Bullying among doctorsBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d2403 (Published 16 April 2011) Cite this as: BMJ 2011;342:d2403
Bullying can compromise patients’ safety. Lorna Powell suggests ways to reduce its incidence in healthcare
Bullying affects up to half of people in the United Kingdom at some point during their working lives and is common among healthcare employees.12 Doctors are no exception, and it is a problem faced in particular by many medical students and newly qualified doctors in the UK and internationally.34 When the British Medical Association asked a group of students if they had ever been the victim of bullying, intimidation, or discrimination while at medical school, more than a third of those questioned felt they had experienced such behaviour during their training.1
“Undermine, humiliate, denigrate or injure”
The UK Advisory, Conciliation and Arbitration Service (ACAS) specialises in workplace relationships. It defines bullying as “offensive, intimidating, malicious or insulting behaviour, an abuse or misuse of power through means intended to undermine, humiliate, denigrate or injure the recipient. Bullying or harassment may be by an individual against an individual (perhaps by someone in a position of authority such as a manager or supervisor) or involve groups of people. It may be obvious or it may be insidious.” Bullying can take many forms (box).
Types of bullying
Spreading malicious rumours or insulting someone (particularly on the grounds of age, race, sex, disability, sexual orientation, and religion or belief)
Copying memos that are critical of someone to others who do not need to know
Ridiculing or demeaning someone—picking on them or setting them up to fail
Exclusion or victimisation
Overbearing supervision or other misuse of power or position
Unwelcome sexual advances—touching, standing too close, display of offensive material, asking for sexual favours, making decisions on the basis of sexual advances being accepted or rejected
Making threats or comments about job security without foundation
Deliberately undermining a competent worker by overloading and constant criticism
Preventing individuals progressing by intentionally blocking promotion or training opportunities
Bullying among children is often easy to identify, but in adults techniques become more sophisticated. At medical school the combination of young adulthood and high intelligence can make for a particularly unpleasant brand of bully. The process can be subtle and go unnoticed by other students and teachers. In its early stages, bullying can go unnoticed even by the victim.
One trainee surgeon explained how his medical school career was defined by teasing from other young men on the course, “I laughed along and accepted my ‘figure of fun role’ and thought it was just a part of some friendships.” He says it was only after a few years he realised that the repeated jibes had damaged his self confidence and that the behaviour of his colleagues amounted to bullying.
The American Academy of Child and Adolescent Psychiatry says that bullies often choose victims who are passive, easily intimidated, or have few friends.5 Discrimination on the basis of personal characteristics such as race, age, sexual orientation, and sex is also common. Female medical students describe bullying more often than their male counterparts,1 although this could be because they are more likely to report incidents they feel unhappy about.
The UK National Workplace Bullying Advice Line believes that bullying is generally a behavioural response to social insecurities. Often bullies want to attract attention and to be held in high regard by those around them—highlighting other people’s shortcomings is one way to achieve this. Jealousy is another common feature, as is a sense of superiority and a need to prove this.
Doctors are high achievers. The grades needed to get an interview for a place at medical school mean that successful applicants are likely to have been top of the class throughout their school years. For many doctors the initial weeks and months of training are the first time they have been surrounded solely by colleagues of similar if not superior academic prowess.
This new environment can make certain trainee doctors eager to stand out from the crowd, and some use underhand techniques to gain academic recognition. US medical students refer to overcompetitive colleagues as “gunners.”
Previously many medical schools operated “norm referencing” systems—taking in a larger cohort than the number of degrees they would eventually award so that students had to compete against each other to qualify. Medical educators once thought such systems produced better equipped, more knowledgeable doctors as they gave students more of an incentive to strive for success. But the line between healthy competition and bullying is often difficult to define. Medical schools in the UK now regard competitive progression systems as outdated as they create unnecessary friction between students.
Anonymous examination and assessment results were also introduced around 10 years ago in the UK. Phillip Bradley, director of medical studies at Newcastle University, said that although this step was primarily designed to protect students from marker bias, it has also reduced competition and the bullying it might inspire.
UK medical schools must now rank students on the basis of their grades as part of the foundation programme application process introduced in 2005. Dr Bradley explained: “Previously students just had to prove their competency in order to pass. Unfortunately I think the introduction of the foundation ranking system has put students back in direct competition with each other.”
Most anecdotal reports of bullying in medical school take the form of exclusion or verbal abuse from other students. Some trainees, however, report feeling intimidated or upset by senior doctors and other people responsible for their training. One survey in the United States found that this type of bullying is most common during clinical rotations and particularly in specialties such as surgery and obstetrics and gynaecology.6
Some medical students and junior doctors believe that their seniors view training as an initiation rite and that this somehow justifies bullying and harassment as a feature of undergraduate medical education.1 Many doctors recall rounds of quick fire questions from a terrifying consultant as a mainstay of their training.
The BMA condemns this public humiliation approach to teaching, but these methods are still reported by British and overseas students. Matiram Pun studied in Nepal and describes intimidating teaching methods as “routine practice” in South Asia. He recalls insults made in front of patients as being particularly damaging. In Nepal students and trainee doctors are heavily involved in care of patients, meaning that derogatory comments made by senior staff affected patients’ faith in his abilities and seriously undermined his confidence.
The Joint Commission (an organisation that accredits healthcare providers in the US) issued an alert in 2008 warning that offensive and hostile behaviour among healthcare professionals not only makes for an unpleasant working environment but can also pose a considerable threat to patient safety.7 The commission did a series of psychological studies that proved that being the victim of rudeness or even witnessing a colleague being insulted can impair cognitive skills. Those exposed to such behaviour performed significantly worse on memory and creativity tasks than their control group counterparts.
Karin Purhouse, chairwoman of the BMA medical students committee, said that intimidating methods of teaching are unacceptable and outdated. She added: “Learning through fear is definitely not helpful and not good for the self esteem of the student. Also, looking forward, those students will go on to be teachers themselves, and I think it’s really important to reinforce positive teaching methods for the benefit of future medical education.”
The transition from student to doctor brings with it a whole new set of workplace relationships, and the high pressure environment in many clinical departments can create a breeding ground for bullying. In many cases bullying behaviour experienced by junior medics is perpetrated by other doctors in a pecking order of seniority, although nurses and midwives are also sources of negative behaviour.8 The relatively transient, short term nature of doctors’ training placements can also perpetuate bullying because permanent staff feel in some way superior to the junior doctors they work with.
Large organisations like the NHS are usually keen to resolve cases of bullying among their staff. Gareth Brahams, an experienced employment lawyer, said that NHS trusts tend to be especially procedural about the investigation of bullying. Brahams added that this very reactive system immediately creates a victim and a perpetrator, sometimes erroneously: “The person who has made the grievance claims the victim status . . . but actually it could well be that the alleged perpetrator has put up with years of bad behaviour from someone and has finally reacted in some minor way.”
One doctor experienced this first hand as a foundation year 1 doctor in a major teaching hospital. He was working with another junior doctor who was not doing a fair share of jobs on the ward. The doctor, who does not want to be named for fear of negative effects on his future working relationships, said, “I was struggling to cope with a nearly doubled workload so took the colleague to one side and professionally explained the situation.” The next day he was accused of bullying in the workplace and had to defend his actions in front of a disciplinary panel.
The foundation year 1 doctor believed he was right to raise his concerns, as patients’ safety was being compromised, but after the wholly unpleasant experience he ended up wishing he had just kept quiet.
Brahams explains: “Employees who make complaints in the interest of patients are often junior doctors and nurses. They’re absolutely right to complain, but once you’ve seen what happens to people who do, it rather puts you off doing it again unfortunately.”
One way to reduce bullying in the medical profession is to instil good professional behaviour in students before they qualify. John Brockman, president of the American Medical Student Association, said: “Encouraging students to respect their classmates is really important as it is likely they will treat their future colleagues in a similar way.”
Doctors’ organisations encourage any doctors who believe they are being bullied to inform their institution or a senior member of staff. Although many victims of bullying find it difficult to approach official bodies, intimidating behaviour in the workplace is never acceptable. For doctors the negative effects that bullying can have on patient care make its eradication all the more vital.
Competing interests: None declared.
From the Student BMJ.