Bullying in Surgery Catherine Ferguson

EDITORIAL

“To bully is to threaten, oppress or tease, either physically or morally, and can include: public humiliation, persistent criticism, personal insult, professionally undermining a person’s professional ability, consistently undervaluing effort and abuse of power. Bullying is not necessarily face-to-face; it may be by written communication, e-mail or telephone.”1 his statement is taken from the Royal distressing, and those who responded are to Australasian College of Surgeons be commended for their bravery in sharing T(RACS) handbook on Bullying and their stories. Harassment, which was published in 2014. Many respondents talked about the Workplace NZ defines bullying as “repeated concept of bullying as a ‘rite of passage’ and unreasonable behavior directed towards and a mechanism to ‘toughen-up’ young a worker or a group of workers that creates a surgeons for the life ahead. Indeed, some risk to health and safety.” RACS trainees surveyed acknowledged that The recent work commissioned by RACS, bullying occurs, but see it as an inevitable and reinforced by New Zealand surveys part of surgical training. However, most of both resident doctors and medical survey respondents reported that far from students, has bought the issue of bullying ‘building resilience’ for the stressful life of a in medicine into sharp focus over the surgeon, bullying behavior has resulted in past few months. However, this is by no depression, feelings of inadequacy, suicidal means a recent phenomenon, and indeed ideation and exiting from surgery altogether. The New Zealand Medical Journal and the Many young doctors have decided against NZMJ Digest have published on work- pursuing a career in surgery because of the place bullying in 2004 and 2008.2,3 A quick behaviors they have witnessed. review of the international literature cites It is well recognised that bullying in the bullying in surgery all over the world, workplace leads to poor performance, with recognition of the issues extending anxiety and absenteeism. It creates a poor back to at least the 1990s.4-6 In the past, learning environment, where trainees this has been termed as ‘uncivil behavior’ suffer from a lack in confidence and inse- and ‘disruptive behavior’, but it is time to curity in their clinical skills. Pfifferling7 accept that this is, quite simply, bullying. reported in 1999 that bullying results in The RACS Expert Advisory Group (EAG) withholding information for fear of being review found that not only was bullying bullied or criticised, not asking for help, prevalent in surgery, but also that it is an withholding suggestions, reduction in self- ongoing problem, experienced at all levels esteem, increased staff turnover, blaming in surgery, and that the consequences are others and dysfunctional teams. far reaching. As well as surveying fellows, For decades, medical training—and trainees and international medical grad- surgery in particular—has adopted the uates, personal stories were collected apprenticeship model of teaching, and this and online discussion forums provided a has been successful in producing surgeons vehicle for honest exchanges and some very with high levels of medical knowledge and thoughtful comments. Some of the infor- technical expertise. However, not only do mation shared was deeply disturbing and our young surgeons learn their surgical

NZMJ 30 October 2015, Vol 128 No 1424 ISSN 1175-8716 © NZMA 7 www.nzma.org.nz/journal EDITORIAL

craft, but also they learn that bullying and change cannot occur in a vacuum. There disruptive behavior are condoned—even are a multitude of policies and manuals valued and accepted—as ‘normal’. It is a sad gathering dust on the shelves of every fact that many of us have become desensi- organisation and institution, but policies tised to poor behavior, to the extent that it is alone—without effective mechanisms to no longer recognised as wrong. Perpetrators monitor and manage performance issues— are not taken to task for their actions, and cannot effect change. Failure to modify colleagues and employers stand by and bullying behavior should be the subject of watch. It is little wonder that we see these disciplinary action without fear of recrim- poor behaviors being repeated from gener- ination, and both professional bodies and ation to generation of our surgeons. employers should be prepared to take Medical expertise and technical expertise appropriate steps towards all health profes- are only two of the nine RACS competencies, sionals when this occurs. which also include; professionalism and The EAG has challenged RACS to take a ethics, communication, collaboration and stand against bullying and harassment, teamwork, advocacy as well as judgment, by fostering cultural change and lead- clinical decision making, scholarship and ership, and improving education, as well teaching, and management and leadership. as improving our complaints mechanisms. Until now, traditional surgical teaching has RACS is committed to answering this call, not focused on these areas, particularly but as a profession we must all take up because most of us are not equipped to this challenge and work together with our teach these skills. The focus must now shift colleagues across the whole of the health to the effective teaching of these skills, and sector—from Medical School to Colleges, to providing today’s teachers with the means DHBs, jurisdictions and beyond—so that the to achieve this. This requires both indi- work that has begun will bring about the vidual and workplace recognition of the cultural change that is so urgently required. value in teaching these skills, and ensuring that there is provision in the workplace for Lieutenant General David Morrison led training educators. In addition, trainers and a review of bullying and harassment in trainees alike need to be educated how to the Australian Army. He is famous for the provide effective and constructive feedback, powerful statement, “The standard you and the difference between feedback on walk past is the standard you accept”. It is poor performance and bullying. time for us all to heed that message and act upon it. Bullying and harassment are patient safety issues. Doctors who are subjected to “Every patient has a right to expect bullying and harassment in the workplace that their healthcare is uncompro- are not performing well and patients are mised by discrimination, bullying therefore placed at risk. Bullying may result and sexual harassment in the in dysfunctional clinical teams that fail to practice of surgery. Every surgical communicate effectively. Trainees may be trainee has a right to an education afraid to speak up when they have concerns free of discrimination, bullying and over patient safely because of the bullying sexual harassment. culture within their unit.8,9 And every healthcare worker— Many publications have discussed the including every surgeon—has culture of bullying that exists in the health a right to a workplace free of sector, and the difficulties seen in trying to discrimination, bullying and sexual change that culture. What is plain is that harassment.”10

Competing interests: Dr. Ferguson reports she is a surgeon and was a member of the RACS Expert Advisory Group looking at discrimination, bullying and sexual harassment. She is the chair of the Professional Standards Committee of RACS and a College Councillor. Author information: Catherine Ferguson, Otolaryngologist, Head and Neck Surgeon, Wellington Corresponding author: Dr Catherine Ferguson, Otolaryngologist, Head and Neck Surgeon, 70 Tinakori Rd Thorndon, Wellington 6011 [email protected] URL: www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2015/vol-128-no-1424-30- october-2015/6703

REFERENCES: 1. Royal Australasian 5. Quine L. (2002) Workplace Bullying of trainee doctors College of Surgeons: bullying in junior doctors: is a patient safety issue. Guidelines to Bullying questionnaire survey. Clin Teach 6: pp13-17 and Harassment (2014) BMJ 324: pp 878-879 9. Wild J, Joshi H, Robson 2. Kelly S. (2004) Workplace 6. Fnais N, et al. (2014) A, Hornby S, Fitzgerald Bullying. NZMJ: 117 Harassment and discrimi- E. (2015) Blowing the whistle: surgical train- 3. Scott J, Blanshard C, nation in medical training: ees’ experience and Child S. (2008) Workplace a systematic review and attitudes towards raising meta analysis. Academic bullying of junior doctors: concerns over patient Medicine 89(5) pp 817- 827 a cross sectional question- safety. BJS 102: pp 40 naire survey. NZMJ Digest 7. Pfifferling JH. (1999) The 10. Expert Advisory Group on vol 121 no 1282 pp 13-15 disruptive physician: A discrimination, bullying quality of professional 4. Myers M. (1996) abuse and sexual harassment of residents; it’s time life factor, Physician advising the Royal Austral- to take action. CMAJ Executive 25 (2) pp56-61 asian College of Surgeons 154 pp 1705-1708 8. 8. Paice E, Smith D. (2009) (2015) Report to RACS