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Abusive culture in medical education: Mentors must mend their ways

2018; Medknow; Volume: 34; Issue: 2 Linguagem: Inglês

10.4103/0970-9185.236659

2231-2730

Tejinder Singh Swaran Singh, Avtar Singh,

Innovations in Medical Education

The discussion surrounding bullying and harassment in medicine has resurfaced in the backdrop of several high-profile sexual harassment cases in highly sought-out work environments like Silicon Valley, Wall Street, and Hollywood, and there is a push for a #MeToo movement specific to medicine as well. Bullying and harassment occur in all organizations, although rates seem to be higher in healthcare institutions, and such behavior may be more common in medical facilities.[1] Despite promising efforts, student mistreatment remains an ongoing challenge in medical education, with published studies continuing to report high rates (80%–90%).[2] Trainees, medical students, and female staff and colleagues are identified as the most likely targets.[3] Tim Field, founder of The National Workplace Bullying Helpline, warns that everyone is at risk of becoming a target of bullying.[4] Examples of mistreatment include sexual harassment; discrimination or harassment based on race, religion, ethnicity, gender, or sexual orientation; humiliation and psychological or physical punishment.[56] One of the very first documentations with regard to student mistreatment in medicine was by Silver in 1982.[7] Since the publication of this article, there has been increasing awareness of and research about medical student abuse, yet nothing much has changed in terms of the abusive culture of medical education; medical students are still being abused in the medical workplace.[8] No review to date focuses on why this problem exists or how we might find solutions to reduce workplace harassment of residents. Only after we fully understand the root cause of this problem can focus be given to implementing methods of resolution.[6] Mistry and Latoo in their review article mention that the traditional hierarchy and teaching by intimidation/humiliation may foster a culture of bullying.[4] Studies in the United States and United Kingdom have suggested that bullying commences with medical students and that this sets up a "transgenerational legacy" as behaviors of bullying are passed down.[49] Some have expressed the view that "intimidation" may be good, to motivate students to study, and may even protect patients.[2] Hospitals and professional associations sometimes foster a culture of abuse through covert sanctions against complainers or by providing tacit approval by failing to act or by discouraging change.[3] In most cases, bullying in the field of medicine is likely to be unintentional and shaped by the power of inequality in the relationships.[4] Bullying Implications For individuals, being exposed to bullying can have serious implications for mental and physical health including depression, helplessness, anxiety and despair, suicide ideation, psychosomatic and musculoskeletal complaints, and the risk of cardiovascular disease.[10] Studies have found increased alcohol consumption, cigarette smoking, and drug usage and decreased satisfaction with residency and thoughts of desertion and even rethinking on their career choice in residents faced with increased stress and mistreatment.[6] There is a clear link between bullying and the quality and effectiveness of training. A doctor in training who is subject to bullying behavior every day is much less likely to receive effective and fulfilling training.[11] Critically for healthcare, doctors who were bullied were more likely to have committed one or more serious, or potentially serious, medical errors and can hamper the ability to provide effective and safe patient care. At an organizational level, the cost of bullying can also be substantial, taking into account absenteeism, turnover, and productivity.[10] Acknowledging and Finding Effective Solutions The problem of bullying and harassment has never been addressed seriously and as a priority despite the fact that the problem is well recognized, has higher prevalence rate, and is negatively affecting the victims and healthcare as a whole. The conversation around student mistreatment reached a crescendo only in 2012 with the publication of P. Chen's article "The Bullying Culture of Medical Schools" in The New York Times. It was a poignant admission of the problem and first major public acknowledgement of the bullying culture by a member of medical profession.[12] Further on in early 2015, the public media (press and TV) published a number of stories highlighting illegal and inappropriate behavior of surgeons in the workplace.[13] Most of the large medical organizations including the Australian Medical Association (AMA) and the Royal Australasian College of Surgeons (RACS) responded to the issue and identified bullying and harassment in medicine as a priority area for change.[14] AMA President, Professor Brian Owler, said, "While the recent allegations emerged from the surgical specialty, the problems are more widespread." We need comprehensive policy, practices, and education to foster a safe and healthy work and training environment, and we must maintain appropriate standards of patient care. There needs to be a zero tolerance approach and close collaboration between all stakeholders – including employers, medical schools, unions, colleges, and professional bodies – to drive the cultural changes required to stamp these problems out. The medical profession must take direct responsibility for its culture, reputation, and standard of professionalism. The AMA, on 9th March 2016, released "Setting the standard," a strategy to overcome bullying, discrimination, and harassment in medical profession. A key part of this is the AMA Victoria Assurance – a pledge of respect and fairness.[15] In March 2015, the Royal Australasian College of Surgeons established an Expert Advisory Group (EAG). The Group was tasked with advising the College on strategies to address this problem. In the United Kingdom, the British Medical Association (BMA) has called for zero tolerance to bullying and provided a report on bullying and harassment in workplace.[3] Most NHS trusts disseminate anti-bullying policies in connection with "Dignity at work," though these need genuine implementation to rise above just being paper tigers. Diana F. Wood in her editorial agrees that it is not easy to prevent bullying and harassment in the workplace and that requires a people to moderate their behavior so that they become positive role models and demands considerable changes in institutional culture.[1] David P. Sklar in his editorial said, "I want to hearken back to the words my mother would often say after an incident of my bad behavior at home or school: 'Can't you just be nice?' But it is obviously not that simple. Some people cannot or will not 'be nice,' and it is our responsibility to identify such individuals and transform them for a conducive learning environment."[5] There are no ideal solutions to the problem but as a major bulk of these occurrences in medicine are thought to be unintentional, there needs to be a huge focus across all practice settings to educate our educators about what constitutes bullying and the detrimental effects this can have on our future colleagues. This alone will not suffice! We as educators and leaders in the medical field have to embrace the change, change our culture, and start considering students and trainees as our future colleagues. We really need to ask ourselves if we can accept ghastly behaviors with sexual advances, demoralizing overtones or humiliation. In a one-on-one discussion with our colleagues, I am positive that every single one of us would agree that it is unacceptable for us to accept the status quo. But the truth is that realizing that is not enough, we all need to empower the cultural change that needs to happen to put an end to this unfortunate and completely unacceptable practice. Let us pledge to get away from the hierarchical system and start treating our students and residents with respect. Let us ask ourselves a simple question "Who was your favorite teacher in school and what did you like about that teacher the most?" I know my answer to this question very well and the major reason why this particular mathematics teacher was my favorite teacher of all time was that he was always encouraging from the first interaction and helped me understand how not to make errors in the future. Don't we all want to be remembered by our students for traits like the one mentioned above rather than for the negatives that we are unfortunately getting known for? As professionals in what is considered among the most noble professions in our world, it is high time for all of us to mend our ways, stand up against bullying, and bring the required cultural change to eliminate this serious problem from our profession altogether. Let us all and make this profession really NOBLE!