‘You’re so stupid… you’re just so stupid.’ My consultant continues, ‘If I were your supervisor, I’d fail you for the entire term, because you’re just so stupid.’

Tears roll down my cheeks, behind my surgical mask. I blink repeatedly, trying to make clear the structures I am trying to operate on. The faster I finish this operation the faster this verbal abuse will end, but the yelling from behind me doesn’t help my confidence. I need to clearly identify the structure and cut it, but for the patient’s sake, I want to be calm when I make the definitive cut. I must first do no harm.

‘Am I going to have to scrub in for this operation?’ he asks. I don’t respond. There is no response I can give that will help. The last two hours have demonstrated that. ‘You are completely useless.’ he says, walking out to the scrub sink.

With my consultant out of the theatre, I quickly and safely complete the key steps of the operation. From here, closing the wound and putting the dressings on will be straightforward.

In an hour’s time, I will phone a senior colleague from the safety of the female changeroom. He will tell me that I need to get better at dealing with this man’s abuse. He will tell me that he can hear the shaking in my voice and that I need to be stronger. The consultant will be my supervisor in my next term, and he has told me that he will fail me for the entire term, because in his eyes I am too stupid to pass. I know that I am not stupid, but I also know that this is not about IQ, or EQ, or anything that I can control.

I was lucky. I will later learn that a bystander reported my consultant’s behaviour and some remedial action is taken. I will never know who the bystander was, and will never be able to thank them, but I will remain ever grateful for their intervention.

Medicine is a hierarchical profession. Bullying is culturally ingrained in Australian healthcare, and operating theatres have traditionally witnessed particularly poor behaviour. Hidden out of sight of the general public and human resources departments, the behaviours of theatre staff – and particularly surgeons – are constrained only by their personal professionalism and perceptions of what constitutes acceptable conduct.

I’ve heard it was worse in years gone by; that back then, surgeons threw scalpels. I graduated from medicine in 2001. I’ve seen a scalpel, and other instruments, thrown. I’ve seen theatre staff reduced to tears. Derisive comments, yelling, shouting, abuse and sexual harassment. I once took a small step backwards in a theatre corridor for my own personal safety, as I judged that if my verbally abusive consultant chose to hit me with his raised hand in front of witnesses, the extra 20 cm distance between us would improve my chances of avoiding significant physical injury. Things may have been worse in the past; that does not indicate the present situation is acceptable.

Scope of the problem

In 2015, the Royal Australasian College of Surgeons’ (RACS) expert advisory group (EAG) found that 54 per cent of RACS trainees and 45 per cent of Fellows less than 10 years post-fellowship reported being subjected to bullying, with senior surgeons and surgical consultants reported as the primary source of these problems.¹ Every year, one in six healthcare workers report that they have been bullied at least once.² In 2016, RANZCOG found that 60 per cent of Fellows and trainees that responded indicated they had been bullied in the O&G workplace, with 34 per cent indicating they had been bullied while working as a consultant.³

Bullying and other unprofessional behaviours affect the way we work, the quality and safety of the care we deliver, our mental health and our self-esteem.⁴ We need system-wide interventions to combat this quality and safety problem, and we also need to evaluate interventions to assess their success in reducing unprofessional behaviours and in improving clinical outcomes.

A study of Australian surgeons’ responses to harassment of a colleague during simulated operating theatre scenarios found that participants failed to acknowledge 30 per cent of harassment incidences.⁵ If you have worked in an operating theatre you know what this looks like. It can be unconscious, but it can also involve active adoption of ‘retrospective deafness and blindness’. The assistant gazes at the wound with rapt attention, the scrub nurse carefully cleans clean instruments and the anaesthetist displays a quiet fascination with the chart. We’re all aware of what is going on, and we’re failing to acknowledge or challenge the problem because of the hierarchy of our profession, or our conflict-avoidant natures, or because of the misconception that bullying behaviours, such as intimidation and ridicule, are necessary teaching tools. Because the perpetrators have power, and we perceive – correctly or incorrectly – that we do not have the power to change what is happening; or, not without significant personal cost.

Definitions

Workplace bullying is defined as ‘repeated and unreasonable behaviour directed at a worker, or a group of workers, that creates a risk to their health and safety’.⁶

‘“Unreasonable behaviour” is behaviour that a reasonable person, having regard to all the circumstances, would expect to victimise, humiliate, undermine or threaten the person to whom the behaviour is directed.’⁷

Bullying can be a human rights violation, affecting a worker’s right to be free from mental, emotional and physical violence, and their right to a safe work environment.⁸

Unprofessional behaviours also include discrimination and sexual harassment. While sexual harassment occurs frequently in medical workplaces, ‘doctors who have been sexually harassed or assaulted by other doctors remain a largely invisible population’ and more support for victims and research into this problem is required. Existing research suggests that victims perceived that in order to respond in a ‘professional’ manner, they should discount the event and its effects, and return to the workplace.⁹ Such idealised notions of professionalism are obstacles to addressing the unprofessional behaviours and, perversely, place the responsibility for behaviour change on the victim rather than the perpetrator.

Actions by various organisations

In the last four years, multiple organisations have taken significant steps to address bullying and other unprofessional behaviours in our workplaces and operating theatres (Table 1). Many of these seek to improve the ability of victims and bystanders to recognise and call out unprofessional behaviour, either directly or indirectly.

Table 1. Action examples from Colleges, Australian private and public hospitals, and government.

Colleges

RACS established an EAG for advice on the prevention of discrimination, bullying and sexual harassment. The EAG identified the three core areas of cultural change and leadership, surgical education and complaints management.

Following the EAG, RACS developed an educational course ‘Operating with Respect’. The course provides advanced training in recognising, managing and preventing bullying and unprofessional behaviours. It aims to foster behavioural self-regulation and the ability to moderate the behaviour of colleagues.

RANZCOG has established a Trainee Support Unit, and a train-the-trainer ‘Supporting Respectful Workplaces’ workshop, which was developed for trainees, specialist international medical graduates (SIMGs) and Fellows who are involved in the training program, aiming to ensure training environments are free from bullying and unprofessional behaviours.¹⁰

Private hospital

Ramsay Health Care Australia launched its ‘Speak Up for Patient Safety’ program, which is based on the Vanderbilt University Medical Centre model. It aims to identify and address behaviours that undermine a culture of safety through peer messenger conversations and by providing assertiveness training to staff.¹¹ Evaluation of the Vanderbilt model found that it ‘can yield improved staff satisfaction and retention, enhanced reputation, professionals who model the curriculum as taught, improved patient safety and risk-management experience, and better, more productive work environments.’¹²

Public hospital

St Vincent’s Hospital Melbourne introduced its ‘Ethos Program’, also based on the Vanderbilt University Medical Centre model.¹³ St Vincent’s Health Australia received a NHMRC grant to evaluate the behavioural accountability intervention’s outcome on patient safety in four hospitals over four years.¹³ The evaluation of any program is crucial; interestingly, one year into the Ethos Program, staff members raised concerns about ‘trivial complaints’ being made through the system, which were reported to have caused significant stress for the subjects of complaints. It was also reported that female staff received 30 per cent more complaints than male staff members.¹³

Government

Australia’s Sex Discrimination Commissioner, Kate Jenkins, is undertaking a national inquiry into sexual harassment in Australian workplaces.¹⁴

The Victorian State Government has announced an awareness campaign to reduce bullying and harassment in Victorian public hospitals. The ‘Know Better, Be Better’ campaign aims to raise awareness of bullying and harassment, actions and reporting behaviour, support and guidance, and legal/workplace/management considerations. The campaign has placed independent facilitators in two metropolitan and four regional hospitals to provide support for workers.

Avenues for change

There are multiple avenues for change, and evaluating the interventions is a key element of achieving cultural change, so we do not perpetuate the ostrich approach or provide band-aid solutions. For too long the emphasis has been on modifying the victim’s response, instead of the actions of bystanders, perpetrators and leaders. Measures to improve diversity and inclusivity in our organisations may also play a role, given that anecdotal evidence suggests victims are more likely to have attributes that are different to the prevailing cultural norm – be they related to race, ethnicity, gender identity, sexual orientation, religion or other differences.

In the last four years, we have seen significant efforts to create changes. Will the interventions make a difference to our operating theatres and hospitals? Only time and rigorous evaluation will tell. But in the interests of our colleagues and our patients, we must acknowledge and address power imbalances, bullying and unprofessional behaviours. If we want safe workplaces free from bullying, we must speak up, listen and act.

1. W Crebbin, G Campbell, DA Hillis, DA Watters. Prevalence of bullying, discrimination and sexual harassment in surgery in Australasia. ANZ J Surg. 2015;85(12):905-9.
2. Victoria State Government. Know Better, Be Better. Available from: www2.health.vic.gov.au/health-workforce/worker-health-wellbeing/bullying-harassment/know-better-be-better.
3. RANZCOG. Bullying and Sexual Harassment Survey. 2016.
4. J Westbrook, N Sunderland. The Conversation. Bullying and harassment of health workers endangers patient safety. 5 November, 2018. Available from: https://theconversation.com/bullying-and-harassment-of-health-workers-endangers-patient-safety-106167.
5. H Gostlow, CV Vega, N Marlow, et al. Do Surgeons React?: A Retrospective Analysis of Surgeons’ Response to Harassment of a Colleague During Simulated Operating Theatre Scenarios. Ann Surg. 2018;268(2):277-81.
6. Safe Work Australia. Bullying. Available from: www.safeworkaustralia.gov.au/bullying.
7. RACS. Expert Advisory Group on Discrimination, Bullying and Sexual Harassment. 2015; p.19. Available from: https://umbraco.surgeons.org/media/1018/eag-report-to-racs-final-28-september-2015.pdf.
8. Australian Human Rights Commission. What is bullying?: Violence, Harassment and Bullying Fact sheet. 2012. Available from: www.humanrights.gov.au/our-work/commission-general/what-bullying-violence-harassment-and-bullying-fact-sheet.
9. L Stone, C Phillips, KA Douglas. Sexual assault and harassment of doctors, by doctors: a qualitative study. Medical Education. 2019;53(8):833-43.
10. A Killen. From the CEO. O&G Magazine. Summer 2017. Vol 19, No 4. www.ogmagazine.org.au/19/4-19/from-the-ceo-10/.
11. Ramsay Health Care. Ramsay Health Care Leading the way with patient safety framework. 2017. Available from: www.ramsayhealth.com.au/News/General-News/Ramsay-Health-Care-Leading-the-Way-with-Patient-Safety-Framework.
12. GB Hickson, JW Pichert, LE Webb, SG Gabbe. A complementary approach to promoting professionalism: Identifying, measuring and addressing unprofessional behaviours. Academic Medicine. 2007;82:1040-8.
13. A Colangelo. St Vincent’s reviews anti-bullying program amid staff backlash. The Age. 23 February 2019. Available from: www.theage.com.au/national/victoria/st-vincent-s-reviews-anti-bullying-program-amid-staff-backlash-20190223-p50zri.html.
14. Australian Human Rights Commission. National Inquiry into Sexual Harassment in Australian Workplaces. 2018. Available from: www.humanrights.gov.au/our-work/sex-discrimination/projects/national-inquiry-sexual-harassment-australian-workplaces.