Saturday, January 23, 2016

Bullying, a multi-legged problem

Notwithstanding Bill Bryson's characterization of this "sunburned country" as a place in which there are dozens of ways to be killed by local fauna*, the chance of actually dying from a spider bite, snake bite, or in other such manner is quite small.  For example, the huntsman above looks pretty ferocious, especially given his 4" (10 cm) span, but he won't kill you.

In contrast, though, Australia shares the unenviable status of other developed countries (US, UK, and the like) in the fact that being a patient in a hospital is a significant risk.  I discussed the situation in one Victoria hospital in a previous blog post.  There, a number of babies died of a result of preventable medical errors.

In the short time I've been in the country, I've heard several people set forth one aspect of the problem, the existence of inappropriate levels of bullying and intimidation by senior members of the medical staff.  Such behavior can directly influence the safety and quality of patient care:

"Most organizations are beginning to understand that this is about patient safety," says Marty Martin, a psychologist based at DePaul University in Chicago. He co-wrote a guide book, Taming Disruptive Behavior [that] details growing evidence linking bad behavior with patient harm.

(Indeed there is reason to believe that such was part of the problem in the aforementioned hospital.)

In a November 21, 2015 article in The Age, reporter Neelima Choahan summarized a day-long summit held by the Australian Medical Association on the topic.

Now comes the question of what to do about it.  Shortly after the article, the AMA issued a position statement on the issue.  The organization's president said:

“Workplace bullying and harassment creates an unsafe and ineffectual work and learning environment due to the continued erosion of confidence, skills and initiative, and can create a negative attitude towards a chosen career.

“The medical profession must take direct responsibility for its culture, reputation, and standard of professionalism. 

“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.

“Employers and education providers must work closely together to develop a strong response to change the culture in workplaces."

This is a start, but this is a tough problem that has been in existence for decades. Let's hope that the Australian medical profession does indeed "take direct responsibility" for improvement in this arena; but there are important roles for other constituents as well.  In particular, there is a nascent patient advocacy movement occurring in this country. With focus and direction, those engaged patients and families can provide respectful and helpful input about the cultural environment in which they are being treated. There is no mention of this resource in the AMA'a position statement or in the president's comments on the issue.  It would behoove the AMA to join forces with such individuals and groups to help make the statement of position a reality throughout the country.


"It has more things that will kill you than anywhere else. Of the world's ten most poisonous snakes, all are Australian. Five of its creatures - the funnel web spider, box jellyfish, blue-ringed octopus, paralysis tick, and stonefish - are the most lethal of their type in the world."


Mary said...

You offer sound advice and I hope AMA takes a move in this direction.

Anonymous said...


I have a friend who was harmed in Australia. She's tried for years to get recognition of the devaluing there. Thank you for spotlighting how "personalities" in the medical profession can be detrimental to the health of the patients.

We the patients appreciate having patients' health before profits.

Neville Sarkari MD, FACP said...

This is a problem that is familiar to all physician leaders who take their jobs seriously. Marty, who you quote, teaches around these areas for the ACPE and does a great job.

The Joint Commission issued a Sentinel Event Alert around 2008 on Disruptive Behavior (of which bullying is a major sub-type). This Alert bulletin helped bring the subject to the forefront in US hospitals. Physician and non-physician leaders then had to spend years working on the issue. Although it is not nearly gone, I believe it is much better than it has been. In part this is because the new generation of physicians coming out of training today behave much better, overall, than their older counterparts.

Simultaneously, hospitals started to be sued over workplace harassment, and the courts made it clear that a hospital could be liable even when the physician was not employed. This fact added the urgency that was needed for this issue to be taken seriously. (Sad that it took this financial stick, but not surprising!)

The solution, although not easy, is understood. Commitment to zero tolerance must start at the governing board level of the hospital. Medical staff rules or bylaws must similarly make clear that these behaviors will not be tolerated. Finally, physicians must condemn it and support a process to sanction those who can't control themselves. Finally, administrators must understand that a physician's financial worth to the hospital can not be a factor in allowing such behaviors.


Neville Sarkari MD, FACP

Beth Boynton, RN, MS said...

A multi-legged problem for sure! As a nurse consultant and author who writes about and teaches healthy communication and related skills I'd like to add a few points:

In addition to Dr. Sarkari's points, I would emphasize that toxic behaviors are often supported by a culture of broken trust that must be repaired. Thus a long term commitment to culture change and acknowledgement of wrong-doing, i.e apology for inappropriate behavior and impact on others can be a very powerful leadership steps that will contribute to success with zero tolerance. There must also be opportunities for learning curves that allow for feedback exchanges, (with facilitation prn). Not to tolerate bullying, but tease out interpretations and work together to improve relationships. Also, no double standards, they are the kiss of death! In addition, a 'No-Innocent Bystander' policy outlined here can be helpful:

Also, I'd like to share that I use an experiential teaching method, called 'Medical Improv' to cultivate emotional intelligence and interpersonal skills that promote effective communication, teamwork, and leadership. If we consider how poor conduct along with some other serious issues like workforce injuries and bad patient experiences are at least in part caused by lack of EQ and social skills, then we can use this effective and fun way to help ALL healthcare professionals grow. I discuss this point further in this Medline blogpost: I'm very happy for questions and feedback!

Paul Levy said...

Thanks, Neville and Beth!

Peter said...

People have also looked at this from a cost perspective. A tiny fraction of a hospital’s active staff contribute hugely to a hospital’s costs—and penalties—to no useful end, except that the physician-king is more deeply stuck in quicksand of his own making.