Bullying in Medicine

By Scott Ashby

110727-N-YR391-008 JACKSONVILLE, Fla. (July 27, 2011) Hospitalman Edwin Torres instructs Jurgen Comberg, a college preparatory medical arts magnet high school student attending Naval Hospital JacksonvilleÕs 2nd Science, Service, Medicine and Mentoring (S2M2) program, on how to prepare a demonstration patient, Hospitalman Adam Christopher, for an electrocardiogram. The S2M2 program is an intensive five-day course where students get real-world experience in patient care areas from the operating and emergency rooms to pharmacy to physical and occupational therapy. (U.S. Navy photo by Mass Communication Specialist 2nd Class Gary Granger Jr./Released)

I’m a fifth year medical student, who started my proper clinical placements this year. Yesterday, I was in surgery, and was asked to scrub in so I could get close enough to see and participate. What happened was as follows:

  • When scrubbing I tried to remember what I had learned in my brief orientation over a year ago about how to do this correctly. I knew if I took too long I might miss the opportunity.
  • I tried to put on my gloves using the correct technique. Nope. Scolded by the scrub nurse. My gloves were no longer sterile and I was endangering the patient. She helped glove me correctly.
  • I approached the patient. Tried to be helpful when the surgeon was passing something. “That’s a sharp, don’t touch it”. Clearly I don’t know what I’m doing. I’m in the way.
  • I got asked to identify some of the structures in the body. Having never seen this surgery before (and possessing a leaky anatomy brain) I made a fool of myself again.
  • Then it was time to close. “Scott, you’re going to close one of the incisions”.
  • Oh God.
  • Hands shaking, I start to do a type of suture I had taught myself on a piece of plastic the week before.
  • This is a real patient. This is a real scar he will have.
  • The term operating ‘theatre’ seems appropriate here. Five or six professionals watching. All paid a lot. All important.
  • I was slow. I was awkward. The anaesthetist suggested I keep my elbows closer because he could see my hands shaking. That definitely didn’t make them stop…
  • He asked the surgeon if they were close to getting done, commenting on another patient who was waiting. ‘Hurry up Scott’ rang in my ears.
  • I finally got it done. Incision closed. Surgeon happy enough.

The thing about this experience was that it was actually almost the best version of these events I could have hoped for. The supervisors I worked with were kind, supportive and patient. They were happy to repeat my work if it wasn’t good enough. They encouraged me to push my boundaries. They said there was no rush and I shouldn’t feel pressured. The nurse was also kind and understanding, explained the instruments during the operation and then after the surgery helped show me how to glove correctly by myself. I couldn’t have asked for a better environment.

This is not always the case.

My story hopefully serves to illustrate how medical education works. It’s hard not to feel inadequate, disheartened and like a nuisance. Fifth year students are thrown into a clinical environment disorientated and under-prepared. Our lives become an endless series of questions being thrown at us, “Do you know this piece of information?” or “Do you know how to do this skill that would make you useful?”

All day. Every day.

“No I don’t know where to find that on this ward. No I’m not confident putting in a cannula. No I don’t know how that drug works. Please take time out of your already busy day to be patient with me and show me. I know it will take longer. I know you would do it better and quicker yourself. And believe me, I know you are busy helping people. I know that, because the 18 months until I have to do the same are ticking away so damn fast. But I have to learn somehow and I don’t know what else to do. So I’m here being a nuisance.”

The other side of the fear-of-inadequacy coin is competitiveness. Competitiveness and medicine have always been closely linked. With less than 6% of applicants getting in to our UNSW Medical Doctorate program, we hold some of the most competitively sought after positions in any university program in the Southern Hemisphere. It doesn’t stop either, with the numbers of medical graduates far outweighing the number of specialist training places, competitiveness within medicine is necessary to specialise.

It is unsurprising we are anxious and depressed. Take this pressure and tack on a few emotional gut-punches from those patient stories that just get to you, along with some personal issues and we have a poor mental health/self-esteem cocktail. A Beyond Blue study found over 50% of us are emotionally exhausted or burnt out, and 20% have considered suicide. These numbers are for students, but the trend continues for junior doctors, who work longer hours, have more expected of them, have the fear of very real consequences, but are still subject to the same feelings of inadequacy and competition.

I explain all this to try and show how utterly imperative it is for us to be well supported, as I was in the operating theatre yesterday. But like I said:

This is not always the case.

Bullying always felt like a high school concept to me. I fundamentally believed that it was a problem that would go away with age, in the same way that when children grow up they no longer steal each other’s toys or wet the bed. Unfortunately, bullying is rife in the medical community, and it is undoubtedly a significant contributor to our cohort’s stress and poor mental health.

Given some of my experiences, I was not surprised when Four Corners reported (among other bullying issues) an abuse of the Socratic Method in the medical community, that students are shamed for their lack of knowledge, often in front of other doctors or students. I have been shouted at for asking for help in front of an office of hospital workers. I have been embarrassed in front of my peers and other health professionals. It has been made clear I’m a nuisance when I try to complete mandated the assessments.

I like to think I will be a pretty good doctor one day. So why am I being driven to the point that some days I go home wanting to quit, cry or just give up. And honestly, as a white male, I probably have it the easiest. Students and junior doctors who are women and of other ethnicities report a confronting blend of harassment, misogyny and discrimination. And when there aren’t adequate reporting structures in place, or previous whistle-blowers have lost jobs or been ridiculed as ‘overly-sensitive’, our ability to deal with such issues is limited.

How is it that a group of well-meaning, intelligent and kind students become the harsh, judgemental professionals we experience? Professionals we are terrified of crossing as they are the gate-keepers of the future we have worked for. I guess this environment proliferates because people do to others as was done to them. Doctors learn how to educate students and juniors doctors by how they were taught.

“I got through it, you can too.” “Just grow a thicker skin.” “You will be stressed in the job, might as well get used to it.”

My question is: do we really want our future doctors to be forced to grow a thicker skin? To learn to care less about their colleagues, students and their calibre as a medical professional? Do we want to blunt empathy in a profession where it is so necessary?

People shouldn’t have to run the gauntlet to prove they can. Going through pain to show you are worthy is a Game of Thrones argument. Similarly, the fact that ‘it has always been this way’ doesn’t begin to justify why something should continue. It’s as lazy as saying the behaviour is acceptable because “everyone else does it”.

We won’t even begin to touch on the issues this has for the quality of patient care, arguably the most important consideration of this issue. But if junior doctors feel intimidated to call for help because they will be embarrassed or bullied then we have a broken system. If students do something they aren’t comfortable with because they are scared of not impressing their supervisor then we have a broken system.

Hopefully with the recent coverage, those who bully will reconsider before they admonish rather than support, rethink before they hold a student to an unreasonable standard. If our generation can have access to decent reporting structures for mistreatment, and can learn from our experiences to become better, kinder educators, then maybe we can stop the propagation of a truly outdated and unnecessary cycle of bullying.