Not so innocent bystanders

It's time for all of us to accept responsibility

“The standard you walk past is the standard you are prepared to accept.” With this wake-up call in June 2013, Lieutenant General David Morrison challenged all those serving in the Australian Army to take responsibility for the culture and reputation of the army and the environment in which they work.1 He made this call in response to an emerging scandal of sexual abuse and harassment in the army. At the 2015 Australian Medical Association national conference in May, James Lawler, President of the Australian Medical Students’ Association, named bullying, harassment, sexual harassment and their mental health as the biggest problems affecting medical students.2 He explained that he could not tell his peers to take a stand against the perpetrators because “the hierarchy is too high and too strong”. Quoting David Morrison, he called on those present to help change the culture of medicine.

Discrimination, bullying and sexual harassment are illegal and breach both published and implicit codes of ethics and professional standards in medicine.3 Yet they are prevalent in medicine and health care, not only in Australia, but in many other countries and cultures and in other professions, notably law.4 Both men and women perpetrate this behaviour, but the most common pattern is a male perpetrator and female victim. The behaviour affects the individuals involved and the organisations they work in, reducing individual and team morale and performance and, in health care, ultimately diminishing patient safety.5

Most incidents are not reported. Reasons for this include lack of confidence in complaint processes, fear of adverse consequences, reluctance to be viewed as a victim and cultural minimisation of the problem.6

Hierarchies lend themselves to misuse of power. Our profession remains hierarchical, and the further one advances up the hierarchy in many parts of the profession, the greater the imbalance between the sexes. This is particularly so in surgery, where only 10% of fellows are female, and few women hold office.7

In this issue of the Journal, Walton points to the profound power imbalance that exists for junior medical staff8 and Mathews draws attention to the system of patronage where trainees depend on powerful senior colleagues for advancement.3 These articles go some way towards explaining why victims cannot be expected to solve the problem or even to take primary responsibility for identifying and naming it.

What can the rest of us, the bystanders, do?

How can peers and colleagues not notice inappropriate behaviour going on around us? Or do we notice but feel disinclined to become involved or reluctant to act? And how do we respond if a student or trainee comes to us for help and support? Or if we are part of a formal complaints mechanism?

Those who are perpetrators, whether their behaviour is deliberate or unconscious, need to know that their peers do not accept and will not tolerate it. The behaviour needs to be recognised and condemned as and where it occurs.

The lack of confidence in complaint processes and fear of reprisals is a sad reflection of the hidden curriculum in medicine, the cultural norms and expectations that run counter to the explicit curriculum of professionalism.

The way forward

“Good medical practice”, the code of conduct issued by the Medical Board of Australia outlines the professional values on which all doctors are expected to base their practice.9 These values include integrity, truthfulness, dependability, compassion and self-awareness. Bullying, discrimination and sexual harassment are incompatible with these qualities.

Problems of discrimination, bullying and harassment are not new, but they are increasingly at odds with the standards expected in the 21st Century. Other institutions are facing up to the darker aspects of their history and culture, bringing them into the light of day and committing to eliminating abuse and exploitation. It is time for all of us to accept responsibility for the culture and reputation of our profession and work to create environments in which respect is the dominant quality of relationships with our colleagues, trainees and patients.