Bully for you: Workplace harassment of obstetrics and gynaecology trainees

According to the General Medical Council (GMC), bullying is said to occur when an individual or group abuses a position of power or authority over another person or persons, leaving the victim(s) feeling hurt, vulnerable, angry or powerless (BMA 2012). Bullying of trainees has serious repercussions in retention and recruitment within the National Health Service (NHS) and more importantly, may have an impact on patient safety (Paice and Smith 2009). Bullying leads to anxiety, loss of confidence and reduced productivity, affecting the doctor's work and home life.

While many older consultants may have trained in a time when teaching by intimidation and humiliation was a rite of passage, medical education is now a shared process with teachers and students working together to achieve competency (Hicks 2000). It is somehow not surprising that obstetrics and gynaecology has consistently featured highly in sector-wide surveys of bullying and undermining (Paice et al. 2004). Our speciality has always been associated with an intense workload and the current climate of economic rationalisation, suboptimal staffing levels, high litigation (obstetrics alone accounted for 50% of litigation claims in the NHS last year) (NHSLA 2012) and demanding management styles easily lends to a culture where bullying, whether subtle or overt, becomes common.

Although the implementation of the European Working Time Directive led to an overhaul of training structure (the so-called ‘accelerated training’ with most trainees facing an approximately 50% reduction in clinical exposure) (Smith et al. 2007), many consultants still expect levels of experience from junior colleagues, as before. They sometimes forget that fixed firms are a thing of the past and trainees must now attend ward rounds, clinics and surgeries with many different consultants to experience a sufficiently wide range of clinical scenarios.

Bullying is a complex issue but most researchers agree that this has to occur repeatedly and over a period of time and the definition prioritises the subjective feelings of the person on the receiving end, i.e. if someone feels bullied, then bullying has occurred. There are five recognised bullying behaviours (Raynor and Hoel 1997):

• Professional humiliation

• Spreading rumours and name calling

• Ignoring someone's presence and restricting access to study leave or training opportunities

• Setting impossible tasks, unnecessary interruptions

• Failure to give credit when due, removal of responsibilities, shifting goal posts.

Many of us have encountered the demanding boss or the unforgivingly strict educational supervisor who needs to ‘bully’ an underperforming trainee to achieve a particular competency. This raises the question if there can be an effective or acceptable level of bullying in order to get the best out of certain individuals; some trainees do require firm management by their seniors but it is important to differentiate between bullying behaviour, which is undermining and destructive and firm supervision, which is constructive and supportive. Houghton (2003) also brings up the point that even consultants and managers can be undermined by their senior colleagues and may be too intimidated to challenge them, and by being silent, perpetuate bullying. Recent GMC surveys indicate that senior obstetrics and gynaecology trainees (year 6 and above) are the ones most likely to report undermining by their consultants (Eaton 2009). There is no doubt that being bullied can lead to a rapid loss of confidence and impaired clinical decision-making, thus resulting in poorer performance. One of the co-authors here will attest to the fact that he felt so immobilised by a series of bullying events that he became not only indecisive but was also unable to supervise or advise his junior colleagues, a loss for the NHS, which had invested time and money in his training. Bullying behaviour has also been implicated in the Bristol Heart Inquiry and the Northwick Park Hospital Report, highlighting the effect of this on Serious Untoward Incidences and patient safety (BRI Inquiry 2001; Commission for Healthcare Audit and Inspection 2006). Based on the survey results, a team from Wessex Deanery has collaborated with the Royal College of Obstetricians and Gynaecologists (RCOG) to create and publicise a number of training videos, which are freely available on the College's website, to combat bullying in healthcare and to provide tools for juniors to respond to such behaviour (Wessex Deanery 2010).

Action against bullying is becoming integrated into medical school curricula, with simulations of harassment from senior clinician's during professional development teaching equipping the next generation of junior doctors to deal better with bullying in the workplace. Individual trusts are also producing their own responses, including workshops and local investigations, together with ‘name and shame’ initiatives. Many NHS trusts have designated champions to enforce ‘zero tolerance’ policies, but trainees may be reluctant to share concerns for fear of reprisals – they may feel that this is futile as the potential consequences could be significant when continuing to work within that team or requiring references to progress to consultant level. Recent articles such as the review by Kumar and colleagues in The Obstetrician and Gynaecologist (2012) help highlight the problem in obstetrics and gynaecology but while we agree with most of the authors’ opinions, we feel that ‘taking no action’ as first-line to remedy bullying in the workplace is not encouraging to the trainee, as this is indicative of a lack of a workable, accessible ‘care pathway’ in many hospitals.

One approach could be a standardised, nationwide scheme allowing anonymous reporting of incidents at each hospital. Complaints over a certain threshold, spread over an extended period of time or from a range of trainees and grades should automatically trigger an informal local investigation. Similar schemes already exist at undergraduate level, providing proof of concept for a wider application (UCL 2012). It is only by generating awareness, confronting this rife problem, sharing examples of good practice and upholding a ‘zero tolerance’ policy, starting from the undergraduate level, that the NHS can propagate sector-wide changes in culture and overcome workplace harassment.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.