital, two of the 3 orthopaedic wards were known to be the least preferred places to work as an intern or RMO. We’d often have to work long hours on the ward/on call and they instructed the senior registrars to NOT sign our overtime sheets. To be fair, that was widespread because of budgeting issues. But it was the constant barrage of low and high level unpleasant interactions made the whole experience distasteful.
One occasion that springs to mind was when one of the senior consultants on my ward got upset because a jelco drip hadn’t been changed after 48 hours. He pulled me up in front of the 6 patients in the bay, literally screaming for several minutes and ending with the classic line, “Don’t you care if this patient dies? Don’t you care?” I was an intern and stood there and took it without saying a thing to anyone. It was extremely humiliating at the time. Later, one of the patients said to me, “Well. He was a fucking arsehole, wasn’t he?”
I can laugh about it now, but at the time it was a fairly unpleasant.
I note, that now the Orthopaedic surgeon is a Professor.
Two os, both Senior Consultants, complained about persistent bullying from the Head of the Service, in the same fashion that had been an ongoing problem for 12 months. The complaint was made to the CEO of the Health Service, who referred it to the SA Legal branch for further investigation. Five months later, after an exhaustive 3 hour interview and presentation of emails written material, a report was issued to the CDEO as “legal-in-confidence” and hence not available for us to see. Fair Work were involved after this, and the comment from the accused included a statement that he had been told he “had no case to answer”! after we had been told the issue was still under review! Despite repeated requests to the LHN CEO from ASMOF, and legal representatives, non decision was forthcoming. The SA Ombudsman declined intervention, and after a further 18 months, long after I had left the service for much greener pastures, and a much happier and healthier environment, I received a letter from said CEO stating that in her opinion there was no case for the bully to answer! HR was no help at any time, and the other resources mentioned either declined to be involved, or were unable to get any resolution! Can’t help but think the top protect themselves, and stamping out this despicable habit will not be possible for several decades, until those who are now being bullied can see how it affected them, and make the decision to not continue the process
Your experience is really difficult and sad. I have left positions in similar circumstances. I hope Part 2 on Mar 11 will be helpful to you when I call bullies and silent bystanders to account. Its complex and cannot be answered in one comment. I would also value your feedback on 11 Mar.
I have gone through similar experience. Behaviours by the bully were clearly unprofessional and some of it was witnessed, I have used informal and formal ways to address it with no resolution. I was told that this can’t be true because this person “bully” is so lovely and kind. I had to leave the service because I was getting victimised as a result of my complaint.
I keep looking back and think what could I have done differently to be able to remain in this place, or maybe it’s not the place I want to be and it’s great that I could leave. It’s been more than 3 months, but I have to admit I am still impacted by it. What would you do?