Bullying in surgery

“The standard you walk by is the standard you accept”

Lieutenant General David Morrison

The External Advisory Group report on discrimination, bullying & sexual harassment advising the Royal Australasian College of Surgeons makes grim reading. Approximately 50% of Fellows, trainees and international medical graduates report being subjected to discrimination, bullying or sexual harassment. Of those,  39% report bullying, 18% report discrimination, 19% report workplace harassment and 7% sexual harassment. This is unacceptable in any workplace and can have wide ranging effects, not only for the trainee but also for patients.

Unfortunately, this problem is not unique to Australia. We also have a similar issue in the UK. A survey published by RCSEd in May 2014 found that 3 out of 5 surgical trainees had been victims of undermining and bullying at work, and 9 out of 10 have observed it first hand. This figure is three times higher than recorded across other healthcare professions in the NHS (BMJ 2013). The figures from the RCSEd survey are backed up by the GMC trainee survey in 2013, where surgery was found to be an outlier with respect to bullying & undermining in the workplace.

There is a reluctance to speak out about these issues for fear of reprisal, that the behaviour will actually get worse or that it could be seen as “career suicide”. In fact, only a third of those who experienced or witnessed bullying behaviour felt able to report it. But where this behaviour is experienced or witnessed but not reported, it contributes to normalising the behaviour. This means a lot of the time we laugh it off, “suck it up” and get on with things.

Surgery is seen as a macho culture, where you have to be tough to survive and unfortunately this kind of behaviour is often seen as part of the training & culture. This may be partly due to the hierarchy within the profession with there often being a parent/child approach with trainees. We should be treating our trainees as equal adults, albeit with less experience. The culture of “junior” and “senior” doctors means that you are still regarded as junior even when you are highly trained & deserve to be treated like the professional that you are. As a senior surgical registrar nearing the end of my training, It was very frustrating not be taken seriously because you are seen as “junior” and therefore are undermined. However, history shows us that we tend to emulate the behaviours of our seniors and so the cycle continues.

This is a significant issue and the RCSEd is determined to address it head on. The college has set up Professional Excellence groups to provide a safe forum to raise concerns. They have also set the Faculty of Surgical Trainers to provide a forum for accrediting surgical teaching.

But we need to do more. We need to change the culture. The days of teaching by humiliation should be long gone. Creating a toxic environment where trainees are scared to speak up can have a detrimental impact on patient safety as they are less likely to raise concerns or ask for help when they need it. It affects good communication and team working. This kind of environment also has a negative effect on the quality of training and the quality of life of the trainee who feels undermined. We need to act as positive role models for our trainees and teach appropriate behaviours.

We need to create an open culture within our organisations where people feel they can raise concerns without fear of repercussion or a lack of faith that anything will be done.
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Time to banish the Poo Taboo

Gut health

Talking about bowel habits and poo is still seen as taboo and many patients are embarrassed to talk to their doctor about these types of symptoms which can lead to considerable delay in diagnosing serious bowel conditions such as bowel cancer or inflammatory bowel disease. Equally important are disorders such as irritable bowel syndrome and faecal incontinence, both of which can have considerable impact on the patient’s life. Recent research has revealed that while over half of people in the UK suffer with a chronic or persistent gut problem, almost 60% believe that talking about poo is unthinkable.
As a colorectal surgeon, I was interested to discover the Gut Week campaign which runs this year from 31st August to 6th September. Now in its 17th year, it is part of an ongoing campaign by Love Your Gut, supported by 5 leading digestive health charities: Bowel & Cancer Research, Bowel Disease Research Foundation, Core (the Digestive Diseases Foundation), the Primary Care Society for Gastroenterology and St Mark’s Hospital Foundation. It’s aim is to raise awareness of gut symptoms and disorders, emphasising the importance of maintaining good gut health and providing resources for further information.
Initiatives like this are so important in breaking down the stigma around bowel conditions. I have had many patients suffer in silence, only coming to see a health doctor when they really can no longer cope. There are many reasons for this, but I think it is primarily because they are embarrassed or feel that it is something that they just have to put up with. I commonly see patients with incontinence or rectal prolapse who have been suffering for years.
So, how do you discuss these things with your doctor? Firstly, it is important to remember that you are not alone. Over half the population will have a gut problem and your GP, surgeon or gastroenterologist will have seen many of these things before. We appreciate that discussing poo & bowel habits can be embarrassing but we will not be embarrassed so you should try not to be. Using everyday words is fine and the more honest you can be about your symptoms the better – it’s difficult to be too graphic with a colorectal surgeon!! If examination is required, the reasons behind this will be explained and it will not be done without your consent.

Embarrassment is temporary but ignoring symptoms may lead to a more advanced diagnosis if presentation is delayed. Dealing with things at an early stage is always easier.

Over the next number of weeks, I will post more about common digestive disorders, their symptoms, investigation and management along with links to online resources for further information.