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Bullying, Undermining, and Harassment in Vascular Surgical Training in the UK: How Can it be Confronted?

Open ArchivePublished:July 28, 2018DOI:https://doi.org/10.1016/j.ejvs.2018.06.041

      Keywords

      Understanding the Problem

      The performance of high quality surgery relies on ongoing education which requires a safe learning environment. However, a recent unpublished report by the Rouleaux Club membership (the vascular trainee body) identified issues with bullying and harassment in UK training. Their national survey (120 vascular trainees, 60% respondents), reported 46% experiencing or witnessing bullying, undermining, or harassment, and over 85% recorded that unsatisfactory action was taken to address it. Although not previously recognised in UK vascular training, this has been reported in other specialties in Britain and internationally.
      In June 2015, the Royal Australasian College of Surgeons commissioned a national survey of members, with 3516 individuals (47.8%) responding from all surgical specialties (81% male, 15% trainees).
      • Cebbin W.
      • Cambell G.
      • Hillis D.
      • Watters D.A.
      Prevalence of bullying, discrimination and sexual harassment in surgery in Australasia.
      Almost half experienced bullying (39%), harassment (19%), discrimination (18%), or sexual harassment (7%) in the workplace. Of the trainees, 88% reported experiencing one or more of these behaviours. For those that took action, the commonest outcome was a continuation of the behaviour. The greatest barrier to taking action was the potential detrimental effect on future career.
      Similar alarming data were reported in a Greek study, with 50% of surgical trainees experiencing verbal abuse, 38% threatening behaviour, 20% sexual harassment, and only 15% of institutions reporting official support mechanisms.
      • Chrysafi P.
      • Simou A.
      • Makris M.
      • Malietzis G.
      • Makris G.C.
      Bullying and sexual discrimination in the Greek health care system.
      Furthermore, the Royal College of Obstetricians and Gynaecologists performed an email survey of UK consultants and fellows and 44% reported being persistently bullied or undermined.
      • Wise J.
      Significant numbers of consultant obstetricians and gynaecologists report bullying.
      The growing evidence of bullying and undermining in training demands recognition and change. One definition of bullying is provided by ACAS (Advisory, Conciliation and Arbitration Service: http://www.gov.uk/acas): bullying may be characterised as offensive, intimidating, malicious or insulting behaviour, an abuse or misuse of power through means that undermine, humiliate, denigrate or injure the recipient.
      The UK vascular trainee survey demonstrated elements of this definition across the country. Bullying may have always existed in surgical training and may relate to the culture and personalities attracted to the profession. The demands and stresses of surgery can also drive individuals to unacceptable behaviour. Increased financial and political influences within a state funded health service may also exacerbate work pressures experienced by surgical trainers. The constant conflict between service delivery and training may compound the situation, resulting in adverse behaviour. While these pressures and the difficult working and learning environment they create are recognised, bullying behaviour is never acceptable and cannot be tolerated. There is good evidence it detracts from training, productivity, and is potentially harmful to trainees and patients.
      • Paice E.
      • Smith D.
      Bullying trainee doctors is a patient safety issue.
      As such, it is beholden on surgeons to recognise those areas needing change. Honest personal reflection of the educator's practice, supported by multisource feedback, can enlighten the surgeon to their behaviour. Collaborative team working can also highlight issues within a unit, and addressing any problem areas is essential.

      Facilitating Change

      Educating the educator is a well established principle, with the Royal Colleges offering specialty specific courses (Training the Trainers and Training and Assessment in the Clinical Environment [TrACE]). The benefit of these over generic courses is the recognition of the unique pressures that surgery exerts on trainers and key issues can be addressed driving behavioural traits. These courses may support the trainer in delivering the required education in a challenging environment, and aid understanding of trainee needs and assessment tools. They also highlight the potential for bullying and harassment, how to recognise it, and what resources are available. The surgical community should mandate that their educators have appropriate training, and health institutions should offer financial support. Such trainer education facilitates objective feedback and assessment, which is more robust than subjective criticism. Understanding these processes promotes honest discussion in a more professional and productive manner. The authors do not advocate a submissive or undermined role of the trainer but more one of an informed, considered professional that has an awareness of the modern educational environment.
      Changing culture within surgery is challenging. Recognising the problem and how individuals perceive it is the first step. In response to the Australasian College survey on bullying, a retrospective analysis of operating theatre video simulation identified that trainees were more aware of instances of harassment and were more likely to intervene than consultants.
      • Gostlow H.
      • Vega C.V.
      • Marlow N.
      • Babidge W.
      • Maddern G.
      Do surgeons react?: A retrospective analysis of surgeons' response to Harassment of a college during simulated operating theatre scenarios.
      Such simulated exercises may be useful in supporting the surgical community in evolving a culture whereby recognition and intervention are allowed and respected.
      The Royal College of Surgeons of Edinburgh recognised the issues of bullying, and developed a comprehensive website providing information and support for trainees and trainers (https://www.rcsed.ac.uk/professional-support-development-resources/bullying-and-undermining-campaign). The Vascular Society of GB&I, in collaboration with the Rouleaux Club, have formulated a pathway for referral of bullying issues, incorporating local, regional, and national bodies (Fig. 1). In addition, a Young Consultant Group has been developed offering advice and mentorship to trainees and new consultants.
      Furthermore, statements from the GMC and the Joint Committee for Surgical Training (JCST), on behalf of the Royal Colleges of Great Britain and Ireland offer advice on recognising and dealing with bullying, undermining, and harassment. Evidence exists of adverse behaviours in other European countries and the respective trainees may find support from their national societies or draw on the resources offered in this editorial.

      Summary

      Evidence suggests that bullying, undermining, and harassment occurs in surgical training at an unacceptable rate and that action is needed. The reluctance of individuals to identify the problems is clear and the surgical community needs to address these issues to change the training culture and environment.
      Taking personal responsibility for one's performance as an educator is imperative, and through personal reflection and feedback we can improve our delivery. The individual interaction between trainer and trainee will be influenced by multiple factors and their recognition and acceptance by both parties encourages appropriate behaviour and avoids conflict. We must all be prepared to evolve to the changing environment and educational needs of vascular surgery and address behavioural issues without fear of recrimination.

      Conflicts of Interest

      None.

      References

        • Cebbin W.
        • Cambell G.
        • Hillis D.
        • Watters D.A.
        Prevalence of bullying, discrimination and sexual harassment in surgery in Australasia.
        ANZ J Surg. 2015; 85: 905-909
        • Chrysafi P.
        • Simou A.
        • Makris M.
        • Malietzis G.
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        J Surg Ed. 2017; 74: 690-697
        • Wise J.
        Significant numbers of consultant obstetricians and gynaecologists report bullying.
        BMJ. 2016; 353: i3576
        • Paice E.
        • Smith D.
        Bullying trainee doctors is a patient safety issue.
        Clin Teach. 2009; 1: 13-17
        • Gostlow H.
        • Vega C.V.
        • Marlow N.
        • Babidge W.
        • Maddern G.
        Do surgeons react?: A retrospective analysis of surgeons' response to Harassment of a college during simulated operating theatre scenarios.
        Ann Surg. 2018; 268: 277-281

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