Humiliation not required

BULLYING is nothing new in medical training. Indeed, it’s almost cliché, the stuff of vintage hospital dramas and comic novels – the crusty senior consultant maltreating his lowly housemen in a benign rite of passage. But for many UK trainees it’s no joke.

In the General Medical Council’s 2014 National Training Survey (NTS) eight per cent of doctors in training reported experiencing bullying or harassment, and nearly 14 per cent reported having witnessed someone else suffering these behaviours. Even more trainees experienced undermining (18 per cent). The NTS defines bullying as behaviour that “hurts or frightens someone who is less powerful, often forcing them to do something they do not want to do”. Undermining is behaviour that “subverts, weakens or wears away confidence”.

These findings prompted the GMC to further investigate bullying in a representative sample of 12 UK hospitals where concerns had been raised. The review focused on obstetrics/ gynaecology and surgery departments, as these specialties have been identified as having particular issues with bullying and undermining. In March 2015 it published the findings of this investigation.

Stop “making trouble”

GMC visitors to the selected sites spoke to trainee doctors in small groups. Among the behaviours reported was criticism from senior doctors that made trainees feel “belittled or humiliated”. Sometimes these criticisms were made in front of other healthcare professionals or even patients. A few trainees reported outright threats of the consequences for their future careers if they didn’t stop “making trouble” by raising concerns over the quality of their training.

Other doctors in training complained that criticisms made in workplace-based assessments were not discussed constructively. This was coupled with an overall failure to demonstrate concern for their educational needs, by failing to engage with trainees or consistently prioritising clinical efficiency over training.

There were also reports of favouritism, with some trainees given access to resources (such as study leave or training opportunities) denied to others. Other concerns involved the failure to acknowledge the importance of doctors in training having a personal life or to consider their stress levels and workload.

Research cited in the report shows that “undermining and bullying in the workplace is bad for patient safety, bad for the health of those involved and bad for the quality of training”. Doctors in training who report having been bullied are more likely to have made mistakes at work and are also less likely to work well in a team – a serious issue of concern as effective teamwork is a proven factor in avoiding clinical mishaps. Perhaps most worryingly, the report states: “doctors who are bullied at work may be less likely to raise concerns they have about patient safety, for fear of the consequences they may suffer”. Nothing less than perfection The GMC investigators found that – for the most part – those consultants perceived as bullying were not malicious in intent but were most often described as “perfectionists”. They had exacting standards for both clinical performance and dedication to work and they expected trainees to live up to those standards. This led to rebukes or criticism relating to clinical knowledge or performance, or bypassing the doctor in training, ignoring them or not allowing them to perform their expected duties. As a result the quality of training was diminished, with some anaesthetists, surgeons or other operating theatre staff preventing trainees from operating so that cases could be finished more quickly. Even more demoralising, the report states that “some consultants or other staff members gave doctors in training the impression that they had little or no interest in them either as doctors in training, or as people”. The report recognises that consultants and senior doctors are often under increased pressure with rising patient demand and ever tighter resources. It goes on to highlight factors that can help mitigate a culture of bullying and undermining and can contribute to a positive and safe environment. These include:

• doctors in training feel valued and supported

• strong clinical leadership

• effective senior leadership and departmental cohesion

• appropriate time and resources for training with extra staff employed if necessary

• strong communication with doctors in training and acknowledgement of training issues.

Niall Dickson, GMC Chief Executive, said: “There is a need to create a culture where bullying of any kind is simply not tolerated. Apart from the damage it can do to individual self-confidence, it is likely to make these doctors much more reluctant to raise concerns. They need to feel able to raise the alarm and know that they will be listened to and action taken.

“We are working with those responsible for postgraduate education at local level to respond to this feedback from doctors in training. We need to develop a supportive culture that actively encourages doctors in training to feel confident in raising concerns at an earlier stage.”

Jim Killgore is an associate editor at FYi

Link:

The GMC’s report, Building a supportive environment: a review to tackle undermining and bullying in medical education and training