Confronting unprofessional behaviour in medicine

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/