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I RECENTLY returned to hospital work and resumed clinical practice after a year or so of research.
While I have been struck by the kindness and support displayed by most of my colleagues, I have also had a stark reminder of the, at times, unpleasant nature of the “hierarchy of medicine”: those telephone consults that leave me with my cheeks burning and thoughts scattered, putting me firmly in my place.
I was introduced to this hierarchy from the moment I began medical school – the pathway to becoming a consultant stretching out ahead of me, with the various stepping stones glinting in the distance. “Becoming part of the furniture” or “blending into the wall” were common jokes thrown around as medical students. We developed chameleon-like qualities, seamlessly adapting to our environment. We became attuned to the best course of action to be most helpful and least burdensome.
As a medical student, I witnessed bullying. I vividly recall standing in an anaesthetic bay watching a consultant do a practice examination with their senior surgical trainee. It was straightforward – something along the lines of “give me the differentials for an inguinal mass and your approach to this work-up”. The trainee’s hands trembled and their eyes darted from side to side as they were unable to conjure up any words – they were like an animal caught in a spotlight. The practice went horribly, and they were ridiculed and told that they were not going to pass their upcoming exams.
The same consultant would relentlessly fire questions at medical student colleagues whom they hadn’t taken a liking to during procedures and humiliate them if they gave a wrong answer, questioning what they were doing studying medicine. They did this in front of other students, their trainees, the anaesthetists and the nurses – I never saw anyone stand up to them, myself included.
I was worried about passing the rotation and was too cowardly to speak up in case I jeopardised my own progress. I studied notes in the bathroom between cases, frantically trying to memorise answers to questions I thought they might ask. I was terrified of getting something wrong. I pulled aside one of their frequent victims to ask how they were coping – they weren’t really, but they had resolved to “endure” the rotation.
This doctor was often kinder on the day after they had an afternoon off with their family. This got me thinking about who they were outside the hospital. What were they like in medical school? Who were their friends, their family, and how did they spend a lazy Sunday afternoon in summer? What triggered this change from a friend, partner and parent to someone who actively made another intelligent grown adult (their surgical trainee, with their own life, family and friends) feel so incredibly small and stupid. It was like the hospital doors acted as a portal to a parallel world, where donning their ID, acknowledging their lofty place in the hospital hierarchy, made it okay for them to belittle those below them.
Thankfully, medical hierarchy doesn’t commonly support such flagrant abuse, and this is one of the only encounters of bullying I have witnessed. But I have experienced and observed plenty of encounters that take a cumulative toll as they subtly challenge your sense of self-worth and belonging in the medical profession.
On my first day as a doctor, I called the radiologist to organise an ultrasound. After introducing myself as the intern, I was promptly hung up on. My registrar gave me an apologetic shrug, and called to order the scan themselves, which was immediately approved.
The first patient I saw in the emergency department with chest pain was a memorably bad experience. I meticulously worked through the chest pain pathway, and nervously called the cardiology registrar, whom I’d been warned was “difficult” to refer to. I was cut off within seconds as they barked questions at me, their tone becoming sarcastic. I completely lost where I was up to and they told me to call them back when I’d worked the patient up properly, and that they didn’t have time to deal with “this”. This experience remained scorched in my mind for weeks, as I replayed how I could have handled this referral better; how I could have been better. In every subsequent referral I made to this doctor, I would fit myself into the small box they had assigned me to.
In contrast, the most confident and valued I feel as a doctor is when I work with people who are approachable, who will listen and are willing to help. When working my first set of night shifts in a hospital a few weeks ago, the registrar on duty pulled me aside to assure me they were there to help and that I could call them at any time. A consultant I’ve worked with several times recently will listen to me while I tell them about a patient, probing my understanding and helping me to construct a thoughtful and holistic management plan. These seemingly straightforward acts make me feel supported and valued; I am confident to ask questions, I enjoy work, I learn more, and I do not hesitate to seek help for a patient I am concerned about.
The existence of the medical hierarchy in itself does not account for the toxic parts of our culture that are quietly, yet methodically, woven into the fabric of our workplace. There is clear justification for a hierarchy in medicine. There must be a clear chain of responsibility for patient care. It is in the interest of patients that the most experienced doctors shape clinical decisions about diagnosis and treatment, and they have a role in communicating their knowledge and skills to their successors.
Additionally, our fear of “speaking up” within a hierarchy does not exclusively operate vertically, but also functions across levels. Ranjana Srivastava, a consultant medical oncologist, shared her experience of not wanting to challenge a surgical colleague’s opinion in Speaking up: when doctors navigate medical hierarchy. She wrote,
“When I ask colleagues what they would have done, each recalls sometimes harboring misgivings about another doctor’s treatment of a patient but feeling unable or reluctant to comment, even when a patient’s life might be threatened — preferring to swallow their discomfort rather than challenge another physician’s viewpoint.”
It is deeply unsettling that the most highly regarded members of our profession are reluctant to challenge another viewpoint. This is a sad and telling consequence of years of working in a system that establishes this as a norm. It starts from being ignored as a medical student, being inappropriately reprimanded for getting something wrong, being hung up on as an intern, being chastised for waking someone up at night for a reason not deemed “good enough”, and being made to feel that, contrary to calling someone out of the best interests of the patient, you are calling to give that person more work or to make their day more difficult.
It is often insidious.
Countless times I have seen another doctor hang up the phone after a perfectly polite conversation, only to roll their eyes, sigh heavily or comment on the low quality of the referral. I have done this too. This sends subtle messages to everyone around them, feeding an undercurrent of ruthless judgement, rather than constructive and open conversation.
Perhaps part of the problem is a hierarchy lacking in empathy. We learn as medical students the importance of communication and of displaying empathy to our patients. Yet we often forget to exercise this as diligently within our own ranks. We quickly forget what it is like to be new, to be junior, to walk onto a ward with 20 patients you’ve never met, to be working in the middle of the night and seeking advice regarding a management plan, which may seem trivial in the light of day. Or perhaps you have a sick child at home, you aren’t familiar with this branch of medicine, you are feeling stressed, or you’ve worked many hours of overtime. Perhaps it is something from that list, or another quirk of being human, that is the reason the person on the other end of the phone doesn’t deliver a perfectly formulated handover, question or referral.
Ultimately, everyone can suffer from the harsh culture ingrained in the organisational hierarchy of medicine. There is evidence to suggest that it leads to poorer outcomes for patients (here and here) and it has a negative impact on the morale and satisfaction of doctors (here and here). Getting “thicker skin” and increasing resilience is a way of further deepening the groove, by establishing the way we experience our place in the hierarchy as an unmalleable rite of passage that one must navigate; one that we have no agency to change. And if you are unable to, well, that is a reflection of you, not of the system in which you are working.
Let us try to weave empathy, kindness and respect into our organisational hierarchy. The onus falls on every person working in it, but particularly on those in more senior roles, who have an influential role in moulding the tone of a workplace. Treating each other kindly and with empathy should not be an abstract goal, or too much to expect. Rather, it should be something we actively pursue and hold ourselves to account, for our own sake, for future medical professionals and for our patients.
The author is an Australian junior doctor.
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 so stated.
Dear Joe Moloney,
I’m sorry to hear about the horrible experience with your son. This is one of the most shocking things I have read on these threads. I cannot imagine the pain that this must have caused. I hope your son was ok and that you and your family have recovered from the trauma. Thank you for sharing.
We are all human and we all have lives outside of medicine. We can all get overwhelmed. I think the experiences you describe actually support the author’s contention. Bad things happen to us and our families. We need understanding and compassion. I’m sorry that people were rude and disrespectful to you, especially when such terrible things were happening in your life outside the public hospital.
Despite having bad things happen to us, we should try and treat others with the compassion with which we would like to be treated. If we are unable to do this, then some respite from work may be required.
If the allostatic load is too much we cannot perform at our best. We are more likely to belittle or bully a colleague. In these circumstances sick leave and professional help may be needed. If not only to provide time to work through the problems, but also provide some breathing room.
I hope you never again have an experience like the one you described and that you can see how acting compassionately will help your colleagues. After many stressful encounters you have ample experience to empathise with your colleagues despite their rank.
Kind regards,
A TMO
Many truths in this article but I fear hierarchy is a necessary evil and in the process to fix some of these issues the pendulum has swung way too far.
And it compromises patient care when a junior dr, or even med student, is now of the opinion that it is appropriate to ignore or even belittle Consultants such as referring GPs over the phone or in writing.
It wastes time and damage care when the only option, after speaking to a succession of juniors, is to track down their Consultant and insist on correct clinical care.
It is a sad day when junior colleagues are so focuses on the “you are not the Boss of me” mentality and happily compromise patient care just to make that point – something, as a Consultant GP with decades of experience, I increasingly experience when trying to organise care for my patients
To the comment from Joe Maloney. There is ample data, and it has been highlighted to you.
I have sat and passed specialist viva exams, and whilst you need to be very clear in your convictions around answering questions, you do not need to do any more than that.
There is no place for belittling trainees, demeaning junior doctors or humiliating medical students in our profession. To subtly imply that it may just be their “sensitivities” is childish and binary. “It’s not my problem that they got offended, they are too sensitive”. Medicine IS changing, and people rightly expect more. They expect consultants to lead, be empathetic, display humanity and to nurture trainees, as well as deliver excellent patient care.
To the commenter above who finished with “Final plea: instead of endless Dorothy Dix fumes of hurt feelings reaching for lazy and often misandristic conclusions, GET SOME CLEAR DATA. (Please?)”: here is some clear data: Prevalence of bullying, discrimination and sexual harassment among trainees and fellows of the college of intensive care medicine of Australia and New Zealand (Critical Care and Resuscitation 2016): The overall prevalences of bullying, discrimination and sexual harassment were 32%, 12% and 3%, respectively. The proportions of Fellows and trainees who reported being bullied and discriminated against were similar across all age groups. Women reported a greater prevalence of sexual harassment (odds ratio [OR], 2.97 [95% CI, 1.35-6.51]; P = 0.006) and discrimination (OR, 2.10 [95% CI, 1.39-3.17]; P = 0.0004) than men.
Would the commenter accuse the data of misandry?
The answer to the canary that dies in the coalmine is not to get a tougher canary but to remove the toxin.
We in Medicine are all ‘conflicted’ – Do we work for monetary reward, an elite lifestyle, power over our colleagues and patients; or do we work in Medicine because we care about other human beings?
Our health system is becoming more destructive and nihilistic; How much more could we achieve for our patients if Medical Professionals worked collaboratively and nurtured each other?
Nurse here. During the start of COVID, our consultants had monopoly on everything about infection prevention in our ICU.
Once, a consultant sends an email around saying, “I have read this from a single journal article, blah, blah” and his suggestions gets done right away with our NUM facilitating everything.
At about the same time, a group of senior nurses suggested something about OH&S, and they were told to submit to a formal letter of request with accompanying literature review.
Bullying some senior medical staff does not just affect young doctors, but basically everyone they see below them. Something was definitely wrong with how they were trained.
Speciaist training should include some ‘pilot training’ the grace to extend understanding and responsibility from pilot to co-pilot, could have prevented many air crash investigations.
It’s amazing any patient care is delivered under these circumstances. Patients can pick up on the uncertainty and worry. It also fosters a defensiveness when junior doctors interact with patients, particularly when patients ask questions for fear of being wrong. That doesn’t help the patient. Saying to someone “I don’t know right now, but I’ll find out” comes across as more authentic.
Yet throughout this article, the old adage “a bad workman always blames his tools” comes to mind when someone teaching another person has difficulties in doing so. The problem of the hierarchy is that is fosters systemic problems that hide away. Not speaking out ultimately makes the workman think he’s right, time and time again. And people who are bullied are likely to bully others. The negative cycle perpetuates itself and is maintained by the hierarchy.
Patients live in a system, health care is a system, learning and training is a system. Education on these systems is needed and ways to navigate. Both to foster growth and support and to call out bullying.
Life is complicated, some of us more sensitive than others, and the list of hurtful incidents listed here deserves sympathetic handling. But ohboy! The inconsistencies! Every system needs a hierarchy of command; yet when the boss expects a worked up case, that’s bullying? (What if s(h)e’s got a difficult situation mid consultation – I’m sorry Mrs K but you’ve got weeks to live . . ; or he’s 2 hours late due to the morning’s complication in theatre; or the AMA legal dept is telling him to settle a vexatious case; or his son’s just shot himself – which happened to me once . . or his wife’s just run off with the anaesthetist ????) SURELY there should be more evidence of life experience when you decide that being hung up on should be called bullying! I can name 2major incidents – thankfully not relating to patient care – when a junior doctor became almost irrationally angry at me with no justification and misunderstanding – once I’d been sleep deprived by hours at a private hospital, too tired to even undress at home, flopped into a comfortable armchair, when I was rung by the public hospital registrar for advice: I can’t even remember what I said, being likely asleep, but she berated me in public later for being arrogant and a bully (WTF?). And the article comments on at least one consultant who was empathetic, then heads off into grand generalisations about toxic culture – sorry, not a consistent thesis: you need more data to be able to claim that.
Have you ever experienced a specialist viva exam? The expectation is you must stand your ground and deliver to tough examiners: it’s not a picnic! Perhaps that “bullying” consultant was simply preparing that registrar.
There! I bet that sets a cat among a few pigeons!
Final plea: instead of endless Dorothy Dix fumes of hurt feelings reaching for lazy and often misandristic conclusions, GET SOME CLEAR DATA. (Please?)
Perhaps the telling summary is the “kindness and support displayed by most of my colleagues” with (fortunately) a minority of personality disordered attack dogs.
I get the same feedback from my daughters in retail and teaching, as well as friends in banking, law, accounting, and various trades. Unfortunately, such brutal people are seen as ‘strong’ – the mean, greedy and xenophobic Queensland premier has just been voted back with an increased majority by her mean, greedy and xenophobic constituents. Happy to take federal taxpayer subsidies for decimated tourism, hospitality and entertainment sectors, not happy to let dirty federal taxpayers come and enjoy those facilities. Happy to let NSW babies die because Queensland hospitals are for Queenslanders. Happy to ban an ACT nurse from visiting her dying father.
The WA premier regards the rest of his fellow Australians as a dirty, inconvenient and unnecessary burden. And remains popular for his Strength. Like the original Man of Steel, Joseph Stalin, he is not for turning.
And when a popular boss like Australia Post’s Christine Holgate rewards staff for doing good work, she gets bullied into resigning, by the PM with the full support of the Opposition and the media.
Many of the bullies Dr Anon encounters probably self-rationalise in similar fashion, ‘by bullying you I am protecting my scan staff / cath lab from overwork, I am sharpening your clinical skills’, etc.
Like all hyperbole, there is an element of truth behind the statements of bullies (even pollies) who criticise the doctor who “doesn’t deliver a perfectly formulated handover, question or referral.” My father died aged 59 because (inter alia) a junior doctor wrote an incorrect history on a request form, a radiologist gave an incorrect diagnosis based on the inadequate history, and an oncologist who read the report instituted palliative treatment for a curable condition. 800 Victorians have died because, without wishing to prejudice a multi-million dollar enquiry, it seems no-one asked whether the highly disciplined ADF personnel would be a better option than untrained security guards.
The question of doctors being “reluctant to challenge another viewpoint” should be easily soluble. When I started at Uni, the orientation week stalls had the Spartacists next to the Young Liberals, the divers and the climbers and the Marxists and the Evangelical Union in one great hodgepodge of polarised opinions. Prof Sam Carey of UTas Geology faculty was once asked what message would he write in big letters on a building’s exterior. It was simply: “Question Everything”. Universities can show that different opinions can co-exist respectfully, and be discussed with emotional fervour and robust reasoning. Opinions can be reinforced or reversed. A University that fails to enlighten its students about respectful disagreement should be summarily closed.
At a practical, hospital level, in my Hand Surgery Unit we meet every week, and review every patient who has had an operation. The audit role would identify a surgeon who has gone mad and is doing inappropriate procedures. The teaching role is that the resident is asked the simple questions: “How would you manage this fracture in the ED?”, the fellows and registrars get the curlier questions, and the consultants all get input into our management. It is respectful, not adversarial.
The trainees learn that in the real world, there are sincere differences of opinion between colleagues about which suture or screw is best, whether endoscopic or open surgery is indicated, incision versus excision biopsy, and so on. Everyone gets a chance to give an opinion or ask questions, the trainees hear the consultants’ reasoning for their often divergent views, and hopefully the junior doctors see that there is a toolbox of therapeutic options, and develop their own toolbox from which to select the optimal tools for their future practice.
As for the “cardiology registrar, whom I’d been warned was “difficult” to refer to”, the best revenge is not referring any patients to that doctor when you are both in specialist practice!
An incredibly true and well-written piece. I could have written it word for word myself from experience (but not nearly as eloquently!). I am now a ‘senior’ doctor myself but it still feels very raw the memory of bullying experiences as a trainee – on several occasions I did speak up and was torn to shreds before a theatre full of staff (who later showed their support of me). It taught me only how important it was to be the change I wanted to see when I myself became the senior person in charge. I now adore having trainees and nurturing them, hoping to teach them that these vital relationships in medicine can and should be different. There are plenty of great people in medicine but the few that perpetuate the behaviours of old and feed off their diminishing of their junior staff need to be called out, and they need to know that those days are over. I think the change is coming.
Yes, it happens in nursing too, way all too often. Thank you for this article, so very much appreciated. Kaete Walker. RN; BA
If it is any consolation , Dr Renaut is not alone with his regrets. Despite the fact that some saints do rise to the
leadership roles they deserve , there are plenty of examples of the Dunning Kruger principle ….. or worse.
Of course , one thing that the bullies , manipulators , bludgers , blockers ,self promoters and even talented
sociopaths can never take away from us is the undeniable satisfaction derived from striving to do the absolute best
that we could for the patient. Probably that’s what matters most in the end. At least , that is what I try to concentrate
on ……
As to how to improve things …….. that is a big topic. But more empathy for our junior colleagues, for sure.
The hierarchy of bullying and the stresses it places on younger doctors in training became one of the topics discussed at an Australian Federation of Medical Women Saturday Forum recently – in light of the recent Physician and General Practice Colleges’ online exam debacles. Doctors in training are powerless to change the system, vulnerable to victimization and harassment, and subject to career sabotage if they dare to raise a complaint and are seen as whistle-blowers. It is up to those of us in our later career years, senior positions or retirement to act as champions on their behalf and to change the system from within. A Medical (or Health Professions) Ombudsman in each state or territory is sorely needed.
A heartfelt thank you for every word you have written.
Thank you for a well written article. I agree that the culture needs to shift massively. In my opinion, there may be hierarchy for decision making when time is critical (rarely needed) but there is no hierarchy for knowledge. Any level doctor may surpass or under perform relative to a colleague at any time. We should share and harness all insights and knowledge without hierarchical boundaries. I believe this is our best hope for minimising human error. However, I’d like to offer a caution. Let’s be kind to all as we call out their poor behaviour. As you say, we don’t know why it is being done, how conversely vulnerable or unaware the perpetrator is.
Most junior doctors, including myself , blamed ourselves when bullied and picked on during meetings or teaching sessions ‘for leaning purposes’, it was always brushed off as ‘ it is the culture’. We rarely speak up as we are too scared or repercussion. If we muster up the courage and do speak up, we are told ‘may be you are being sensitive’ or ‘you misunderstood the situation’. Once I was told to ‘let it go’ as there was only a few months left to the rotation and to avoid running into the bullying person during that time!! And if the bullying behaviour was very clear and happening repeatedly , I was told ‘your supervisor is stressed due to This and that and she probably didn’t mean it’. It went on for months and months till I ended up leaving the place just to avoid being bullied as I don’t know where or who else to turn to or speak to. Unfortunately, the anti-bullying policies won’t work if the people in the department/hospital really want to acknowledge there is bullying and try to tackle the problem even if the bully is your close colleague/friend. We all need to fight this toxic culture , each and everyone of us whether you have been bullied or not.
It seems the majority of hierarchies behave in this manner .Being a registered nurse for 40 years it was rife in the 70’s worse in some cultures outside of NZ. But it continues today, we thought naivley it would change with university training however academic snobbery added to the dynamics amongst peers and worse in management.
I now believe that there are many toxic workplaces in the medical and nursing arena’s .I do regret spending time in this area .The places I did not experience this treatment I could count on one hand , mainly in another country.
Interesting that since the 1990s, communication skills and empathy have been highly regarded qualities for prospective medical students and prioritised in selection interviews. And yet we see that modern doctors may not be any better at these important skills ( as suggested by this opinion piece, and supported by my own observations ) than their older counterparts who entered medicine purely on academic results. These attributes may be more a reflection of underlying personality traits, a spectrum of which is seen in Medicine just as in the general community . We have known for some time that prospective medical students can be coached to pass selection interviews ( as well as the UMAT/GAMSAT tests) , which brings into question the validity of the whole selection process. We have all seen many academically brilliant and talented young people missing out on selection. into Medicine. In my opinion all medical schools should be graduate schools, with academic grade point averages the main selection criteria. Teaching of interpersonal skills and inter- professional relationships should be part of the course.
Excellent article…should be compulsory reading for ALL medical staff, particularly those in teaching hospitals who often have a misplaced sense of self importance.
Step into the shoes of a medical administrator trying to improve things in a systematic manner. Feel the unwarranted, rude and personal abuse.
Thank you so much for this honest and frank opinion piece.
As a senior doctor, I too notice this (far too often), and wonder why it continues. It can change, but even senior doctors are scared to speak up, and if they do, they can face a similar aggressive response or even be threatened with dismissal. There is a code of ethics for both physicians and surgeons but really this is not widely implemented I think this sort of thing has become so ingrained in medical culture that people forget what it is like to be kind…..and also everyone becomes so very tired by years of competitive and small-minded behaviour that they don’t have the energy to fight it. Unions are a help and can provide much-needed anonymity, but have been denigrated and marginalised by such cultures.
I think we need an Ombudsman at a Health Service level in each state, but he/she would also need some teeth, and be supported by hospitals which actually really believe in a new culture rather than paying lip service and squeezing staff to do more with less.
You, as the juniors, are absolutely right to speak up and to continue doing so. Together, we have a chance. Most doctors are not really intending to be cruel – they’re just passing on learnt behaviour which has become second nature and which needs to be called out.
That you feel the need (wisely) to remain anonymous says it all about hierarchical interactions in medicine.
Interesting article. Surgery, probably more than any other specialty, has always been infiltrated with an absurd paternalism that still pervades even today despite RACS saying they’ve tackled bullying. This ludicrous notion that everything is controlled by a handful of individuals who have elevated themselves to a position of power, usually by doing nothing more than sitting on endless committees. It’s usually to compensate for being an extremely average clinician and a spectacularly deficient personality. Explains why, for example, very little meaningful clinical research is done, resulting in such a slow advancement of science. How someone can occupy a public hospital position for 30 years and not contribute to a single clinical trial is simply beyond comprehension. Yet it is the rule not the exception. Disgraceful.
Being associated with these people is my one big regret in going into the specialty and it represents a totally wasted opportunity for me to do something meaningful within the profession.