Confronting unprofessional behaviour in medicine
BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k1025 (Published 07 March 2018) Cite this as: BMJ 2018;360:k1025
All rapid responses
A great pleasure of my working life was to offer A level students work experience.
I asked each one what they thought was the most important quality of a doctor.
The most frequent responses included caring, compassionate, knowledgable,
hard working etc etc to which I would respond 'Like Shipman?'
I was therefore pleased to see that Shapiro defined professionalism as
'behaviours that support trustworthy relationships'. For me, trustworthiness
has always been the most important quality of a health professional.
However, Shapiro would seem to contradict herself later when she asserts that
'everyone deserves respect'. Respect should be earned by professional behaviour,
and not considered an automatic given of knowledge, status etc, This cultivates
humility and guards against arrogance.
Competing interests: No competing interests
Dear Sir/Madam,
Barry Schwartz (1), “There is a reason for hope. People want to do the right thing, in the right way, for the right reasons. This type of wisdom is within the gift of us all if we would only pay attention to what we do and how we do it. Most importantly we need to pay attention to the structure of the organisation (system) in which we work, so we can ensure that it enables us to develop practical wisdom rather than suppress it”.
This editorial on tackling unprofessional behaviours follows on from the article on the anti-bullying campaign that has recently been launched by the RCOG and RCSEd. I fully support the message and sentiment that there is no place in our profession for this type of behaviour, and applaud any campaign that further raises awareness of the growing body of evidence behind the repercussions to both ourselves, and to our patients, when it occurs. Though I would agree that we have a collective responsibility to address these issues, it feels that both the editorial and the campaign appear to shy away from asking why the medical profession is currently exhibiting such a high rate of disruptive behaviour.
In the same way that we do not come to work to make errors or to cause harm, it is rare for staff to come to work to intimidate, undermine or cause harm through our behaviours. This is a far more complex issue then merely challenging unwelcome behaviour and asking people to behave in a more professional manner, though this may be a good starting place for some.
The intense pressure we work under, in a system that simply cannot cope with the demands upon it, leads directly to the symptoms of decreasing reserve and increasing burnout that are currently affecting our profession. To neither scrutinise nor address the root causes of bullying means we are perpetuating a myth that the current situation is a healthy work environment. We have normalised high stress work environments where both emotions and workloads regularly run at near fever pitch. The system within which we now work is in perpetually stressed - is it any wonder that many of us working within it are distressed? To ask people to consistently behave in rational ways within such environments is, in itself, simply irrational. No amount of training has prepared us for coping in today’s NHS. This inevitably spills out into our everyday interactions.
We are being told that lapses in colleagues’ behaviours need to be reported, challenged, confronted but factors such as burnout, suicidal thoughts, poor workplace morale, staff shortages are as much contributing factors to these lapses as they are consequences of the disruptive behaviours. We all have lapses of judgement – we are after all human beings as well as doctors.
Our tactics around approaching disruptive behaviour do not need to be heavy handed to achieve positive results. As far back as 2009 Hickson et al (2) improved patient safety through addressing what he termed “disruptive behaviours”, with a “cup of coffee” conversation. His research showed that when a disruptive behaviour was addressed quickly and compassionately in an informal setting, 60% of doctors changed their behaviours with all the benefits of improved care and team working described in Civility Saves Lives.
What might be a more effective approach?
We need a combination of ideas and practices that spark the desire to change our work culture. Ideas that speak powerfully to who we are and to our aspirations as healthcare professionals include: Learning from excellence (3); compassionate governance; appreciative leadership; development of emotional intelligence and self-awareness; and Civility Saves Lives (4) – when we are respectful and kind to each other we bring out the best in our teams and we perform at our best as individuals.
These approaches promote respectful and compassionate behaviour to each other, which we know enables us to deliver excellent compassionate care to our patients. We need to create environments that allow the people within them to flourish.
Our challenge is not each other, but the system which dehumanises those within it, squeezing the compassion and resilience from us. These issues are simplified at our peril and to the detriment of our profession. We are more than just professionals, we are human beings, and we all need the right environment to perform at our best.
Dr Shewli Rahman
1. https://www.ted.com/talks/barry_schwartz_on_our_loss_of_wisdom
2. https://news.vanderbilt.edu/2016/04/21/medical-professionals-can-change-...
3. https://learningfromexcellence.com/
4. https://www.civilitysaveslives.com/
Competing interests: No competing interests
I wonder if the current lack of response to this article may infer the complicity of many doctors in what has up to now been ingrained, normalised acceptable “unprofessional” professional behaviour. Bullying, intimidation, and sociopathic behaviour, has been entrenched within the profession with peers and colleagues standing aside and through their own inaction, also too sadly therefore becoming “part of the problem”.
To make a concerted change to this becoming unacceptable “unprofessional” behaviour may require a me too hashtag change of mindset by the profession. as a whole.
Competing interests: No competing interests
The Mentor - Trainee Relationship
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The milieu of medical training is unique in that the mentor - trainee relationship acquired voluntarily or otherwise during the formative years is a significant component in the professional behavioral pattern of each member of the medical profession. Teachers are the models.
Sustained, deliberate efforts may inculcate appropriate professional behavior across the profession. It is an achievable goal. A worthy effort indeed !
Competing interests: No competing interests
The common and lame excuses people use for unprofessional behaviour
I appreciate how this editorial encourages confronting unprofessional behaviour in medicine.<1> However, it does not address what happens if the offenders skilfully make excuses to defend themselves. I recently came across the British Medical Association website, which posted the Secret Doctor’s encounter of rude and unprofessional behaviour by her registrar.<2> The Secret Doctor’s co-worker said this registrar speaks rudely to everyone. Although that was meant to comfort the Secret Doctor, it also sounded like telling her to simply move on and avoid taking things personally. This incident illustrated a lame excuse people use for unprofessional behaviour: just because one is not intentionally targeting an individual, it is justifiable to continue the rude behaviour.
In the same post, the Secret Doctor’s co-worker stated her registrar’s stress at work was the culprit of his rudeness. Isn’t this another lame excuse to justify rudeness? As this Secret Doctor rightfully suggested, people should pick a speciality with fewer emergencies if they cannot keep their composure.
The post mentioned how the Secret Doctor’s intellectual input to the team could be wrongly perceived as calling shots. The Secret Doctor rightfully stated her input was meant as a team approach to problem-solving. Nevertheless, her seniors could argue that her behaviour is disruptive and disrespectful. They can put negative feedback in her end-of-placement evaluation, complain to her supervisor, and accuse her of lack of resilience.
It is insufficient to tackle unprofessional behaviour if we are simply expecting the juniors to independently speak up. I agree with this editorial’s view on safe and fair processes for reporting concerns. However, I would like to see more detailed suggestions on how to handle the common excuses offenders use, such as claiming they are treating everyone equally, working under stress, and blaming others for over-reacting.
References:
1. Shapiro J. Confronting unprofessional behaviour in medicine. BMJ. 2018;360:k1025.
2. The Secret Doctor. ‘He speaks to everybody like that’. he shouldn’t. London, UK: British Medical Association; 2017 Sep 4; cited [2018 May 12]. Available from: https://www.bma.org.uk/connecting-doctors/b/the-secret-doctor/posts/he-s....
Competing interests: I have been paid for working as a medical doctor, but not writing this letter.