Eradicating abusive behavior: Time to adjust the educational paradigm

The role of clinicians in providing a safe and supportive learning environment for students and trainees is fundamental to produce our future medical workforce. The Royal Australasian College of Surgeons (RACS) recently commissioned a comprehensive review of the prevalence and impact of discrimination, bullying, and sexual harassment in the workplace, following publicised accounts of sexual harassment against female surgical trainees. The subsequent report establishes that abusive behavior perpetrated by surgeons upon trainees, international medical graduates and others is commonplace and highly disruptive (RACS 2015). It highlights the sense of helpless frustration and apathy surrounding concerns of abuse and how some remain dismissive of these concerns. The report is further evidence of how an undercurrent of poor professional culture corrupts the learning environment. While these findings are not unique to surgeons or to the surgical training setting in Australasia (Fnais et al. 2014), the report brings a sense of urgency to the debate around creating and maintaining quality learning environments. It challenges us to consider how we can empower individuals to name and act on unprofessional behavior without fear of retribution or adverse influence upon training and career progression. It raises the issue of how we embrace supervisor training as a core part of resourcing our hospitals, where much of the education and training of our medical workforce occurs. The report also brings into question whether the existing medical education paradigm is appropriate for enabling meaningful cultural change against abusive behaviors. A thoughtful and strategic approach, building on what we already know, is required to ensure there is broad engagement in the processes and ownership of the changes that must follow. It is distressing that transitioning into clinical practice exposes trainees to mistreatment by those entrusted to support their learning. Communities of practice are obligated to foster trusting, productive relationships between supervisors and those they supervise (Lave & Wenger 1991). Abuse cannot be accepted as a normal process of enculturation into the medical profession. Past experience, however, cautions us that meaningful reforms to correct the culture of abuse in the clinical training environment are elusive (Fried et al. 2012; Fnais et al. 2014). The reasons relate in part to failures in systematically resourcing clinicians to be skilled supervisors (Kilminster & Jolly 2000) and in holding to account those who fail to meet acceptable standards of supervision (Subramaniam et al. 2015). A further factor relates to professional competence residing largely in the hidden curriculum (Fried et al. 2012; Birden et al. 2013), despite professional behaviors being definable, teachable and measurable (Cruess et al. 2009). While standards of behavior are outlined in various professional codes and mandated through regulations, these are only of value if there are ample opportunities to teach and assess professionalism and if there are safe and responsive channels for reporting and remediating unprofessional behaviors (Birden et al. 2013). Some jurisdictions have commenced the system-wide task of addressing unprofessional behaviors (GMC 2015) but it seems that many others lag in explicating professionalism in the workplace. It will be necessary to underpin such strategies with an explicit professionalism curriculum that becomes a requirement of continuing professional development, consistent with the expectation that all in the profession are responsible for maintaining professional standards. Perhaps a more fundamental reason why efforts to influence the culture of abuse have been ineffectual lies in what we truly value as the essential attributes of being a doctor. We continue to make allowances for clinicians who breach professionalism as long as they are clinically expert (Fnais et al. 2014). This is symptomatic of a culture that values measurable, clinical expertise above that of professional competence. The perception that some professional skills are somehow optional in clinical practice is particularly concerning when we consider the evidence that poor professional behavior, specifically abusive behavior, threatens patient safety by degrading the performance of individuals and teams and stifling communication when it matters most (Flin 2010). It is necessary to reconcile the discrepancy between valuing clinical expertise over and above professional competence. The literature clearly demonstrates the dependence of patient safety on professional behaviors. This provides a valid platform for demanding equal measures of professional competence and clinical expertise. The introduction of the Surgical Safety Checklist is an example of how professional behavior and the culture of surgical practice can be positively influenced through a patient safety agenda (Walker et al. 2012). The current revision of the CanMEDS Framework describes patient safety and quality improvement as ‘‘cross-cutting’’ concepts to each of the seven core CanMEDS domains (Wong et al. 2014). The elements of patient-safety competence that are reliant on respectful behaviors are specifically articulated in the Medical Expert, Communicator, Collaborator, Scholar, and