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When I became a doctor, I joined a profession, I joined a health service, and I joined a culture.
The first two of these are part of my identity and make me incredibly proud. But the culture – of that I’m not so sure.
‘Culture’ sounds grand. It sounds desirable. Perhaps it being such a nice word, with the resonance of theatre and opera, is what makes us so slow to question it.
But culture is just a way of saying ‘this is how we do things’ without bothering to explain why. It describes, but it also decrees, how and why we act.
The culture I entered as a doctor was not cultured. It was sexist, hierarchical and given to dangerously excessive hours.
It changed, and it continues to change, because courageous people stand up to challenge it. The culture is not fixed.
When I meet people who are being bullied, my anger doubles when I am told it is part of the culture. Par for the course. Only to be expected in a stressful and competitive world.
So what is this culture? What causes it? And how can we make it better?
It is a culture in which more than a fifth of doctors have suffered workplace bullying or harassment. Thousands of them across all branches of practice. If this were any other kind of occupational disease, affecting the workforce on this scale, we would have tackled it by now. It’s about three times higher in the medical profession than in the wider economy.
We know what this does to individuals. The corrosive, undermining, worming away of self-esteem. The loss of hope, joy and value in what we do. We know from the Francis Report what it can do to a workplace and what it can do to patient care.
When we look for a cause, it’s important to say this isn’t the same as looking for a reason or a justification. But the BMA’s own bullying and harassment project, which we set up last year, has found that three major factors fuel this culture.
The first of these is workload pressure. It’s almost a knee-jerk response when you ask managers, especially, why bullying happens. They might call it ‘bullying down the line’, the grim cascade which begins at the top with unreachable targets and the risk of public humiliation for missing them.
As a retired hospital chief executive recently wrote in a candidly named article – the ‘bully’s perspective’ – it’s a system driven by anxiety, where those at the top feel they have no choice but to pressure those below them. Those doing the bullying are not some cold, confident cad from a Victorian novel but they are themselves anxious, insecure and possibly bullied themselves. They pass it on. It may then be passed on again.
It is so important to say that explaining is not the same as excusing. But it is useful to explain if we can. Being stressed at work does not make the bullying or undermining of colleagues acceptable. But they need to reflect, and ask, particularly in those high-pressure situations, whether they have treated others as they would wish to be treated themselves.
We should also remember that these behaviours can be a product of stress, but they of course also add to that stress. If you feel stressed, then others are likely be feeling stressed themselves. Who wants to make the situation even worse? And of course there needs to be attention paid to the underlying causes of this stress – the unsustainable workload so many in our profession is facing in an under-funded and over-stretched National Health Service.
The second factor in bullying we have identified is hierarchy.
Hierarchies are everywhere. They can be a sensible way to divide up roles and responsibilities. They are not inherently bad.
But they can create distance between people. They can make it easier to forget there’s another human being further down the line, and not to think about the impact that you are having on them.
What I hate is the assumption that bullying just comes with the territory if you are in a particular position in that hierarchy. Junior doctor colleagues are still being told to ‘keep your head down, it won’t last forever’. ‘It’s a rite of passage’. ‘We’ve all been there’. We may have all been there but it did neither us nor our patients any good and now we have the power to stop it. So why don’t we?
A third of SAS doctors told us they had been bullied or undermined at work, and that many said it was linked to their status as an SAS doctor in the hierarchy. It is they we can thank for initiating our BMA project. If people are being bullied by virtue of their job title, it means there is something rotten about the rivalries and the different status we have grown up with, and we need to improve relationships between doctors, and with other staff groups.
Finally, we come to the third striking issue about bullying and, by definition, it’s the one you hear about the least. It’s silence. It’s where incidents are experienced or witnessed but not reported, and as a profession we have a particular problem here.
Doctors are less likely to report incidents of bullying and harassment than other staff. According to NHS staff surveys, almost half of NHS staff who were bullied or harassed said their employer was made aware of it by themselves or a colleague. But for doctors, only for a third of those bullied or harassed, a report was made, and for junior doctors it’s only a quarter.
The GMC’s national training survey puts this down to a fear of adverse consequences, and a lack of confidence that anything will change. This is clearly linked to hierarchy, when you might feel that you’re putting your career at risk. And remember that those who are bullied may be feeling anxious, vulnerable and isolated. They just want it to stop. They fear that reporting it might make it worse, might antagonise their bully further. Their confidence may have been so badly hit that they start to think yes, maybe the bully has a point, maybe I’m no good at this, t, what if I am not cut out to be a doctor after all?
We know that more needs to be done to improve the system for reporting and resolving incidents. We have years of experience of supporting doctors in the workplace, and will use this information to help work for positive change.
But we also need to think about the silent witness, the bystanders who could speak up, but for whatever reason do not. We need to ask why decent people don’t speak up. They may think it’s down to the victim. They may assume others will speak up. They may just want a quiet life.
Here’s what they need to know. Bullying is not just a vile transaction between perpetrator and victim. It affects us all and it affects our patients too. I’m sure a lot of you will know the excellent work of Chris Turner, an emergency medicine consultant in Coventry.
Chris’s campaign, Civility Saves Lives puts forward the evidence base which shows that workplaces where staff are rude and abusive make more mistakes. It may be the product of stress, but it creates stress. It creates error. It creates harm.
Chris talks about the culture in the 1950s when his mother, a student nurse, used to give out cigarettes to patients because some doctors recommended them.
We look at the culture of the past and we laugh at it. Yet we look at the culture of the present and either don’t see what’s wrong with it or assume it can never be changed.
I don’t want to work in a culture in which bullying is seen as the ‘norm’. We should chuck it out with the cigarettes. For us, for those who follow us, and for our patients too.
Anthea Mowat is chair of the BMA representative body. This is an edited version of an address she gave at the Tackling Undermining and Bullying in the NHS conference in Birmingham on 8 February, jointly organised by the Royal College of Obstetricians and Gynaecologists and the Royal College of Surgeons of Edinburgh
Find out more about the BMA’s work on bullying and harassment
Excellent and very timely presentation
I contacted the BMA about being involved in your work on bullying and harassment as someone who now has extensive personal experience., well know to BMA Scotland. I got a polite reply, but noone has been in touch since. I fear this is, yet again, paying lip service only to the problem. But at least you replied, unlike the RCOG.
Very true, Anthea.
its not just in medical there is very much a predominant bullying and harassment culture within nursing also. Am in hope that the new Chairman of NHS Tayside will acknowledge this and have no tolerance for such behaviour