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Published Online 1 September 2023

The elephant in the operating room: calling out bullying and discrimination in surgery

Publication: The Bulletin of the Royal College of Surgeons of England
Volume 105, Number S1

Abstract

It is imperative that we acknowledge that these issues still exist and enact change.
  Michael is the equality and diversity officer as well as the South East Thames regional representative for the Association of Surgeons in Training. He is a chief registrar in gastrointestinal surgery at Guy's and St Thomas' NHS Foundation Trust, and a specialty editor for the Bulletin.
It has been refreshing to see equality, diversity and inclusion (EDI) sessions at most of the national conferences in 2023. Many surveys were conducted to prove that there is a problem in surgical training.1-4 Unfortunately, however, there is still work to be done in recognising the issue across the board in surgery.
This year, I was at a conference presenting a global review on racial discrimination in surgery5 and one of the comments received during the session was: "We don't have this problem in the UK.'' This was despite having presented previous reports about racial disparities among doctors for job applications and General Medical Council referrals.6,7 This ignorance, sometimes wilful, must be recognised and as a community, we must start to openly address discrimination and bullying in surgery - the elephant in the operating room.
In an ideal world, racism, sexism, homophobia, and prejudice towards different backgrounds, accents, religions and faith groups would not exist but as this is not the case, purposeful steps must be taken to deal with this problem. Representatives from the various surgical specialty and trainee associations as well as Women in Surgery and the Pride in Surgery Forum have been doing a great job in leading EDI sessions with the aim of increasing surgeons' awareness about the existence of misconduct and poor behaviours, and their effects on individuals. But it is also worth mentioning that misconduct not only has a significant negative effect on the individual(s) involved but also on the whole team and on the NHS. This includes specific impacts resulting from bullying and harassment on staff health, sickness absence costs to the NHS, staff turnover, limited productivity, compensation, sickness presenteeism and litigation costs, with an estimated financial cost of over £2 billion per annum.8 Subsequently, this can be reflected in patient care and safety.
Discriminatory and bullying behaviours do not necessarily come exclusively from senior colleagues; they exist at every level in healthcare and beyond. Nearly a third of specialty and associate specialist doctors as well as a quarter of locally employed doctors (who are predominantly international medical graduates) have reported that they experienced bullying, undermining or harassment by work colleagues or patients.9 Furthermore, international medical graduates are less likely to report misconduct than UK graduates.10 According to a British Medical Association report from 2018, doctors from minority ethnic groups are targetted more often than their White colleagues while disabled staff in the NHS are the most likely to experience bullying or harassment (32%), followed by lesbian, gay, bisexual and transgender staff (27-30%).11
In an ideal world, racism, sexism, homophobia, and prejudice towards different backgrounds, accents, religions and faith groups would not exist but as this is not the case, purposeful steps must be taken to deal with this problem
It is worth mentioning that when people speak about how difficult their journey was, it can be perceived as perpetuating negative sentiment, which is not always welcome. Despite this, it is imperative that we admit that this problem exists and that we take meaningful action while providing ongoing education. We need to continuously re-evaluate our own behaviours. We also need to guide and support one another, and we should encourage those who have experienced poor behaviours to feel empowered to speak up.
Isn't now the time to think about taking action? How can we take all the surveys and case reports proving the existence of misconduct in surgical training to the next level? How much longer are we just going to present the frustrating experiences of trainees without guiding them or offering them solutions? These are the questions we asked ourselves before conducting a survey among Association of Surgeons in Training (ASiT) council members in January 2023 to identify the need for bullying, discrimination and harassment guidance. The survey showed that 55% had experienced bullying, 78% had witnessed it and 67% did not report it. Similarly, 38% had experienced discrimination, 62% had witnessed it and 69% did not report it. These are striking and contemporaneous results among trainees in the UK and Ireland, demonstrating that we have a problem that needs to be tackled urgently.
Misconduct not only has a significant negative effect on the individual(s) involved but also on the whole team and on the NHS. This includes specific impacts resulting from bullying and harrassment...with an estimated financial cost of over £2 billion per annum Discriminatory and bullying behaviours do not necessarily come exclusively from senior colleagues, they exist at every level in healthcare and beyond
At the ASiT annual conference in March 2023, we conducted a breakout session on bullying, discrimination and harassment, and the possible need to develop standardised guidance for reporting. We started by having case discussions and asked the attendees to share whether they had experienced or witnessed poor behaviours. We also discussed whether the attendees were aware of pathways for reporting misconduct. None of the delegates were able to name a pathway for raising concerns (with the exception of local pathways for reporting to clinical and educational supervisors if they were in a training post). When asked why they were hesitant to speak up, the most common answer was "nothing will change'' or "I will be considered a troublemaker''. This correlates with our council survey and previous work in the literature relating to NHS staff.1
We understand that it can be difficult for trainees to speak up; they might be worried about any potential impact on their career progression (especially where a power imbalance exists between offender and trainee or if a trainee is from an under-represented group). I personally know how it feels, having worked internationally in healthcare and training systems with highly prevalent bullying and discriminating cultures.
Unfortunately, we cannot change the past but we can work together constructively to build a brighter future in surgical training. We need to encourage any victim of misconduct to speak up and seek guidance. We believe that while issues may vary on a case-by-case basis, offenders need to understand the possible consequences of their behaviours5 in line with the General Medical Council's published statement supporting a zero tolerance approach to bullying and harassment in the workplace.12 In addition, different ways have been suggested to reduce misconduct and to deal with wrongdoers, whether by rehabilitation or by restorative justice.5,13,14
I hope that we are finally admitting the presence of an elephant in the operating room (and more generally in surgery), which will enable us to take the first step towards meaningful change. We need to educate ourselves about the EDI principles and re-evaluate our behaviours before educating others.
For those of you who are victims of one of these offences, you are not alone. Many others have been experiencing bullying, discrimination or harassment; some of them tried to speak up while others decided to suffer in silence. We are here to help you during this difficult and unpleasant experience; you can speak to any EDI or regional representative in your association. We have recently created standardised guidance to support victims and witnesses of bullying and discrimination in reporting poor behaviour in the workplace. This will go live very soon.
I am certain that by recognising the elephant in the operating room and taking these meaningful strides towards addressing this problem, we can work together to call out and tackle bad behaviours. We can build a brighter future with healthier and happier surgeons.

References

1.
Carter M, Thompson N, Crampton P et al. Workplace bullying in the UK NHS: a questionnaire and interview study on prevalence, impact and barriers to reporting. BMJ Open 2013; 3: e002628.
2.
British Medical Association. Racism in Medicine. London: BMA; 2022.
3.
Rhead RD, Chui Z, Bakolis I et al. Impact of workplace discrimination and harassment among National Health Service staff working in London trusts: results from the TIDES study. BJPsych Open 2020; 7: e10.
4.
Clements JM, King M, Nicholas R et al. Bullying and undermining behaviours in surgery: a qualitative study of surgical trainee experiences in the United Kingdom (UK) & Republic of Ireland (ROI). Int J Surg 2020; 84: 219–225.
5.
M El Boghdady, Ewalds-Kvist BM. Racial discrimination in surgery: a systematic review. Updates Surg 2023; 75: 795–806.
6.
NHS Race and Health Observatory. Racism in medicine must be tackled for the NHS to honour its founding principles and maximise its workforce potential. https://www.nhsrho.org/blog/racism-in-medicine-must-be-tackled-if-the-nhs-is-to-maximise-its-workforce-potential-and-honour-its-founding-principles (cited July 2023).
7.
Majid A. What lies beneath: getting under the skin of GMC referrals. BMJ 2020; 368: m338.
8.
Kline R, Lewis D. The price of fear: estimating the financial cost of bullying and harassment to the NHS in England. Public Money Manage 2019; 39: 166–174.
9.
General Medical Council. Unfair treatment affecting many SAS and LE doctors, GMC survey. https://www.gmc-uk.org/news/news-archive/unfair-treatment-affecting-many-sas-and-le-doctors-gmc-survey (cited July 2023).
10.
Jalal M, Bardhan KD, Sanders D, Illing J. Overseas doctors of the NHS: migration, transition, challenges and towards resolution. Future Healthc J 2019; 6: 76–81.
11.
British Medical Association. Bullying and Harassment: How to Address It and Create a Supportive and Inclusive Culture. London: BMA; 2018.
13.
Acosta D, Karp DR. Restorative justice as the Rx for mistreatment in academic medicine: applications to consider for learners, faculty, and staff. Acad Med 2018; 93: 354–356.
14.
Pillado EB, Li RD, Eng JS et al. Persistent racial discrimination among vascular surgery trainees threatens wellness. J Vasc Surg 2023; 77: 262–268.

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Published In

cover image The Bulletin of the Royal College of Surgeons of England
The Bulletin of the Royal College of Surgeons of England
Volume 105Number S1September 2023
Pages: 28 - 31

History

Published online: 1 September 2023
Published in print: September 2023

Authors

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M El Boghdady
Equality and Diversity Officer Association of Surgeons in Training, UK

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