HOW is it possible that endemic bullying (here, here, here and here) persists in medicine despite a Senate inquiry, viral social media campaigns, doctor education, incident reporting and other initiatives to improve awareness, mutual respect and medical culture?
In some cases, we can blame health systems issues, such as medical workforce shortages, lack of funding and unsafe hours, but in other cases, we must take collective responsibility for failing to hold individual doctors to account for their damaging behaviours.
Most doctors readily change after being counselled about poor social skills, rudeness, bullying, sexual harassment, discrimination or racism. But others refuse to accept they have a problem, and risk damaging their reputation, position, career or, in a recent case, their accreditation. Why would doctors do this? And why is it so difficult for others to call them out and intervene effectively?
One of the reasons may be due to narcissistic personality disorder (NPD), which occurs in up to about 6% of the general population. In my experience of working in clinical and board leadership roles across many different medical workplaces for nearly three decades, doctors with untreated NPD may manifest bullying behaviours in a number of ways.
Fundamentally, a doctor with NPD is arrogant, feels entitled and believes others have a problem. In subtle or not so subtle ways, they let other colleagues know they are “special”, exaggerating their exceptional skills in patient diagnosis and management. Patients often adore them as they also inflate their achievements in their consulting rooms, while making derogatory comments about the clinical management of other doctors.
Consequently, a doctor with NPD may seem charming on the surface and have many admiring followers. Generous one day and dismissive or aloof the next, they justify their quick temper as necessary to keep other doctors on their toes and to uphold a high standard of patient care.
To avoid being reported, doctors with NPD may slowly undermine their victims with repetitive nit-picking and sarcasm, drip feed low grade abuse that is difficult to call out, avoid eye contact, roll their eyes with disdain when no one else is looking, or give out backhanded jabs dressed up as jokes. Intermittent stonewalling and private taunting are also tough to prove.
It is particularly difficult to call out an employer or supervisor who has NPD, as on the surface, they may appear to be trying to help their victim. In reality, they may be quietly investing their time into their subordinates for “a return”, exploiting them financially, expecting them to work unreasonable hours, taking credit for their achievements, performance managing them unfairly, focusing on their vulnerabilities with patronising concern, or making veiled threats about job or training security to keep their victims in their place.
Nothing is ever good enough, which creates excessive fear in the workplace, paradoxically reducing the performance of other doctors and endangering patient safety (here and ). Others find it difficult to challenge the doctor with NPD as they twist words, misconstrue situations, or are easily slighted by routine peer review, constructive feedback or minor criticism.
More severe behaviours of NPD include pathological lying, nasty competitiveness or smear campaigns against other people. This often occurs without the knowledge of victims, who are unable to defend themselves against false rumours because they are the last to find out. The falsehoods often focus on what hurts doctors most, for example, being accused of failing to pull one’s weight, a lack of integrity or, worse, incompetence.
When confronted, the bully lacks empathy and may pretend nothing has happened. To maintain their superior status, power and control, the perpetrator may also play the martyr or accuse a victim of being toxic, dishonest, mentally unstable or “not up to it”, which causes further harm. A doctor with NPD is often quick to threaten legal action for defamation while continuing to spray lies about others, which is a very effective way to split people. As a result, the complainant is sometimes wrongly accused of poor behaviour, rather than supported by others in the workplace.
A common myth assumes victims of bullying are oversensitive, weak individuals who are unable to stand up for themselves. More often, bullies target high achieving victims who they envy. When a target lacks boundaries in relation to self-protection and self-care, they try to appease and tolerate the bully for too long. The mind games are irrational and there is nothing the victim can do to “win” or fix the situation when the rules keep changing. Any individual intervention only makes matters worse while the perpetrator continues to enjoy “playing” with their victim.
In response, victims naturally become upset, hypervigilant and defensive, and when their stressed demeanor confirms the doubts of colleagues about their mental health, they may gradually lose their support network. Recommending self-care strategies, resilience training and cognitive behavioural techniques in this situation can be harmful because further responsibility is placed on the shoulders of the victim to change, but this doesn’t stop the bully’s destructive behaviour.
Change is also difficult because doctors with NPD usually don’t regard narcissistic traits as negative as they feel superior to other doctors and often say so directly or indirectly. Witnesses fear getting involved for fear of becoming a target themselves and remain silent when it appears “there are always two sides to a story”. In some recent high profile cases, hospitals, medical services and other health providers have turned a blind eye to bullying, particularly when doctors are senior, generate healthy incomes or have skills that are in high demand in an area of workforce shortage.
With all these challenges in mind, how can we hold bullies with NPD to account?
Greater awareness of damaging behaviours is important. Anyone can exhibit narcissism or narcissistic personality traits or types from time to time in different forms from mild to severe. When doctors are under stress, they can “act out” or their behaviour can worsen. The more we recognise the traits in ourselves and others, the less likely they become a problem. However, unfairly labelling or stereotyping doctors as narcissists is to be avoided (here and here).
NPD is different and pathological. It is a diagnosis not to be taken lightly, requiring comprehensive consideration of diagnostic criteria and intensive management, including long term psychotherapy by a treating psychiatrist.
There are many reasons why doctors with NPD need our help to get help. They lack insight and rarely seek help themselves. The quality of patient care may be at risk, particularly if the doctor is impulsive, overconfident about their capabilities or ignores peer review. A bully with NPD has an adverse impact on the health of their victims and patient safety by creating a negative workplace culture. They can be depressed and, in severe cases, may be at risk of harming themselves if they lose their professional standing or are ostracised by their colleagues when their negative behaviours are exposed.
Notwithstanding the challenges, the damaging behaviours of a bully with NPD, must be called out and monitored by a collective of respected senior doctors or a senior leadership team, rather than expecting individual victims to “muscle up”. Bystanders must speak up. Unless complaints about bullying are dealt with appropriately by medical workplaces, they will continue to be aired through social media, and reported to Work Safe authorities, the Fair Work Commission, the Australian Human Rights Commission, and in a recent case, to Parliament, to the detriment of all involved.
Although I have written previously on the high threshold for mandatory reporting to the Australian Health Practitioner Regulation Agency (AHPRA), which is rarely met for doctors with mental illness, severe NPD may be an exception if patients are placed at substantial risk of harm. In this extreme scenario, the notification should be undertaken by a group of respected senior doctors, and only after expert legal advice to ensure notifiers have statutory protection from legal action. Unfortunately, if all else fails, it may take an intervention by the Medical Board to ensure the doctor with NPD attends regular psychotherapy as part of restrictions on their medical practice.
None of this is easy. However, we should never allow the damaging behaviours of a doctor to reach this level. Collectively, good doctors must take responsibility for holding bullies to account and believing victims.
Individual doctors cannot be expected to initiate and endure onerous complaints processes on their own. If you feel you are being bullied, consider enlisting the following network of support:
- Seek regular debriefing from a skilled GP, psychologist or psychiatrist, who understands the irrational nature of the abuse and your inability to “fix” it on your own. It helps if your doctor is independent from your workplace to allow them to advocate effectively on your behalf, especially if you require stress leave or wish to make a complaint.
- First try an early harm minimisation approach to the damaging behaviours. If this does not work, try to have no contact or avoid contact with the bully, but if this is not possible, remain brief and always professional.
- Try to enlist the support of trusted people at work, particularly other victims of the bully. Address “splitting” promptly by communicating clearly with others.
- Do your work to your best ability, proactively seek out kind colleagues, and stop trying to seek the approval of the bully – nothing will ever be good enough. Do not seek the understanding of the bully or share your vulnerabilities including your distress, as it will be used against you.
- For extreme stress at work, practise “extreme” self-care outside of work – do what works best for you in terms of relaxation and rejuvenation. Stay connected with people you love outside of work.
- Do not internalise the irrational behaviours of the bully and do not waste your precious time ruminating or rehearsing how you will respond at your next meeting – there is no right way to “play” irrational mind games. Instead, spend your time with people who support and energise you.
- Obtain a copy of your antibullying workplace policy and follow the correct procedure about making a formal written complaint if this is appropriate. If your workplace does not have a policy, access information about routine complaints processes on the Fair Work Commission and Safe Work Australia
- An antibullying policy will usually recommend documenting the damaging conversations, emails, telephone calls, minutes of meetings or any other objective evidence of a repetitive pattern of destructive behaviours; and to make a formal confidential complaint in writing about the bully to the appropriate manager or senior doctor in the hospital, medical service or other health provider. As the support of witnesses and other victims is also important, try to maintain your relationships with these people.
- During a complaints process, it is your right to have confidential meetings without the bully present, especially if you believe you will be bullied in a joint meeting or there is a power differential between you and the bully. If you have been subjected to bullying, you are entitled to a formal apology as well as reassurance that the bullying will stop and others will be protected.
- Also try to maintain a constructive relationship with your manager/senior doctor to whom you make the formal complaint. During any investigation, anticipate that the bully will deny your allegations and attack your integrity, competence and work ethic. For these reasons, attempts at mediation are often not appropriate. Avoid being defensive, but be ready to calmly counter these unfair attacks when they are brought to your attention. Stay focused on the main issues when you make a complaint, and always use facts and evidence, not hearsay or rumour.
- Remember that your emails, letters and social media posts may be scrutinised by others in an investigation, and used against you unless you are always polite and professional. Therefore, never write anything that could be later construed as defamatory or “emotional”.
- If your manager/senior doctor is the bully or is also being targeted by the bully, it may be necessary to submit your complaint to a more senior human resources director, CEO, or Chairman of the board, if they exist. Whistle blowing policies apply in this situation.
- Under the Fair Work Act, board directors and CEOs must ensure that effective occupational health and safety policies are in place, outlining non-compliance penalties and the use of just and fair disciplinary processes. Board directors and CEOs can be held liable if occupational health systems fail and they, therefore, understand and fulfil their responsibilities, which include routinely monitoring staff turnover rates, incident reports, staff and patient complaints and outcomes of exit interviews to identify any problems. However, do not prematurely complain at this level unless you have exhausted the other avenues documented in workplace policies.
- If there is a patient care issue, seek medico-legal assistance from your medical indemnity organisation in any complaints process to explore all options. Also seek their advice if it is appropriate to pursue a complaint to regulatory authorities, including AHPRA when patients are at substantial risk of harm.
- Enlist the expert advice of experienced legal professionals to address unlawful behaviours.
- Continue to debrief with your independent GP, psychologist or psychiatrist regularly. It is not humanly possible to endure a complaints process without regular mental health care outside your workplace.
Endemic medical workplace bullying. Too many people have been hurt. It stops now.
Clinical Professor Leanne Rowe AM is a GP, and co-author of Every doctor: healthier doctors = healthier patients. In the past, she was Chairman of the Royal Australian College of General Practitioners Council, Deputy Chancellor of Monash University, non-executive Director of beyondblue, and acting Chairman of Barwon Health. All views are her own.
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.
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