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Health care and harassment: Now is the time to address unhealthy habits

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Grey’s Anatomy – the television show and not the textbook – has been running for more seasons than I care to count.  All I know is that it has spanned several different stages of my educational and professional life and seems to have as strong a following as ever.   Not unlike the legal world, mining the hospital and health care environment for inspiration can yield highly entertaining programming.  One archetypal character that frequently appears in both drama and comedic form is the curmudgeonly demanding senior doctor.  This doctor is both admired and feared, as conveyed in scenes that routinely show the medical bully berating the more junior resident in training.  And while this may make for entertaining television programming, any supposed benefits of an overly aggressive approach to education and leadership in medicine are less apparent in reality.

Dr. Gabriel Horne, a cardiologist practising in Nova Scotia, experienced the consequences of a hostile work environment firsthand.  She decided to fight back.  Her battle waged through the judicial system for more than a decade.  But in 2018, Dr. Horne received vindication for her efforts in a landmark decision of the Nova Scotia Court of Appeal.[1]  Underlying the complex legal saga are fairly straightforward facts.  When Dr. Horne refused to involve a senior colleague in her research and the resulting publications, he accused her of having mismanaged patients and launched a campaign to discredit her clinical competence, which ultimately led the health authority to revoke Dr. Horne’s privileges.  The senior physician ignored all of Dr. Horne’s attempts to communicate – including when she paged him regarding patients – and thwarted her ability to comply with research protocols.

Intimidation tactics and abusive exercises of authority can be subtle and difficult to prove.  The challenge is augmented when unwarranted attacks on a physician are cloaked in concerns for patient safety – regulators, hospital executives, and educators of physicians in training have an obligation to intervene if there are genuine competency concerns.  As Dr. Horne’s case illustrates, once a physician has been accused of substandard clinical competence by a colleague with credibility and high regard in the right circles, it is a major undertaking to try and erase the black mark on the physician’s record.

How then, do you responsibly address legitimate risks to patient safety while addressing problematic conduct that has long been considered acceptable (or at least tolerable) in medicine? It will require time and incremental cultural change, and at a minimum should include: recognition of the problem, training, and accountability.

a)  Recognition of the Problem

Exposing physicians to harsh conduct and challenging their tolerance for functioning in a difficult environment is sometimes applauded as a noble means of weeding out the weaker ones and allowing the most resilient to flourish professionally.  Even if this idea is not unique to medicine – as the growing body of evidence indicates – the time for revisiting the soundness of the concept is now.

When bullying, harassment, and discrimination are prevalent in the workplace, the tendency is for employee productivity to diminish and absences to increase.   Beyond the impact on the individual employee, unprofessionalism or disruptive conduct in medicine can impact patient care: there is a higher rate of medical errors attributable to bullied physicians.[2]  It appears that bullied physicians are more likely to: be compelled to handle clinical scenarios that are beyond their level of knowledge and expertise; work beyond their assigned hours and personal limits; and consider leaving the practice of medicine altogether.[3]

The first step in addressing the issue of harassment in all its forms is to acknowledge that it is indeed problematic.  Health care practitioners will need to recognize inappropriate conduct when it occurs and gain a deeper understanding of its broad repercussions, not only on the individual, but on the delivery of health care itself.

b)  Training: Learning to identify harassment and knowing where to go when you see it

With increased training and education, individuals become more adept at identifying and understanding what constitutes harassment.  A survey conducted in 2008 indicated that physicians have a narrow definition of what constitutes bullying especially relative to the nurses surveyed in the same study[4].   In other words, physicians may not even recognize conduct as threatening or disruptive because they have been trained to offer those in authority and peers a wide berth when it comes to workplace behaviour.     In contrast to the 2008 study, the 2018 National Resident Survey conducted by the Resident Doctors of Canada, suggests that there is an increasing awareness of harassment in the medical community: more than three quarters of residents (78.2%) experienced at least one form of harassment or intimidation during the year preceding the survey[5].  What is not entirely clear, is how exactly the respondents defined harassment and whether they were truly informed about the parameters of appropriate workplace conduct.

Educational institutions, regulators, and health authorities are making more of a concerted effort to integrate lessons on professionalism and collegiality into their training programs and policies.  This is an excellent start.  Additional and ongoing training on what constitutes acceptable conduct, and that takes into account the unique working conditions of health care services, will further assist.

In addition to increased training on what constitutes harassment, it is equally important to ensure that people know what to do when they do observe bad behaviour.  In the 2018 National Resident Survey, one fifth of the respondents did not know if their program, medical school, or university had a policy to address intimidation and harassment. Of those who knew about such policies and who had experienced a form of harassment, 10.4% had used that institution’s resources to address the event, and the majority of this group considered the resources to be inadequate.  These findings suggest there is much room to improve.   Training is one way is to ensure there is greater awareness of policies amongst employees and build the capacity of internal teams within health care institutions to handle delicate interpersonal workplace issues.  To be effective for this purpose, training must be tailored to the specific work environment and delivered in such a way that participants can ask questions and facilitators can assess participant comprehension.

c)  Accountability

Any real change requires that the repeat offenders and perpetrators of harassment and bullying within the profession are held accountable.  When individuals who have been exposed to mistreatment see that their employer or organization is equipped to handle timely and responsive investigations, confidence in the system increases and fear of retaliation subsides.

Hospitals can be limited in their ability to exert sanctions against physicians and some other hospital staff if they are not employed directly by the hospital.  To overcome this, hospital management would be wise to make sure that any agreements they do have with such individuals clearly set out the expected behavioural standards and, to the extent possible, build in the ability to take the necessary steps to address inappropriate conduct when it occurs.

The Canadian Medical Association Code of Ethics has long enshrined principles of collegiality and respectful conduct towards peers.  These are not just empty professional ideals: they must be brought to life through daily practice and dedicated efforts to combat problematic conduct as it arises.

[1] Horne v. Queen Elizabeth II Health Sciences Centre, 2018 NSCA 20.

[2]Paice, E. and Smith, D. Bullying of trainee doctors is a patient safety issue. The Clinical Teacher. 2009; 6(1): 13 – 17.  See also: Holroyd-Leduc, J.M. and Straus S. E. #MeToo and the medical profession.  Canadian Medical Association Journal. August 20, 2018; 190 (33).

[3] Mbadiwe, T. Bully for us: Confronting Medicine’s Bullying Problem. Medical Bag (April 17, 2018) online: https://www.medicalbag.com/home/lifestyle/bully-for-us-confronting-medicines-bullying-problem/, citing Paice, E. and Smith, D. Bullying of trainee doctors is a patient safety issue.  The Clinical Teacher. 2009; 6(1): 13 – 17.

[4]  Rosenstein A.H. and O’Daniel M. A survey of the impact of disruptive behaviors and communication defects on patient safety. Joint Commission Journal of Quality and Patient Safety. 2008;34(8):464-471.

[5] https://residentdoctors.ca/wp-content/uploads/2018/10/National-Resident-Survey-2018-R8.pdf