Surgeon wellness is a hot topic in 2018 and for good reason. In study after study, our colleagues report that both trainees and practicing surgeons are digging deep to mitigate burnout. We are just beginning to understand the detrimental consequences of burnout ranging from job dissatisfaction to suicide. The alarming thing is that suicidal ideation is a real problem. In a study sponsored by the American College of Surgeons, 6% of respondents considered suicide and there was strong correlation with burnout.1 Bullying represents one of the most fundamental ways in which a surgeon can experience loss of control; despite the attention paid to burnout and surgeon wellness, bullying at the workplace among surgeons is conspicuously absent from the national conversation.
Yet a culture that permits bullying is neither new nor unknown. In a recent study of Australian surgeons, 47% of surgeons (both trainees and practicing surgeons) reported being a victim of bullying and 68% reported witnessing bullying.2 A US Workplace Bullying Survey conducted by the Workplace Bullying Institute in 2007 reported that 49% of workers are victim of or witness to bullying and a significant number of victims suffer posttraumatic stress disorder. The sad truth is that we would likely to find bullying is endemic if we looked carefully enough.3
It is difficult to discuss bullying among surgeons. For one, many instantly picture the overgrown schoolyard bully of yesteryear. Sadly, bullies are real and they are professional adults who may be in senior leadership positions across the country. Additionally, it is confusing to talk about bullying because it is often lumped with harassment and discrimination. To be sure, there is significant overlap among bullying, harassment, and discrimination, but there is a significant difference. Antiharassment and antidiscrimination policies specifically include “protected classes” and address unprofessional behavior specifically targeting a person's race, color, religion, sex, nationality, disabilities, or veteran status. Surprisingly, there is no federal or state policy against bullying at the workplace if not directed at these protected classes.
Bullying is well defined. It is the systematic abuse of power and is defined as aggressive behavior or intentional harm-doing by peers that is carried out repeatedly and involves an imbalance of power, either actual or perceived, between the victim and the bully.4 According to the Workplace Bullying Institute, bullying is the repeated, health-harming mistreatment of one or more persons (the targets) by one or more perpetrators. It is abusive conduct akin to psychological violence and is characterized by threatening, humiliating, or intimidating actions or words. Most unfortunately, it is not uncommon and very few bystanders speak up.
SCENARIOS AND VULNERABLE POPULATIONS
Scenario 1: A resident presenting during morbidity and mortality conference becomes flustered when asked a question. A faculty member notes this, then repeatedly interrupts and ridicules the resident throughout the presentation. The bullying faculty member persists in their behavior when this resident presents during any conference for months.
Trainees are common targets of bullying. Bullying may persist when perpetrators recognize signs of weakness. Behavior like this involves the quintessential components of bullying—power imbalance, misuse of that power, and harm doing (to humiliate in this example).
Scenario 2: A junior faculty member (JFM) is meeting all documented benchmarks for career advancement, including publishing regularly in reputable journals. However, a senior faculty member from JFM's clinical division repeatedly tells her that her research is low-value, dismisses her contributions to academic discussions, and discourages residents and students from collaborating with her. JFM hears from another colleague that the senior faculty member was talking about her “not being suitable for academic promotion.”
Junior faculty are also at risk because academic advancement is largely controlled by a few people with a lot of power who may have a direct conflict of interest for resources or prestige with JFM. Public devaluation and strategic isolating are very powerful tools for limiting the impact of a faculty member.
CULTURE OF SILENCE AND THE VICIOUS CYCLE
Surgery is particularly susceptible to bullying for several reasons. First, we value hierarchy immensely; other specialties are afraid of us and we are afraid of our leaders.5 Second, we practice an unspoken code of silence; often loathe to speak up against a colleague for fear of retaliation.6 Third, we work in high stakes and stressful environments. Whether we are in the operating room, trauma bay, or even at morbidity and mortality conference, people bully while hiding behind the veil of patient care. Lastly, trainees and junior faculty observe and emulate bullying behavior, especially if the bully is perceived as influential and successful. Bandura's Social Learning Theory posits that we learn aggression and bad behavior from watching role models.7 Even worse, we have rationalized and normalized bad behavior—the saying goes “he's a surgeon, that's how they are.”
THE PERFECT CRIME
Bullying is the perfect antidote to self-worth and job satisfaction, and results in an individual feeling a loss of control of their environment. It is the perfect crime that leaves no visible marks but effectively destroys one's ego, identity, and resilience. Sadly, resilience is sometimes the only thing standing between the victim and total collapse.8 Those who are victims of bullying often suffer in silence, fearing retaliation. Ironically, the silence likely encourages further bullying behavior; it is quite Pavlovian in nature for the bully to garner positive reinforcement from effectively isolating and silencing the victim. Similarly, bystanders are reluctant to report witnessed bullying.
For those brave enough to report bullying behavior to departmental or medical school leadership, several obstacles impair the eradication of surgical workplace bullying. First, the bully is often an established, recognized figure in their specialty who has amassed significant power and who may bring significant clinical income to the institution. Next, there are no state or federal statutes against bullying at the workplace and few institutions have direct policies against bullying, although most have concrete antiharassment and antidiscrimination mandates for protected classes. Lastly, as 1 key component of effective bullying involves strategic isolation of the victim, the victim is often powerless to seek institutional resolution.
IS THERE A SOLUTION?
The Workplace Bullying Institute claims that only the institution (or employer) has the power to effectively stop bullying.9 This makes sense as there is usually a significant power dynamic where the bully is in a supervisory role. Institutional policies should be developed to address bullying and prevent retaliation.
Leaders of academic surgery have an opportunity to influence the culture of the department. Leaders should empower victims to speak up rather than attribute the victim's experiences to “being soft or overly sensitive,” or to counsel the victim to “not take it personally, he does that to everyone. ” Quite contrarily, most bullies do not misbehave toward superiors and bullying is a very personal attack on the individual.
University of Washington School of Medicine specifically names bullying as unprofessional conduct and has a clear reporting and disciplinary structure (https://www.uwmedicine.org/about/policies/professional-conduct). Similarly, the University of New Mexico is committed to a workplace “free of bullying in all of its forms. ” (https://policy.unm.edu/university-policies/2000/2240.html). These policies can and should serve as models for other institutions.
Australia's Royal College of Surgeons embarked upon a massive campaign against bullying in the workplace.10 Their work to date demonstrates that curtailing this behavior is difficult as years after their initial efforts, the incidence of bullying at the workplace remained unchanged. Despite the absence of substantial improvement in the incidence of bullying, some important lessons were learned from that exercise. First, they named the problem and showed that it is common. Second, they set a standard within the professional community that bullying is not tolerated. Third, they demonstrated that there is a collective will to study and curtail bullying.
A CALL TO ACTION
Research is desperately needed in bullying at the workplace among surgeons. There are many questions to be answered. For example, do institutions that implement 360-degree evaluations have less bullying or unprofessional conduct by leadership? Do women bully men? What is the effect of workplace bullying on faculty attrition and satisfaction? Will leadership respond to bullying if they understood the opportunity cost lost to talent drain and attrition? What institution policies exist to prohibit bullying activity? What impact does bullying in the surgical workplace have on learning climate?
There is no shame in being bullied as a surgeon. In fact, studies show that victims of bullying are targeted because they are brave enough to stand countercurrent to the dominant culture at the institution. Among victims of bullying within surgery are talented, productive, well-liked individuals who demonstrate strong ethical values.
For victims of bullying, do not let the bully define or consume you. And for bullies, recognize that you are dismantling the foundation of collaboration, innovation, physical, and mental well-being. Bullying is a silent epidemic in American surgery that requires engagement of our best selves to achieve a cure.
Bullying at the surgical workplace is a real problem and likely contributes to burnout and faculty attrition. Many questions remain unanswered and research in this area will help the important process of eradicating bullying among surgeons.
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7. Bandura A. Aggression: A Social Learning Analysis. Oxford, England: Prentice-Hall; 1973.
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