Confronting unprofessional behaviour in medicineBMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k1025 (Published 07 March 2018) Cite this as: BMJ 2018;360:k1025
- Jo Shapiro, director
- Center for Professionalism and Peer Support, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
Revelations about harassment and bullying in different working environments continue to make daily headlines. Medicine is not exempt: we have tolerated and continue to tolerate behaviour that harms each other, our patients, and our relations with society. The solutions will need to come from within the medical profession because the context and culture of our work are unique.
In a wider sense, the problem can be framed as one of professionalism in the workplace. Professionalism is an umbrella term to define behaviours that support trustworthy relationships. Unprofessional behaviours range from criminal, such as sexual assault; non-criminal but illegal, such as sexual harassment; and disruptive, such as bullying, which is not illegal but harmful and unacceptable. I will focus here on non-criminal behaviours.
Many people have examined the definition of medical professionalism as well as the sociological contexts and prevalence of unprofessional behaviour.123 But we face great challenges in preventing recurrent unprofessional behaviour. We urgently need to meet these challenges more effectively.4
Understanding the effects
In handling reported concerns of unprofessional behaviour involving over 400 health professionals, I have rarely met anyone who intended to demoralise or intimidate. Yet that is precisely the effect their behaviours have had on others. What matters is the effect, not the intent. Unprofessional behaviour can be devastating and can affect patient safety and quality,567 the clinical learning environment,8 and the wellbeing of the healthcare team.9 Over time, this may contribute to clinician burnout10 and even suicide, as well as to poor workplace moral and reduced productivity, retention, recruitment, and institutional reputation. This harm is often hidden but truly costly.
Even the most prestigious professionals must be held accountable for unacceptable behaviour such as harassment, humiliation, or intimidation of learners and other members of the healthcare team. We have rationalised our tolerance of these behaviours in numerous ways: the offenders are highly intelligent or technically competent or world renowned experts; they bring the institution a great deal of revenue; they have high standards for everyone, including themselves; they are trying to educate and improve others’ performance; they are patient advocates; their victims and targets have their own performance problems; the behaviours are caused by systems problems. Although all of this may be true, none of it justifies unprofessional behaviour.
In addition, many of us are fearful of facing harassers and bullies. As victims, bystanders, and leaders, we fear retaliation, byzantine processes for investigating concerns, exhausting counterattacks, and institutional resistance to this major culture change. Given the hierarchy in medicine, it may be a serious career risk for a subordinate to give direct feedback to a supervisor; therefore, we must have safe systems to report concerns. Hierarchy should be that of responsibility, not of respect—everyone deserves respect.
In the past, we may have been unaware of how destructive and dangerous such behaviours were, both to patients and to the healthcare team, including vulnerable learners. But given the unassailable data on the damage of such behaviours,256789 we can no longer turn away. Cognitive and technical competence is not sufficient and can never outweigh the responsibility we each shoulder to behave professionally and to hold ourselves and our colleagues accountable.
Meeting these challenges requires institutional will and collective responsibility. For prevention, we must set clear expectations for behaviours, including the responsibility to confront or report colleagues’ lapses of professionalism. It is especially important to determine whether there is a pattern of unprofessional behaviour and if the behaviour is illegal, egregious, or both. We should train healthcare providers in skills such as giving difficult feedback, conflict management, and combating unconscious bias. We need to create safe, accessible processes at the local level for reporting concerns and have a process for assessing the validity of the concerns; the process needs to be fair to both the reporters and those accused.11
We should give feedback so that the individual has an opportunity to improve, focusing on behaviours not on character or diagnoses. We should listen with compassion to the response to feedback, including what the triggers and contributing systems issues are. Although we must work to improve systems, we must simultaneously be clear that the behaviours are harmful and must stop. It is crucial to state explicitly our zero tolerance for retaliation, as well as the process for monitoring the behaviour. Finally, we need to impose escalating consequences for those who continue to behave unprofessionally.
It is our collective responsibility to support a culture of trust in medicine.12 Just as we hope to be treated with trust and respect by our patients and society we need to uphold that trust as individuals and as a profession. The stakes are high, but the rewards are even higher.
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.