Medical disrespect

Bullying doctors are not just unpleasant, they are dangerous. Can we change the culture of intimidation in our hospitals?

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Photo by China Daily/Reuters

Photo by China Daily/Reuters

Ilana Yurkiewicz is a third-year student at Harvard Medical School and a blogger for Scientific American. She does bioethics research at Harvard, and her work has appeared in The New England Journal of Medicine.

He comes to the operating room late, greets no one, and berates the nurse for not setting up the stepstools the way he likes. He tells the resident she doesn’t know the anatomy and sighs when she adjusts her grip on a surgical tool. He slaps the hand of the medical student when she reaches for the retractor to pull back skin for a clearer view. The operating room is tense for hours. ‘I need a different clamp,’ he says at one point, ‘this one is too dull.’ ‘I’m on it,’ says the scrub nurse. ‘You’re not,’ he retorts, ‘or else it would already be in my hand.’ All of us adorned in blue scrubs and surgical caps stand on edge, braced against the next wrathful outburst. ‘I want to see the tip of my blades,’ the resident explains, staring intently at the monitors where her laparoscopic instruments have not quite come into view. ‘Just cut,’ the lead surgeon barks at her. By the end of the operation, the intern’s hand shakes as he sutures the wounds closed, to the beat of the running condescending commentary on his halting speed and less-than-perfect stitches.

One doesn’t have to work in a hospital long to experience or observe some form of disrespect. This is hardly a secret. The bullying culture of medicine has been widely written about and portrayed in popular media. In one study, published in 2012 and conducted over the course of 13 years at the David Geffen School of Medicine at the University of California, Los Angeles, more than 50 per cent of medical students across the US said they experienced some form of mistreatment. Behind closed doors, we share advice on whom to hang around and whom to avoid.

At the start of my third year of medical school, when we would finally enter the hospital wards, we had an orientation: ‘Wear a raincoat,’ the doctor standing at the podium advised. I could expect to get rained on.

For the most part, I’ve been pleasantly surprised. The majority of doctors, nurses, and other health care professionals I’ve worked with have been courteous and respectful: strong teachers and compassionate caregivers. I have met colleagues whom I would feel honoured to work alongside in the future and mentors whom I’d want to treat my own family should they become ill. I’ve been amazed by residents who work 24-hour shifts and somehow still have the energy to teach those who do not yet know as much as they do. I both admire them and am grateful for them.

But there is a reason those orientation warnings exist. The surgeon who chides the nurse for her inability to be in two places at once? The nurse who snaps at the medical student for reading the patient’s chart the same moment she wants to write it in? They are a substantial, troubling minority, and they can set the mood for the rest.

Most of my friends in medicine have witnessed flagrant episodes of hospital bullying and have juicy tales to tell. But medical disrespect is usually far less dramatic, dished out in the form of ‘micro-aggressions’: exasperated sighs, a sarcastic tone, the dismissal of alternative ideas. It’s the subtle put-downs about a trainee’s competence that erode confidence; the public shaming for an incorrect answer on rounds; or the denial of simple privileges such as taking a chair or reading a chart. It’s the psychological effect of being called by your rank instead of your name, or having it made clear that your presence is a burden instead of a help. It’s being ignored. It’s other team members looking on when the disrespect occurs, afraid to challenge it and defend those lower on the totem pole. These are the acts that affect our state of mind in small but cumulative ways. This is the stuff that creates a culture.

You learn to deal. This is how it is. That’s the system. It’s ingrained. You excuse bad behaviour with the platitude: ‘That’s just the way (s)he is.’ You appreciate from your elders that it could be much worse – at least they can’t throw scalpels at you anymore. You make allies and whisper in solidarity with those in the trenches alongside you. You train yourself, just as they advised you on your very first day, to wear a raincoat. You start to wear it, and it becomes thicker as your training progresses. You add boots and an umbrella. Then, as you get better and more confident, perhaps you become impatient with the inevitable lack of expertise in the new trainees. Maybe in a few years, you start to rain on others.

We’ve known for years that entering the ranks of medicine means developing a thick skin to criticism and being made to feel small. For a long time there was a mystique that this culture held everyone to high standards, and it was the price we paid for the care we got. What is disturbing is the increasing recognition that bullies are not only bad people to be around – they’re bad doctors, too.

Get admitted to any hospital, and you might notice that no longer is a single doctor on your case. Contrary to popular television scriptwriting, treating patients is rarely about the inspired intervention of one brilliant physician or surgeon. Rather, we work more like an ecosystem, with every organism in the hierarchy contributing to the whole. In the old days, interns straight out of medical school would man the hospital wards, see very sick patients, and learn to become doctors by practising on them. They’d experiment, they’d figure out stuff, and they’d grow. And sometimes, when they were wrong, patients would pay the price.

Today, we still recognise that newly minted doctors must be trained, but there are more checks and balances in place for patient safety. Interns still see very sick patients and propose plans of action, but those plans are run by more experienced doctors before being implemented. In teaching hospitals, we meet on team rounds daily, discuss updates on patients, and talk through goals for the day. Questions get run by senior residents, and senior residents run things they’re unsure of by attending physicians. Whenever there is uncertainty, the question works its way up the hierarchy. At the same time, decision-making reports back down, so that the newest of the doctors carry out the plans and learn by doing.

So far, so good – this is a better system than it used to be. But it is also much more dependent on the communication and relationships among different members of the team. Now, enter the culture of disrespect. Suppose an attending physician makes withering critiques or unreasonable requests. A resident, hoping to avoid such abuse, slowly but surely starts to hold back. She holds back some questions for fear of burdening and, under the constant stress of being scolded, becomes immersed in details of efficiency. Whether she intends it or not, she gives off vibes of unavailability, spending hours hunched over a computer in the physician’s conference room cranking out progress notes and scheduling patient appointments. Meanwhile, a patient starts to take a turn for the worse, but it’s not completely clear-cut – his vitals are just a bit off, his belly seems distended, and he complains of abdominal pain but is also known to the team as someone who complains. The nurse hesitates to voice her concerns to the resident, who is swamped doing paperwork and updating discharge summaries exactly the way the attending prefers. The patient continues to go downhill, and by the time word gets out the patient is much sicker – and needs to be treated far more aggressively – than would otherwise have been the case.

A substantial body of data attributes medical errors to interactions among hospital workers. Calls for improved patient safety gained traction from the late 1980s through the early ’90s, when Australian researchers reported a shocking find: the vast majority of medical errors, some 70‑80 per cent, are related to interactions within the health care team. In the early 2000s, a report by the Joint Commission that accredits health care organisations in the US studied adverse events over a 10‑year period and discovered that communication failure was the number-one cause for medication errors, delays in treatment, and surgeries at the wrong site. It was also the second leading cause of operative mishaps, postoperative events, and fatal falls.

The link between harsh words and medical errors was reignited in 2012 when Lucian Leape, professor of health policy at the Harvard School of Pub­lic Health, published a two-part series in Academic Medicine. ‘A substantial barrier to progress in patient safety is a dysfunctional culture rooted in widespread disrespect,’ Leape and his co-authors asserted. ‘Disrespect is a threat to patient safety because it inhibits collegiality and co-operation essential to teamwork, cuts off communication, undermines morale, and inhibits compliance with and implementation of new practices.’

It’s not that jerky personalities are reserved for those at the top. There are nice people and mean people at every rank. But in a system dependent on the proper functioning of hierarchy, it works like this: when anger and intimidation flow down, information stops flowing up. The chain of communication becomes clogged.

In a system dependent on hierarchy, it works like this: when anger and intimidation flow down, information stops flowing up

This information block goes beyond doctor-doctor interactions. In a now-classic, 1986 study by William Knaus and colleagues at the ICU Research Unit in Washington DC, communication between nurses and physicians was the single factor most correlated with increased mortality in hospital intensive care. Meanwhile, newer research by Alan Rosenstein and Michelle O’Daniel at the healthcare alliance VHA West Coast in California has identified a pervasive trend in which nurses are reluctant to call physicians – even as a patient deteriorates. Some of the most popular reasons provided, according to their research? Intimidation. Fear of confrontation. Concerns about retaliation.

In another study by Rosenstein and O’Daniel, nurses and physicians self-reported behaving badly in near-equal numbers. Most felt this behaviour resulted in increased errors, lower quality of care, and lower patient satisfaction. Seventeen per cent could name a specific adverse event that occurred as a direct result of disrespectful behaviour.

When someone is unpleasant or demeaning, something switches in the minds of those on the receiving end: they sacrifice honest communication to save face. I’ve seen it in action so many times that the pattern has become predictable. Preoccupied with fear of appearing incompetent, team members keep uncertainties under wraps. Other times the opposite occurs. Annoyed that they’re being denigrated and prideful themselves, others fight back – even when they’re unsure of the thing they’re fighting about. Once I saw two residents argue back and forth in front of the attending about a finding on a physical exam; the issue was unrelated to the patient’s illness, and the fight, a clash of egos, took mental energy and focus away from the patient’s needed care.

Many in medicine actively protect the culture of disrespect because they hold a fundamentally flawed idea: that harshness creates competence

Contrast that with cultures steeped in mutual respect. I’ve been on some truly outstanding medical teams that worked in opposite ways. Though everyone knew their place in the hierarchy, it also felt more egalitarian. Patients came before pride. The senior staff told others how to reach them and opened the lines of communication. Nurses attended morning rounds with the doctors; their input was valued and they were kept in the loop at every step. One night, we were on call with a ‘watcher’ – that is, a patient who could take a turn for the worse quickly. The resident made clear her door was open – literally and metaphorically. The nurses came by often and clarified orders. When the patient began to look even slightly ill, the nurse immediately got the doctor. They examined the patient together as the doctor explained what to do next and why. Questions were encouraged. Communication was crystal-clear. And the patient did well.

Yet despite such outcomes, many in medicine actively protect the culture of disrespect because they hold a fundamentally flawed idea: that harshness creates competence. That fear is good for doctors-in-training and, by extension, good for patients. That public shaming holds us to higher standards. Efforts to change the current climate are shot down as medicine going ‘soft’. A medical school friend told me about a chief resident who publicly yelled at a new intern for suggesting a surgical problem could be treated with drugs. The resident then justified his tirade with: ‘Yeah, yeah, I know I was harsh. But she’s gotta learn.’

Arguments such as these run counter to all the data we have on patient outcomes. Brutality doesn’t make better doctors; it just makes crankier doctors. And shame doesn’t foster improvement; it fosters more mistakes and more near-misses. We know now that clinicians working in a culture of blame and punishment report their errors less often, pointing to fear of repercussion. Meanwhile, when blame is abolished, reporting of all types of errors increases.

We can no longer deny the facts. Bad cultures lead to bad outcomes. Jerks do not make good medicine. They foster a backwards atmosphere that degrades trust, tarnishes open communication, and promotes cover-ups.

Creating a culture of respect is not just about feeling good, for its own sake. It’s better for patient care.

Pointing out dysfunction is easier than solving it. The million-dollar question is: does it have to be like this? And if not, how can it be improved?

Some medical programmes are already taking steps to tackle disruptive interactions. A leader here, the David Geffen School of Medicine at UCLA, began to address the problem as early as 1995; they created workshops and training sessions, established a Gender and Power Abuse committee, and developed mechanisms to accept confidential reports of mistreatment. More recently, Massachusetts General Hospital in Boston developed a model for team restoration following disruptive interactions.

Programmes to spot and eliminate disrespect work well with one-time instances of explosive behaviour. But from my experience, the worst offenders are serial offenders. That some have made it to the top of the food chain suggests there was no sufficient deterrent for behaving that way. That must change. Medical trainees are already evaluated on many qualities these days. The powers-that-be can prioritize respectful behavior on that list. If we evaluate and ultimately promote trainees on honest communication and keeping their egos in check, we’ll cultivate good behaviour from the start.

We can’t ignore a system that takes loads of formerly ‘nice’ people and churns out jaded, bitter, and gruff ones

At the same time, change should emerge from within the hospital itself. Instead of looking away sheepishly when our colleagues are mistreated and apologising for bad behaviour with tired mantras, we should push back. Bullies have ripple effects. Medical students mimic the behaviour of residents who mimic the behaviour of attendings until a problem with attitude can extend from a few people to an entrenched culture. Instead of riding that wave, we could shun bad behaviour. This is easier said than done. But cultures change because people within commit to changing them; it won't come by decrees. A culture that shames bullying makes the bully look like the bad guy, rather than making the recipient look weak.

In a similar vein, we should put an end to the premium that the medical establishment places on saving face. This is a hazard. It feeds the egotistical environment that can lead to ignoring input and failing to ask for help. It creates doctors who value looking like they know what they’re doing at all times more than actually doing what is best.

Finally, we should be getting to the root of the behaviour. Why do people behave badly? Some are just jerks. Some imitate jerks. But we also can’t ignore a system that takes loads of formerly ‘nice’ people and churns out jaded, bitter, and gruff ones. We have to call attention to the external factors that can contribute. The lack of sleep. The poor hours. The system that overbooks and overworks. Environments such as these persist in part because of our unique vantage point in taking care of others at some of the worst points in their lives. How can I say ‘I’m tired’ or ‘I’m hungry’ or ‘He hurt my feelings’ in the face of such profound human suffering? Yet it’s hardly absurd to ask for better working conditions. When working in a system that treats us all humanely, we’re more likely to be humane to each other, and to our patients.

Read more essays on health policy and medicine

Comments

  • mhsutton

    The core of your message - that we challenge the flawed idea of harshness aides competence is essentially a positive one. I support it wholeheartedly.

    However, I wholeheartedly disagree with your - deliberately controversial - tag line 'bullies are bad people'.

    No they are not, they may be less competent because their attitude does not aide their patient care, but they are not 'bad' people. They operate on flawed understanding of relationships, sometimes unaware of the effect their behavior has on others.

    This is not a defense of bullying, but a call for empathy and an invitation to communicate more non-violently as means to reach your noble goals.

    • Ilana Yurkiewicz

      Thanks for reading, and I very much appreciate your comment. I do agree with you; bullies are not bad human beings -- perhaps just misguided. Headlines are created by magazines and not by the writers themselves. Hopefully the rest of the article will be clearer about the message. Respect and empathy should indeed be priorities throughout the process of changing this system.

    • FWiederman MD

      I am aware of the truths in the article (too long) by Dr. Yurliewicz. I felt many of the emotions written in some of the inflammatory replies. The reply I find most constructive is by mhsutton above. So much of the answer lies in conflict management at all levels. Why isn't conflict management taught in Medical schools and residency programs? Conflict management is not magical, can be formally taught, and can have an effect like magic. Bullying is a form of impairment.
      I've worked with some nurses, administrators, and contract groups who are bullies…and who often use bullying styles to cut corners on care and increase personal profit or aggrandizement. The problem is universal.

      • http://www.drcharlesparker.com/ Dr Charles Parker

        Let's take this important discussion just a bit further. Why not teach the process of conflict resolution in grade school, starting in Gr1? Bullying is born of insecurity, most often insecurity w both self and process. Thinking more deeply about process should start early, as balanced process can be managed easily. Witness the excellent book by Dr Edward de Bono: "Six Thinking Hats" - http://astore.amazon.com/cpbks-20/detail/0316178314 I've used "Six Hats" for years on many levels. It's a book on a deeper level about metacognition and group psychology - an environment/reality - a process - that as medical professionals we are never trained to manage. Read "Six Hats," and put aside "Leadership Secrets of Attila the Hun." Fear arouses anger and, as pointed out so well in this article, diminishes work efficiency. As another important management consultant, W Edwards Deming once said: "If you can't describe what you're doing as a process, you don't know what you're doing."

    • George Anderson

      This is what the Joint Commission had in mind when the initiated the mandates for "disruptive physicians".
      George Anderson

      • sd

        The Joint Commission "disruptive physician" mandates as they are currently written are a great tool for nurse and other bullies to go after doctors. The Joint Commission took the lazy way out by limiting their interest in disruptive behavior to the behavior of physicians. All disruptive behavior, whether it is from an Administrator, nurse, clerk or any other role in medicine is detrimental to patient care. The bullying culture in medicine will not go away without recognition that anyone bully another person, regardless of how high or low the bully is on the totem pole. In my practice, my schedule is manipulated by the office manager bully, who has been there for 30 years and gets away with whatever she wants. I feel very sorry for the poor cancer patients who come to see me for medical care as their overbooked appointments are just one of the tools this bully has in her arsenal.

  • robertmeerdahl

    this is something the airline industry realized (after some high profile accidents), and created "crew resource management"

    "CRM is concerned with the cognitive and interpersonal skills needed to manage resources within an organized system, not so much with the technical knowledge and skills required to operate equipment. In this context, cognitive skills are defined as the mental processes used for gaining and maintaining situational awareness, for solving problems and for making decisions. Interpersonal skills are regarded as communications and a range of behavioral activities associated with teamwork. In many operational systems as in other walks of life, skill areas often overlap with each other, and they also overlap with the required technical skills."

    basically, if you are afraid of getting screamed at for asking if the flaps are supposed to be down, as a junior flight officer you might keep quiet, sometimes with disastrous results

    • Kay Funk, MD – Yakima

      One of the responsibilities of the junior flight officer is to address the situation constructively; "afraid of getting screamed at" is not an excuse to fail to act.

    • QuantumSofiaRN

      Your commentary and example are discussed by Malcolm Gladwell in Outliers chapter on The Ethnic Theory of Plane Crashes. Regardless of framework where we create disparity inequity will follow. Even within these posts I see the competetiveness and defensiveness of I am , a Dr, nurse or EMS. We collectively seem more preoccupied with status rather than focusing on whom we serve. Listening, making a decision to connect rather defend I believe is the solution.

  • Matt Baen

    Bullying, aggressive - and often cowardly when called to account - overgrown infants need to be shunned in every facet of life. They should be fired, lose tenure, de-licensed, expelled, evicted, divorced - whatever it takes it to remove them from positions of leverage over others. No matter how high or low on the socioeconomic scale there's almost always a tinpot dictator poisoning the environment. Their lack of social impulse control and abusiveness are a huge social, psychological, and economic drain. There's a myth that bullies are effective or "get the job done", and that needs to end now.

    • Eric Brown

      So, your solution to bullying is to be even more bullying? How many rights do people have before you're going to cost people their jobs & their families? I'm sure that people like you want the shunning to follow them around, as well, so that these accused "bullies" are left homeless.
      No, thank you.

      • Matthew Hopkins

        Won't *somebody* think of the bullies? Those poor bullies, let's be real empathetic about them, those fragile and valuable snowflakes that they are.

        No, these are human vermin that poison the well of all they touch; social, psychological, economic, they're a blight upon us all, including their spouses and children who they abuse.

        Losing their jobs, families, and homes is getting off easy. Easy because while it isolates them from the rest of us, it doesn't address the core problem, their toxic personalities.

        You know, in an earlier era, lobotomizing them en masse was an accepted solution to behavioral problems. Compared to the sorts who were lobotomized a century ago, bullies have it coming. I don't expect physical lobotomies to make a comeback for them (unfortunately), but I would expect some medical attempt at forced personality alterations. It's for our good, and theirs.

        We're long overdue for this particular witchhunt, and unlike so many witchhunts, we'll see dramatic societal improvement as a result of this one. Since witchhunts are a society's immune system response to harmful behavioral problems, we might as well have a deserving target, and has there ever been a more deserving target than bullies? It's their turn next, and we all know it. Let's get it going!

        • Eric Brown

          Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive. It would be better to live under robber barons than under omnipotent moral busybodies. The robber baron's cruelty may sometimes sleep, his cupidity may at some point be satiated; but those who torment us for our own good will torment us without end for they do so with the approval of their own conscience.

        • Eric Brown

          Oh, and a bit from Wendell Berry:

          “Condemnation by category is the lowest form of hatred, for it is cold-hearted and abstract, lacking even the courage of a personal hatred. Categorical condemnation is the hatred of the mob. It makes cowards brave. And there is nothing more fearful than a religious mob, a mob overflowing with righteousness – as at the crucifixion and before and since. This can happen only after we have made a categorical refusal to kindness: to heretics, foreigners, enemies or any other group different from ourselves.”
          But self-reflection isn't your strong suit, is it?

          • Kay Funk, MD – Yakima

            Eric, your posts are far more thoughtful than:

            "We're long overdue for this particular witchhunt, and unlike so many
            witchhunts, we'll see dramatic societal improvement as a result of this
            one. Since witchhunts are a society's immune system response to harmful
            behavioral problems". (Can these words be anything other than ironic?)

            But the last sentence interferes with communication.

          • Eric Brown

            I'd like to think that Matthew is being ironic, but given other behaviors I've seen from people like him, I actually think he's serious.

        • Kay Funk, MD – Yakima

          I can't even tell if this is being ironic.

          A person who is up at 2AM doing life saving surgery does not deserve to be called "human vermin that poison the well of all they touch".

          And that doctor's first duty is to the patient, not to the feelings of the support staff.

          The unhelpful escalation of anger on both sides of the discussion above shows that there are strong feelings on both sides. What we need is willingness to communicate on both sides.

          • LLB

            Why don't we start when kids are little, before they even get near medical school? I was horribly maltreated by peers in school from the age of 7 until my father died in a plane crash when I was 12. It was in all the papers and that finally got them to lay off. But permanent damage to my social skills and self confidence had already been done. I still feel "different" from other people, and don't know how to approach, how to enjoy, how to talk to other people. Add to that the ugly, cruel, rude words from professionals higher on the food chain in school, and the constant fear that any minute someone with complete power over me could just have me thrown out, with thousands and thousands of dollars in debt and no degree, and then jobs after school where people acted the same way, and it hasn't added up to much of a life. I think some people who are this way probably were bullying others way back when they were 8.

          • M. Tipton

            LLB, Having grown up in a home with an alcoholic father and an angry mother, I can relate to your feeling different. It's taken me years to accept my differences and when (even) my daughter says "Mom, you're so weird", I can now say "thank you" and mean it. I hope the same for you someday.

          • sameer

            the 'support staff' are people too, you know,they deserve being treated with respect because a surgeon or whatever cannot do anything and I mean anything without his/her co-workers and ultimately it reflects the patient care.Bullies survive in this world because of sensible people who don't react when these bullies show their insecurities and lack of confidence.The world will be a better place when children and given formal classes about how to behave like human beings and when laws are enforced to make bullies take atleast 4hours of a lecture of descent behavior every time they even think of hurting another person's feelings no matter how much they are PMSing.Its their least duty to apologize if they hurt someone's feeling unintentionally. and for bullies who do it intentionally,I would really hope there are laws to teach them a lesson for life and humiliated the same way they humiliate others.

        • Darlene Moak

          And Matthew, you're even a little scarier than Matt. A return to lobotomies for "behavioral" problems (an adjective that I have learned to despise)? Really?

      • inquisitive

        In pretty much any other industry, if a person was really horrible to work with or work under, they would find themselves fired or transferred somewhere that no one had to look at them. That's not bullying, that's business. If you don't want to be fired for being terrible, don't be terrible. That having been said, if the person in question is really good at their job (but horrible with people), they should be told exactly what the problem is and given opportunities to improve, including therapy if needed.

        • jkraszkowski

          Except there is no accountability for doctors. They can do and say what they want and no one will call them on it. In fact, some that do, like nurses, are then in turn attacked by the very same folks that were abused by the physician. Its fascinating primate behavior and sure there is lot of research on its impact but in 40 years I've to see a study that attempts to correct it. Why...society doesn't care.

          • inquisitive

            Some of the folks that are the worst at dealing with people are those that have no idea how to. And they're unable to see just how bad they are at it--think 'dunning-kruger effect'. Social rules are one of those things you either just get--or you don't.

            I agree that no one should have to be subjected to horrid behavior from coworkers. I also think that people should be given a shot at improving. There are lots of courses in how to diagnose and treat in med school, but there is no Tact 101. Let people that are having problems take a course on how to develop emotional intelligence. This signals to the person that there's a problem that needs to be fixed and gives them something to work toward to fix the problem. No one wants to be bad at their job--especially a doctor.

        • Eric Brown

          I was responding to Matthew Hopkins & Matt Baen, who seem to think that losing one's temper should result in losing one's medical license, and have "Poor Impulse Control" tattooed on one's forehead.
          Well, I don't believe that Matt's punishment fits the crime.
          Punishments should be proportional and limited.

    • Kay Funk, MD – Yakima

      This comment lacks specificity, nuance, measurement and science. Are you a doctor?

    • Darlene Moak

      Matt, if I saw you walking down the hall toward me, I would run screaming in the opposite direction. You are far more arrogant and judgmental than I am - and that's a pretty high standard to overcome.

    • Dr. Nice

      Hi: With the proliferation of malpractice suits out there, I'm sorry, but the patients are the bullies. Yes, patients suffer in a bullying culture, but we're all under the gun.

  • djhbaw1

    I've learned to trust the nurses more than the doctors. They're less vain and while they can be a bit lazy, they're always more honest and usually just as insightful.

    • NotAnurse

      Just as insightful? You obviously have your head up your ass if you think a nurse in more insightful than a doctor...

      • djhbaw1

        I did say "usually". But this has certainly been true for many of my visits. The doctors are off spouting their big words, but the nurses really know what's going on.

        You're probably one of those doctors who secretly hate nurses for being competent.

        • Darlene Moak

          Oh honey, give it up - you lost this fight.

          • sameer

            A live example of how bullies think they won some 'fight'.Thats only because sensible and calm people avoid them.

      • sameer

        are you insightful??LOL

    • PA RN

      "A bit lazy"? I'd laugh out loud if I wasn't so exhausted from being on my feet for 12 hours, no break/lunch, and 2 hours of paperwork completion after giving shift report. Must have a typo. Taking the high road here.

    • Km,RN, CPAN

      I am disgusted by your comment that nurses "can be a bit lazy!" I work very hard, don't have time to sit down or even use the bathroom! Nurses are at the bedside and know their patients intimately. I am the "eyes and ears" for the physicians I work with. My experience has also made me very insightful and I am frequently the one who picks up a serious problem. On a personal level, I am the one who accurately "diagnosed" my son's Chronic Regional Pain Syndrome which was greatly exacerbated by a physician who didn't have a clue. This was backed up by a leading MD in the field. Nurses are getting more respect by some physicians but there are still many who denigrate and belittle. In addition to my years of experience, I regularly read and learn and attend conferences in my specialty. I am also certified in my specialty. Fortunately, many of the doctors I currently work with are generally respectful and recognize the value of my opinion and concerns. But physicians who feel nurses are lazy are part of the problem!

      • djhbaw1

        Sheesh, you toss off a bunch of complements but add one barb and boy you don't hear the end of it.

        I certainly don't mean someone like you. And if you'll note, I agree with you about the respect given to nurses. But I've also been around the hospitals for some time and a number of nurses seem to be just punching the clock. They're certainly smart and valued, but I've learned not to expect much initiative from a significant number of them. Sure there are some who are different but they stand out.

      • Craig

        Many, not just an odd few, nurses do not know the vitals or why the patient still has an IV when they call you at 3 am to ask if the infiltrated device can remain out. That said, this is tragic because to quote an old colleague of mine: "without the spoke of good nursing, the medical wheel cannot turn". And i wholeheartedly agree as well as encourage all my "helper bees" to be more involved with the patient.Km, thanks for being one of the best.

        To the original discussion, the underlings involved also have different levels of sensitivities, and as a respected teacher for years, I can tell you it is tough to know who will tear up at even the slightest authoritative tone. For many, this is positive stimuli, for some, negative bullying. The trick as a teacher is knowing how to read the audience.

    • hosahalli padmesh MD

      very long letter, good discussion, no matter what bullying should be monitered,many MD,S DO IT, unfortunately surgeons are the worst, its not about patient care, its all about ego, bad perception and training, bullying should be stopped at any cost, no excuses.
      h padmesh md.

      • theheadman

        Surgeons are responsible for the patient but the surgeon has no say over who is hired to work with him/her in the operating room. Often support people in the operating room lack knowledge about he operation, have little or no experience, lack initiative, and demonstrate very little common sense. It can be very stressful for a surgeon to operate on the patient and manage the personal in the operating room effectively. Also, the operating room personal work on a shift but the surgeon works by the case. This leads to inefficiencies as people slow down as the shift comes to an end.

  • Cliff Haby

    Three comments. 1) there is a difference between using the language "bad people" and "people with unacceptable behavior". I think we would be best served steering language away from the dichotomy of good vs. bad. Let's figure out what works best. 2) One finds a similar set of behaviors among some university professors ... . 3) On the "plus" side, to have a Ballet one often needs a "prima-dona" .

    • Margaret Fleming

      I think I read the article thoroughly. What about mean doctors and patients! In acute spine rehab, I had some cruel remarks from the admitting doctor, who also was the only doctor around much of the time. This continued disrespect and criticisms of not doing our best can put the patient into a downward spiral and a feeling of helplessness. God knows all I wanted was to get better and walk around normally!

      "Nurses attended morning rounds with the doctors/" Great for intra-medical communication, but that's a tough one for me. During radiation this year, the nurse was always standing there when the doctor paid a quick visit. It's impossible to ask a doctor to change something or do something differently or to explain something more completely with the nurse standing there. It's like trying to negotiate with your employer in front of other employees! Sick people are not always in shape to think of inspired ways to ask for something.

    • Kay Funk, MD – Yakima

      Well said.

  • jpmct

    Use of the term "bully" to describe anyone who makes one's workplace uncomfortable always conjures an air of puerile incompetence in the user of the epithet. Operating rooms are places where a team approach is paramount to success. Intolerance for a team member who arrives without knowledge or attitude that promotes such success should not be surprising...and should not be discouraged. While I agree that there will always be surgeons whose demeanor and carriage could be more socially gratifying, the overwhelming majority of successful medical team leaders create an atmosphere of expectation. This expectation leaves those who are prepared with a sense of accomplishment...and those who are ill-suited with a sense of being "bullied". I would suggest that we leave this childish terminology in the schoolyard where it belongs.

    • Kay Funk, MD – Yakima

      Very well said.

  • Rafael M

    Great articles. That makes me remember the book "checklist manifesto", which the author shows how important is the concept of team in any heath procedure. Futhermore, mister Feyman have show in his book "what do you care what other people think" that the spaceship challenger have exploited because one of the technicians was afraid to report a mistakes in a rubber band

  • James White, M.D.

    Having practiced medicine in two specialties over the last 42 years, and having experienced all that is related in this article, first hand, the bitter truth is that we live in an age opposed to heroes, most especially white male heroes, such as Caesar, George Patton, Chester Nimitz, and Douglas MacArthur. One might include Jonas Salk and Denton Cooley in the club of heroes, and many more.

    Yes, there are excesses, but if done in the quest for excellence, those characteristics should be at least forgiven, and sometimes even admired. We have devolved into a pantywaist nation of "feel-gooders", in which decisions are made by committees (you do know that the camel was designed by a committee).

    The road to the top of the mountain is rugged, and to deal with life and death daily with your own hands is a Herculean difficulty. Do you not imagine when McAuliffe replied "nuts" to the German demand for surrender at Bastogne, he knew he had probably invited hundreds of further casualties?

    But I am a dinosaur, and will observe the results of the "feel good, be nice, and don't work them too hard" programs in progress, while I continue in my own way. Dominus vobiscum.

    • Kay Funk, MD – Yakima

      I think that Dr. White is saying that saving lives should not be taken for granted. He's right.

      A good outcome for the patient is the first goal.

      • James White, M.D.

        Yes, thank you, Kay; that is exactly right. An old man cannot be convinced that "systems analysis" will yield much, when working with the human animal. Just between us docs, it is axiomatic that "doing the best for the patient" is not always synonymous with "doing what the patient wants," which leads to bumpy roads often. Best of luck in your career. Jim White, Baton Rouge.

        • Fred Parris

          Interesting discussion. To the point of the importance of communication between doctors and staff the imposition of "duty hours" for physicians has actually degraded patient care in some settings as the continuity of the same resident following the case as long as practicable has been lost. Unintended consequences often follow good intentions. References readily available.

          • James White, M.D.

            Thank you, Fred. Might I tell you that I have spent a hundred (or a thousand; time flies) nights lying on a cot in the hospital, next to a seriously ill patient so as to be immediately available, if unexpected problems arose. (Not referring to teaching hospitals, with residents, here.) The reason for this was so that I could look myself in the mirror, no matter the outcome, and know that I had done my best. "Regulation" of duty hours, and medicare "treatment guidelines" are destroying the relationships of physicians and patients alike. Best, Jim White.

          • Fred Parris

            Agree Jim. I supervise at UCSF on the clinical faculty and the residents are not getting the experience I recall, but unfortunately many will be employees of some HMO or the government.

  • Michel Demeester MD

    When I was 25 or 26, I made a big mistake. my boss, a lady, professor of cardiology at Presbyterian Hospital, Columbia university, yelled at me violently in front of 5 or 6 people. Then silence. I had to answer. So did I: I answered, "Sir, yes Sir" - full stop.
    She was somewhat surprised; she did not react, but had a slight smile ... That was
    it. Actually, she knew I had understood her. And I knew she knew it

    After this incident, I had the utmost respect for her and I tried to be "perfect."
    And she also respected me

    Is this a matter of culture? I doubt it. She was just a “strong” lady.

    Later, I had to deal with people who liked to be aggressive and insisted on my mistakes

    I never considered that it was a matter of culture, but a straight
    individual conflict. I had to deal with a rude & stupid person, unworthy of respect and I treated him or her accordingly. How? A matter of circumstances and
    balance of power. If they had too much power, it was "double or quit" ( literal translation of French “quitte ou double” =win or go.

    It does not mean that there is no medical culture. It is established on empathy, as you stress. Empathy is biological - not cultural: it is a necessity for the human species, namely, for the human newborns to survive - Some,in South America (Humberto Maturana) prefer the word "love" - It is essential between the doctors - of different age and experience, between doctors and nurses and between both and the patients. In any team - of which the patient is inevitably a member - strict hierarchy is a must, as is a lot of communication and mutual respect. The
    role of the boss is essential: (s)he gives the tone as the conductor ( in French, we
    would say the “la”). Empathy is obviously not enough but it is the “foundation”.
    The boss/leader also has to combine two qualities : “Auctoritas” & “Potestas” as the Romans used to call them.
    Auctoritas is the capacity to solve the most complex problems and to make “emerge” the best solution, be the author of the answer ("author" has the same etymology). Auctoritas imposes respect. Potestas is power, even violence to impose one’s will and to force the others if need be. Potestas inspires fear A lot of people believes that they have authority and impose an authoritarian atmosphere. In fact, this is confusion : they just have some power. They inspire no respect nor trust.
    Auctoritas & Potestas are acceptable together by the members of the team if they are applied with empathy; they combine correctness & justice. In the absence of empathy, arbitrary power prevails. And conflict as you describe, and very negative outcomes, also for the “leader”.
    Anyway, "culture" contains many other dimensions.

    • Kay Funk, MD – Yakima

      The problems of human nature and the exercise of power never change. The historical perspective is so valuable.

      Empathy is great, but I would also recognize the role of technical expertise in "the capacity to solve the most complex problems and to make “emerge” the best solution".

  • http://kalamazoopost.blogspot.com/ Tony Indovina

    Maybe things are different at Harvard. In my experience (20 years out of residency), the systems approach to medical mistakes, bad outcomes and near-misses has evolved several generations since the 1986 article quoted here, and medicine is likely better today (any recent studies?) This is somewhat like debating the efficacy of leeches and the curative properties of mercury.

    As referenced by robertmerdahl upthread, medicine is adopting the airline industry approach of developing redundant systems, de-briefing after cases, root-cause analysis meetings, etc. It's a systems issue.

    As for bullies, I just don't see it. Granted, I trained in a state school program in the smallest city with an accredited program and people had genuine Midwestern politeness. Now I work in a community hospital with no residents and few medical students. The nurses are my neighbors, their kids go to school down the street. Why on earth would I be rude to them?

    I suppose bullies exist but review committees exist to keep them at heel. Fortunately, medical professionals at all levels are self-selecting out of the field as they realize that maybe they will be happier as a professional blackjack player or cowboy. Good riddance.

    I especially take issue with the student doctor's lament: "But we also can’t ignore a system that takes loads of formerly ‘nice’ people and churns out jaded, bitter, and gruff ones. We have to call attention to the external factors that can contribute. The lack of sleep. The poor hours. The system that overbooks and overworks."

    Again, her experience is way different from mine. First of all, who says these people were "formerly nice"? Maybe they were sociopaths at birth. Furthermore, we learn and gain expertise by repetition and I thrived on hundred hour weeks as a student and resident and was happy to see everything first-hand. Now, my schedule is easier and I'm happier relaxing with a cup of coffee discussing a patient's concerns or management with the nurses. The "system" doesn't "overbook", we do. I drive a Toyota.

    Study hard, learn how to care for patients. Rudeness tells us more about the purveyor than the recipient. Have compassion for their struggle, that's part of your training too. And when that doesn't work tell your program director.

    • KM, RN,CPAN

      As a nurse with 35 years experience, I have repeatedly been subject to condescending and bullying behavior by physicians. I have learned to stand up for myself and be a true patient advocate, regardless of whether I know I will be criticized or even publicly humiliated about my concerns.

      • http://kalamazoopost.blogspot.com/ Tony Indovina

        I guess the larger point is that nobody should be subjected "repeatedly" to bullying behavior. Bad behavior is reported up the chain, there's a process. In some locations, nurses have unions that are part of the process, but even without labor unions work place rules exist. "Standing up for oneself" is admirable, but not necessary and often counter-productive.

    • sameer

      Calling lack of sleep and poor hours as external factors and using them as excuses to be rude to others and liberating frustration is never the answer,that would only make the hospital life more and more miserable as it already is.

      • http://kalamazoopost.blogspot.com/ Tony Indovina

        "excuses to be rude"? Who said that? Not me.

    • John S MD

      I am dealing with a physician that has been terrorizing the nurses every time he is coverage on call. And he is good at it as this is done exclusively over the phone....he has never come in to see patients in over 10 years. Administration would rather he not follow JCHO standards than deal with him. For years, he only communicated by fax, blew up if the nurse actually called him. Faxes have recently stopped (only when my malpractice risk manager advised me to request I not be on the same week end as him and I relayed this to the hospital.) Nurses still won't call, rationalize to themselves that the clinical problem "is not that bad," reluctantly ask the psychiatrist to deal with the medical issue among other avoidance strategies. Administration has ignored his behavior (for years) to the point that he convinces administration the nurse was the problem and then management disciplines the nurse, throwing him or her (rarely a him) under the bus....seen it many times. Like most (if not all bullies) he demonstrate all the characteristics of a personality disorder. (DSM for practical reality version)
      1 "There is nothing wrong with me, I'm not the problem."
      2 Puts the blame on everyone but him/herself (Try asking them what they think is THEIR contribution to the repeated conflicts)
      3 The more they try to solve a problem, the worse they make it
      4 Never learns from their mistakes, never gets better, repeating same behavior
      5 Uses phrases like born under wrong stars, always bad luck or feeling is unjustly being picked on or "That Dr. S has it in for me." (I am chairman of the physician behavior committee)

      Personality disorders never truly "get it." They can use direct strategies like bullying or reverse bullying (painting themselves as being the victim of your abuse). Often such physicians justify their behavior because they say they are passionate about their job and get frustrated at subordinates' incompetence or "unprofessional attitudes." A good question is to observe there are several other physicians that work with the same support staff and they never get into the problems he or she does. Why is he/she the only one? The best answer I've heard was from a specialist who said the other physicians were inferior or did not care about the quality of patient care. I think I said something like, "I'm glad to hear you care so much about the patients' welfare, but why should that get you in trouble?" "Every one is jealous of me." was his answer. The words change but the music is repetitive (I'm not the one with the problem.)

      In my view, the personality disorder is not the problem (problems can be solved). Rather, it is the sinister way they get those around them to behave in unhealthy ways. (Giving them what they want, looking the other way, abusing them rather than healthy limit setting, etc) The personality disorder invites us to join them in their musical of dysfunction. We are the problem if we perform on their stage. Make sure you are working on the right side of the equation. Good luck all.

      • http://kalamazoopost.blogspot.com/ Tony Indovina

        It sounds like your disciplinary system needs to be tweaked. I can honestly say that that type of behavior would not be tolerated in most institutions. And who practices medicine by fax? WTF?

      • theheadman

        Why don't you have the disruptive physician undergo an independent evaluation and counseling for better coping strategies? On the flip side, have you asked him if the resources that the hospital provides match his responsibilities? Where is your empathy and understanding in your letter and in your hospital position? Finally, borderline personality disorders represent 2% of the population and are more common in women than men. If the bully is the bull, then the passive aggressive person is the chameleon. These people hide well in the workplace but are no less disruptive.

      • VeryQuestionable

        This can be taken several ways. Considering as most people don't post overly revealing rants on websites, I have to question if you're not just jealous that whoever you're talking about is doing better than you with this perceived "disorder."

  • maruja de lujo

    What a great article! The culture of bullying occurs in all sectors, of course, but it can do much more widespread, serious, long-term damage in the health-care sector than in – say – the restaurant business.
    The relevance and importance of the article is made even clearer by the pompous responses defending badly behaved doctors and the culture of bullying.

  • Debbie Thompson

    As someone who heard that Neuroborreliosis, Rocky Mountain Spotted Fever, and other infections, were "in my head" for at least 30 years, by over 70 different doctors, (finally found the one who saved my life, or I wouldn't be here writing this), I found that many of them do a great job at bullying sick and dying patients, as well.

  • Gary Craig

    When Physicians learn how to tame their ego's as " Know it Alls" they might start to regain the respect they crave. Orthopedic Surgeons and Dermatologists seem to be the worst offenders. They seem to possess a mind set of ' My way or the Highway.

    • Kay Funk, MD – Yakima

      Physicians don't "know it all", but they know VASTLY more about the practice of medicine than non-physicians. It's not helpful to dismiss the importance of that knowledge gap.

  • ibisdoc

    When I read the title, I thought that this would be an informative article of the latest trend of know-nothing administrators (with one or two year "advanced" degrees) bullying doctors. Instead, I was disappointed to see that it was more of the same drivel, "blame the doctor" mentality that is fashionable these days.

  • g75401

    To enhance the medical industry's abilities to deliver competent care, one must identify the core values of the members that self-select for medicine. I suggest any of the research of Jonathan Haidt regarding the moral basis of those choices. If you attract a lot of hierarchical-individualists to the profession, they will institute a hierarchy and the hierarchy is maintained by way of intimidation and non-constructive criticism-afterall, a hierarchy has people at the bottom and people at the top, right? If medicine tried to attract egalitarian-communalists instead, that hierarchy wouldn't exist and the mechanism used to enforce hierarchy wouldn't be created. Sounds simplistic, but it's social science in 2014.

  • trentlanders

    As a hospital administrator worker, you usually know all the dirt on doctors, nurses, interns, practitioners, etc. When a situation get out of control as described above, I simply enlist the help of "friends" on the out side, by telling them the peripherals of the problem. They confront the doctor upon leaving the hospital by stopping his car, dragging him out, giving him a light beating and admonishing him to be more of a mentor to his inferiors of the medical staff and make an effort to improve the quality of patients' treatments under his care. It is amazing how the doctors' attitudes turn around if they don't want to see my friends again. Better medicine through intimidation...just what the doctor ordered.

    • Kay Funk, MD – Yakima

      Well, I'm PRETTY SURE that this is irony.

      But I don't see what it contributes to problem solving.

    • QuantumSofiaRN

      trentlander violence meeting violence is hardly the road to cure

  • meyati

    All I know is that a bully poisoned me. All through each visit, it was -what if your lipids, etc,go out of range. He did his research on me well- what will happen to your disabled vet son, if you have a stroke? I didn't know to look up statin- I just looked up the brand name-and the sites and FDA said it was wonderful. My Achilles tendons went out-one ruptured. I'm in a medicare advantage/HMO where a patient needs to be on a long, long waiting list to change doctors. I'm finally free of him

  • Estarianne

    Something not really mentioned is how these relationships affect communication with patients. Does the nurse who is bullied by the doctor take it out on the orderlies? Or on the patient? I have been the victim of a bullying, disrespectful nurse and I can tell you there is a terrible powerlessness in being abused by a person with so much control over your health and comfort. Even if the abuse is something that would appear minor on paper, the failure of trust is huge.

  • jkraszkowski

    What struck me about the research was that this topic isstill being researched. Unbelievable that money is still being spent on proving the impact of abuse but not one report or one penny spent on actually developing and implementing a method of correcting this problem. I have been hearing and observing physician bullying since the late 70's. Yet here we go again.This is the true measure of how much we as a society don't care about the issue ....30+ years after physician abuse had been measured and defined we are yet to develop a system of correcting it.

  • http://regionalextensioncenter.blogspot.com/ Bobby Gladd

    Interesting article. You can't have a "critical thinking organization" in a culture where one speaks truth to power at one's peril. In health care specifically, it's then a patient safety issue.

  • BeachyGal

    I am an EMT. Last week a woman went down on a subway platform in NYC. Naturally, I rushed over to see if I could help. She was bleeding from a cut in her mouth and was not coherent. I told a stander-by to call 911 and proceeded to do a standard assessment. Another EMT came along to help. The woman was improving and could cooperate with the neural/stroke tests so seemed to be stabilizing. An ER doc was announced and I offered to yield the patient to his superior training when he starts yelling at me to leave the woman alone! He refused to take over and also created a huge scene when I refused to leave her. I am afraid I was not gracious in this regard. He would not help nor let anyone else do so. That is not how I see my duty.
    I doubt he has had anyone talk back to him as I did. I am not proud of that public display and have resolved never to get drawn into such a thing again. I could never work with such a wretch on an every day basis and I hope there evolves an effective remedy for my colleagues who must do so.

  • LLB

    Hate to say it, but it's the same in veterinary medicine. Only, for the majority who don't go on to an internship or residency, it's a lot more likely that inadequately trained people will get thrown into a situation over their heads (I'm talking about surgery here) because the vast majority of veterinary graduates go right into private practice, where there is a lot of financial pressure NOT to supervise, not to train, not to help.

  • Suzi Q 38

    Usually surgeons.
    "Take no prisoners."
    In a way I would like that if he/she were doing my surgery.
    Everyone would be on a heightened alert for the duration, all parties striving to do their best.

    Hopefully, when the surgery is over and successful, the others in the room can make fun of him/her when h/she leaves.

    I don't hire surgeons for their bedside manner.
    Likewise, I would not care if others saw the humor in all of the negativity and made fun of my surgeon. H/she would deserve it.

    • Nancy Lebovitz

      The point of the article is that harshness *doesn't* get excellent performance-- it gets people who are afraid to say something when things are going wrong.

  • Graciany Miranda

    We need to train with people like that to better appreciate good colleagues once we leave school...still sucked though.

  • M. Tipton

    I am an RN. The psychiatrist I work for has an explosive temper with his wife and with me, but never with his patients or our secretary. We have worked together for 15 years and I am about to retire. Two years ago I began to fight back and have made it clear to him that his behavior is unacceptable and I won't stay at work if he doesn't calm down. That usually leads to a halfhearted apology filled with "but you..." or "but my wife..." He blames his temper on his culture, which is not American. If I wasn't so close to retirement and the job market for people my age was better, I'd be out of here in a heartbeat.

  • danwalter

    "residents who work 24-hour shifts..." There's another problem right there.

    • TH

      Residents who do not work 24h shifts is creating an entire generation of physicians who cannot function when they are tired.... and there is no 80h work week rule in the workforce and they are making mistakes when tired as attendings that training while tired during residency would've taken care of when they had backup.

      TH

  • TJK

    This discussion is equally relevant in the aviation world. Civil air transport and military aircraft are flown and maintained by teams. Entry, continuation, and certification requirements and human dynamics and cultures are much like medicine: similar high standards, intense and demanding training, same stakes. And egos, career concerns, potent hierarchies, varying skill levels, falibilities and foibles, and the endlessly varied interplay of personalities under stress.

    As the recent crash landing at San Francisco (and others) illustrate, strong crew coordination (professional expertise, courtesy and cooperative effort, open communication, crosschecking, and so on) is essential. When rude or abusive misconduct occurs or social standards irrelevant to mission performance prevail, people die.

    One difference between medicine and aviation appears to be, however, that aviation has in place a highly developed, enforced training and operating structure to ensure crew coordination, leadership, and proper conduct.

    All pilots of crew-served aircraft go through extensive simulator training, repeatedly, and are periodically monitored in flight. In those sessions, crew coordination is a required, quantified goal. It is graded, and passing is essential for continued flight assignment.

    Unlike the civil and military aviation establishments, medicine does not have a statutorily defined, purpose built, independent and dispositive structure peopled by educated and experienced experts for enforcing "crew coordination".

    It may be that such close supervision and regulation would be impractical or even counterproductive in medicine.

    Nonetheless, principles, organizations, and practices developed out of aviation blood lessons have created and maintain safe, effective performance, individual and collective. Such principals, structures, and practices, appropriately translated and applied, might be useful in medicine.

    See earlier posts from Mssrs. Meerdahl and Indovina

  • QuantumSofiaRN

    Experience in healthcare has shown me that this culture permeates throughout all divisions of care in hospitals. I cannot express my gratitude loudly enough. Thank you for having the courage to speak up and find a format to be heard. There is no room for bullying or disrespect , maladaptive behaviors that scream of ill health. We have lost sight completely that care is our root . Lets try to inject a little faith , relinquish ego and selfish agenda and create a safer place where our hospital culture grows from building each other up so that patients get the proper care they deserve. Put the verbal scalpel down and the pulse back on care. Wake up and learn the way that we serve best is by learning FIRST to give.

  • http://ritalawrence-langata145.blogspot.co.uk Rita Lawrence

    Still one year out from the Robert Francis QC critical report on the Mid Staffordshire Trust scandal related to unsafe patient care, he has had to appeal for an end to the defensive culture and reinstatement of professionalism through openness with the public and role modeling, stating that the attitude that pretends 'can do' leads to a deterioration to open and honest cultures that can put things right. Medicine has been a closed culture and when we have licensing boards that target individuals who work in broken systems then shame them publicly by putting their names in the 'professional' state board paper as well as on line the culture continues to reflect they way the people in charge operate. I question the bench mark for professionalism when they fail to look at the whole system and when they publicly humiliate those who are licensed by them.

  • Ray,D.O.

    First of all it is 3rd year medical student IY, not doctor yet. Has she ever wondered why some of these bullies are typically the surgeons and leaders in a department? I wonder if IY has any type of understanding the pressure many of these "Bullies" have? Many are in actual charge of that patient's life whether in surgery or on the floors. Has IY ever gone in to tell a wife, husband, son, daughter or another close contact that you were unable to revive their loved one? Has she ever been in charge of that surgery or procedure that needs to goes as perfectly as planned? Most likely not and until she has she should hold off on making accusations of bullying. I'm even sure she is just as guilty of bullying on her way up the food chain whether in high school or college as she was admitted to Harvard. She want life to be full of butterflies and rainbows but that is not the way life is.
    My second point is that in my 18 years of experience I have been involved in many aspects of teaching and I have found that the Allopathic system is way more apt to fall into the Bullying teaching methods. Whereas the Osteopathic system is a much more helping environment with regards to learning and less of the Bullying pulpit. I would encourage IY to leave the ivory towers of the Harvard lectors and participate a month at a Osteopathic learning site. In my 18 years those physicians I encountered that did their training at Harvard, University of Michigan, Emory and Georgetown these were the ones that were the more judgmental and condescending physicians I've ever encountered. So be careful throwing stones IY you are most likely headed down that road.

  • Darlene Moak

    As someone guilty of quite a bit of bullying over the years, I think I can speak from the "other side" of this debate with some authority. The truth for me was that while I am not bipolar I have what I think is a biological tendency towards aggressiveness. I got better when i started taking a mood stabilizer (Lamictal). I'm not perfect by any stretch of the imagination. But I wish I had been put on something in this class of medications ten years sooner than I was. I think it would have made a lot of difference.

    • http://thinkbirth.blogspot.com/ Carolyn Hastie

      Thank you for sharing your experience Darlene. Very generous and courageous of you to share that insight; and useful information to put into the mix. You bring a very important aspect to think about into consideration.

      • Darlene Moak

        Thanks for the reply, Carolyn, much appreciated!! I have to admit that I also did better after I left an academic environment & struck out into solo private practice - at the end of the day I had only myself to answer to. As I said, I'm still not where I'd like to be but I'm better than I was. Thanks, again.

  • Amy

    hmm the great majority and worst examples of bullying I've experienced/observed at my work places has been nurse-led (this includes - always female - junior doctors being ridiculed for their body shape and in one case being physically struck multiple time. Another great divide to address another day...

  • Robert Fielder

    If there was ever a time when a culture of intimidation produced better doctors, it was a long time ago. Unfortunately, as Ms. Yurkiewicz so effectively states, that culture remains firmly entrenched in too many of today’s healthcare systems and changing it is going to require much more than the lip service that’s been too often paid to it to date.

    Making that change has to start with the realization that interpersonal conflict within any group or organization is a constant. Often manifesting itself as anxiety or excitement that you can see it being transferred up and down the hierarchy or across team like static electricity on a cold morning.

    As the dichotomy of anxiety and excitement suggests, the realization must be accompanied by the understanding that conflict itself isn’t inherently good or bad; rather it’s the reaction to it or the reaction caused by it, that determines its effect.

    In some organizations, the by-product of conflict is largely positive, some times enormously so. The resulting focus and excitement produces a highly motivated and engaged workforce, constantly challenging themselves and others to improve their performances and processes.

    Regrettably, in the greater share of hospitals and practices, the outcome or impact of conflict is negative and the results are the stifling of ideas and initiatives that complicate and compromise the teamwork essential to quality care.

    Securing the right reaction to conflict is determined by the organization’s preparations to address it. Specifically, healthcare organizations need to develop a Dispute Resolution System (r2rnot.net) geared to promote closer contact and greater communication in the midst of conflict rather than allowing the action/reaction process to turn negative.

    Senior Leadership must get their collective "heads out of the sand" and realize that the absence of conflict isn’t a litmus test of their managerial skills but rather collective denial that allows existing conflicts to go unseen, unacknowledged and unaddressed. In those organizations, managers and supervisors are rewarded for keeping conflict under wraps and behind closed doors. Those organizations focus on smothering conflict rather than aggressive surfacing it and having proven means and methods readily available to address it.

    As we’re discovering, the Joint Commission’s well-intentioned foray into Conflict Management with their Leadership Standards for 2009 may be making things worse. Are we surprised that the sole reliance on Codes of Conduct with the rigorous reporting of behaviors violations have failed to produce any meaningful improvements in those reported behaviors? Experiences in other environments confirm that Peace Keeping Police Actions like Codes of Conduct without the simultaneous introduction of effective, Peace Making endeavors usually back fire.

    It is these missing Peace Making Endeavors that are the critical elements of an effective Dispute Resolution System. Such systems give voice to the “abused” while allowing both parties to participate in designing the steps needed to achieve a lasting remedy. In some instances, just providing a safe environment for the parties to
    hear and see one another can promote the healing process.

    Having facilitated such sessions, I can report that many of the “abusers” are often truly surprised that their actions have caused such damage and are sincerely contrite when made aware of that impact. In many instances these reformed individuals become the most effective champions of proactive dispute intervention.

    Sometimes additional steps are required either prior to or in addition to these encounters. Offering peer or (even) professional coaching on communication and conflict skills has proven to be immensely productive in elevating the individual and collective dialogue and achieving the transformation of conflict. Providing peer and/or professional mediation to facilitate conversations and to manage the environment can be very effective in restoring the communication and rebuilding the relationship.

    Dispute Resolution Systems can have 3 or 4 stages or components, like those referenced above. Others may have 6 or 8. The CMO or HR can administers the program or it may function better under the purview of an independent compliance officer or Ombudsman. These are all local options to be decided at the hospital or practice.

    The biggest challenge to the development of these systems is
    the need for their continuous presence and constant oversight. Securing the commitment necessary to sustain such on-going activities can be easily compromised by the incremental nature of the improvement the processes achieve. But those improvements are real, revealing themselves in greater employee and provider retention, engagement and productivity as well as improved clinical outcomes and patient satisfaction

    Those healthcare executives not put off by the on-going cost of such intervention systems are restrained by an understandable concern that any overt effort that “goes looking for trouble” is likely to find it. But as with most rehabilitation, the first step lies in acknowledging that a problem exists.

    Converting conflict from a negative to a positive requires an organization wide effort and commitment - a systemic approach that encourages everyone, leadership and rank & file alike, to acknowledge their upsets and disputes while eagerly and actively seeking ways to resolve them. Until that doesn’t happen, conflicts continue to fester, damaging relationships, disrupting critical communication and compromising
    the delivery of quality medical care.

  • socrates2

    One can spot emotional weaklings a mile away. They tend to be individuals who misdirect their anger sideways or downwards, seldom upward--where the real source (catalyst actually) of their anger lies. They're not only weaklings but cowards, striking at targets they know are too intimidated or too vulnerable to fight back.
    The thing to do is articulate that they are displaying anger. I did that once to a boss. "Why are you so angry? This is no reason to get angry." Said boss responded, " I am not angry!" Everyone in the room sadly shook their heads and understood. Denial was the boss's response. But most importantly the boss became aware from the looks around the room that the boss's hostility and displays of temper were creating a dysfunctional work environment.
    Be well.

  • George Anderson

    I am a major provider of coaching for disruptive physicians. In fact, I was a presenter at the Februay 2013 AMA Conference in Hawaii where I presented on my work with physicians who exhibit problems in impulse control or civility.
    The good news is that Emotional Intelligence for impulse control can be enhanced with coaching.
    George Anderson, MSW, LCSW, BCD
    http://www.andersonservicescom

  • Ray Foster

    Meow.....

    "Sticks and stones may break my bones, but words can never hurt me" unless I let them. Physicians need to learn to do their best when at their worst, and under the most difficult conditions.

    If your feelings are hurt when your superior is snippy with you for not being as good as you need to be, get another job-- or grow a pair.

  • pjpj45

    What a lazy article. It's kind of like being all offended over docs making a couple hundred thousand a year for being the ones that get up in the middle of the night and such to do the job, but not writing about the insurance exec getting a 4 million dollar bonus for being best at denying payment to the doc and nurses and such that got up and took care of the person. Medicine is a lousy situation overall and to focus on the "bully's" and not on the overall nightmare; to me that's lazy journalism. If someday only super super nice people of the world decide to take on the lousy job of doctoring, and no greedy people run insurance companies, then great, maybe this type of article would not feel so only half done. But in the meantime, put a little effort into the research and how the pieces all fit together in what is pretty much a horrid stressful job and situation in general.

  • Marty Schulman

    The UC San Diego PACE Program has various professional development programs including those that focus on anger management and boundaries. For more information see http://paceprogram.ucsd.edu/cpd.aspx

  • Stephen Miller

    Wow!! this certainly has brought out a great deal of angst. As an old and retired surgeon, I am struck by several factors./ One of which is our failure to get beyond ourselves and look to other industries.; namely the airlines and their use of cockpit protocol. Unlike in the past, all of the members of the team are afforded an opportunity to participate in the events taking place on their airplane. Comments are accepted in a relatively non-judgmental way and this attitude has significantly reduced the incidence of "accidents".
    I am also interested in the categorization of the bully as a jerk. Did the jerk/bully become a physician and continue his/her behavior or did the environment produce the antisocial behavior of bullying. The former, if due to a remediable trait, needs to be identified early during medical training and altered. If that is not possible, the individual should be "washed out" as they will never learn nor participate in meaningful communication during times of stress. If, on the other hand, the behavior was learned in a learning environment, that environment needs to be drastically altered and the participants in bad behavior no longer allowed to teach and be required to go to behavior/anger management courses to maintain their licenses, board certifications and membership on a hospital or organizational medical staff.

  • volcanbird

    I wish all of you would "think" about what effect you have on the patient with your inbred culture. Those of us with "rare" disorders can't find good doctors who can behave themselves, listen, not judge, HELP, or refer us on. I wish we could see the ***** behind your names, so we know the 95% worthless and the 5% that are really there to help us!

  • skanik

    Is it me, or is it true that a significant number of doctors are not super bright.

    I know it is hard to get into Medical School and all - but some doctors seem to have

    gotten where they are via very hard work and not overly high intelligences.

    Unless a patient is near death/extreme agony isn't the best course of action

    for the doctor to carefully and patiently converse with the patient...?

    Now with the industrialisation of medicine - will doctors even have the time

    to sit down and converse with their patients or will the Insurance Companies

    provide a script for every situation with little boxes to check off so that time

    might be saved.

  • Davey Wavey

    How precious! A young budding physician who wants to change the world. Perhaps the next Atul Gawande. I assume that in the many years of experience she's had taking care of patients, she has been and walked in the surgeon's shoes. I'm sure she has seen the complications that occur after an operation, perhaps due to the incompetence of others (that's not that to say there aren't complications as a result of the surgeon's actions). And I'm sure she has taken care of patients for weeks, maybe months, day in and day out, because of those complications.....NOT! If you had, perhaps you would understand the urgency and concern, and thus the stress, that the surgeon experiences, from demanding and expecting competence from those around involved in the care of his/her patient.

    Michael Debakey, one of the world's most renowned cardiac surgeon, was also known as a tough taskmaster. By your definitions, I'm sure you would have labeled him as dangerous. I'm also sure that the hundreds, perhaps, thousands of residents, trainees, and students who have had the fortunate experience of learning from him would beg to differ.

    Look Ms. Yurkiewicz. I'm going to give you a little advice. Grow a pair! The world can be a rough place out there. "You are not special"!. It's not all about you. Unfortunately, I fear that we are creating a generation of snowflakes and you are one of them... melting at the slightest hint of heat.

    And if you are going to pass yourself off as a journalist (let's be real. You're just a blogger), then I may more inclined to take you a bit seriously if you wrote like one. I don't know much about journalism 101, but I assume that one of the basic principles is to be objective. I think you made a half hearted effort to come across as that, but really, how hard would it have been to get the perspective from the surgeon or his colleagues? What about the OR staff, particularly the scrub nurses who work with him? Or other medical students who have rotated on his service? Perhaps, you're in the minority. You may be just a snowflake. Unfortunately, the world does not always cater to you and your desires.

    I'm sorry if I've been too harsh. I hope you haven't melted away by this point. I only want to save the world too, even if it involves one misguided medical student. Because, if you continue on this path, I fear you'll be one of those clinically incompetent physicians who have no clue how the practice of medicine is carried out, and will be one those administrators who try to legislate how we should practice. It's already happening. We don't need more of those. Now let's sit around and sing Kumbaya, and I'll even give you a hug...On second thought, I take that back. I may get sent to HR and get slapped with harassment.

    • re: Mr. Davey Wavey

      The crux of your entire argument is wrong. The focus of Yurkiewicz's article is not on herself, but patient care.

      The rest of your argument is irrational venom. I'll leave it be. Though I do wonder if you would have worded things in quite in the same way had you "grown a pair" and used your real name.

      • Davey Wavey

        This is too funny. Please don't mistake Ms. Yurkiewicz's pseudointellectual article as anything but a forum to air out her grievances under the guise of concern for patient safety. And certainly don't be impressed by the Harvard Medical School label associated with her. She was a student who was briefly a guest in the surgical arena for what? 3-4 weeks? And from her observations, she suddenly became an expert in the association between the surgeon's behavior and patient outcomes? I'd be more impressed if she went and talked to his patients, his colleagues, his coworkers, nurses, etc and more objectively looked at his outcomes, and reported on that.

        BTW, "re: Mr. Davey Wavey", the irony of your last words may be lost on you. It's like the pot calling the kettle black. Regardless of whether my real name is used or not, the point I tried to get across still remains accurate and expressed my true feelings. We've become so concerned about acting PC, and suppressing our true feelings, that it's not worth putting my name to it. Reminds of a trend towards days of McCarthy.

    • Kate Clancy

      That's seriously the best you've got? You're just going to be a troll-y douchecanoe that tosses a few straw people arguments at the computer screen's general direction? This is so not worth lighting up the bat signal for.

      • Davey Wavey

        and you seem like an entitled bat. Is that the best you can do? Please. You're what's wrong with the latest generation. They are the product of your coddling. I pity your kids when they grow up and realize that not everyone gets a prize for coming in second.

    • Just an observer

      Based on your other comments, it sounds like you are a surgeon in Boston. Methinks Ms. Yurkiewicz hits a little too close to home, eh?

      • Davey Wavey

        Not close to home at all. Just a product of a generation when tough love was practiced if you got out of line. If you got into trouble at school, the teacher spanked you and the parents would thank the teacher for the lessons in discipline. Now, its the entitled generation. If there's even a hint of a slight, real or imagined, it's scream bloody murder and make sure that everyone around knows that they're unhappy, and cry that they aren't respected.

    • Anti-bully

      Yikes. Projecting much? Here's a suggestion: try making an argument. You know (or you probably don't) -- with data, and citations, and reason -- like the author did. Once you make a personal attack, you lose. Make your entire "argument" a rant of a personal attack, and it just reveals your own insecurities.

      If you're a doctor, I pity your patients and wish you'd used your real name so I'd know whom to avoid. I'd bet a lot that you prove the author's point by being horrid for patient care. I reckon you should re-consider your career. And your general approach to life.

      • Davey Wavey

        Haha. Did you like fail reading comprehension? The criticisms the author had of the surgeon was laughable. All I saw in the article was the surgeon demanding excellence from his co-workers in a stressful operation. You want to know what is disruptive behavior? A surgeon throwing instruments. A surgeon slapping someone. For a medical student, who spent only a few weeks on the service, to be able to associate his behavior with being a bad doctor, is ridiculous. And she supported her article with citations?? You should try reading those articles cited. Just because you read it on the internet doesn't make it true.

  • Former Med Student

    I would like to add a note about the evaluation section. Yes we should evaluate medical students on their ability to work as a team and be civil. Yet the problem still lies in those at the top. Those disruptive physicians and residents are still evaluating those below them. I have seen nice people get bad evaluations because the jerk above them didn't like them. They were rude and disruptive because they could get away with it. The solution lies in promoting good teachers. Let students anonymously evaluate their teachers. If someone consistently demeans and bullies students, then they should not be allowed to teach or evaluate students. Period. The solution lies at the top, not the bottom.

  • Dante

    What are you aiming for? A medical utopia where everyone is polite 100% of the times, regardless of circumstances and work load? If that's the case, unfortunately this is not possible. Not as long as you're taking 24+4 calls at a busy academic hospital and not as long as you have multiple roles to fill in: academic, research, clinical, administrative etc. There will always be a time when someone snaps eventually, and to label such occasional mishaps as bullying is preposterous at best. Of course I'm excluding the habitual bullying. The best way to work is to recognize the shortcomings of your colleagues and adjust as necessary. If you're the one who's complaining the most about bullying, chances are you're the problem, not the person being pointed at.

  • Mute Angel

    Yes, there is a culture of aggressive intimidation and bullying by a majority of doctors toward patients (doctors practicing in the Minnesota area). And yes, it is extremely dangerous. It has gotten to the point where doctors are holding themselves above the law. The are engaging in practices which should result in jail time.

    The medical boards need to immediately begin tracking patients, particularly those who do not seem to be getting adequate care from the medical profession. I believe you will be shocked by the things you encounter.

    I would recommend you begin by reading "The Psychopath Within," by James Fallon. He is a medical doctor researching brain scans of psychopaths (taken from prison populations). Dr. Fallon's brain scan was added to the pile, only to find that he had the most extreme case of psychopathology predictors of the entire pile of scans. In his books, Dr. Fallon goes on to describe how he learned from family and coworkers alike, that he indeed has all the predominant symptoms of psychopathology.

    This book represents a watershed moment in the history of the medical profession. The screening process which begins with medical school application and continues all the way to employment, has been unintentionally giving psychopathic individuals the highest likelihood of being ultimately selected to practice medicine.

    It is no coincidence that patient populations are now dealing with cold-blooded doctors, who game their way to the top of the profession, where they become leading authorities and most powerful, influential doctors in the profession.

    This is a very serious matter. Every indication is that many doctors would score high as predicted psychopaths, and because of their abnormal lack of empathy, they are rapidly creating a system which is dysfunctional, and which focuses on doctors' needs rather than the patients' needs.

    You must act on this matter immediately. Every day patients lives are being harmed or even destroyed. The edict, "first do no harm," has been rendered meaningless. Because of the complete lack of authority or control over doctors, these professionals are becoming a danger to the patient community.

    It is good that this problem is beginning to be discussed. Nothing less than a complete overhaul of the medical profession is called for. Medical schools should also add psychological testing as a factor when selecting which candidates will someday be doctors, a critical resource for every community in the country.

  • Elizabeth Egan

    My son, a third-year med student, began rotations two weeks ago. His confidence has been shattered as has his desire to continue medicine, all because of an arrogant doctor with a God-complex who is verbally and physically abusive. He won't report the man for fear of retribution, being expelled from the rotation. How in the world can hospitals allow such unprofessional, unethical, and ILLEGAL behavior continue in their facilities? I am heartbroken

  • Jade

    Way. Too. Dramatic.

    Is it only doctors that have this problem?

    Lol...Poor you.