Hospital bullying requires everyone to share in the blame and solution

The following column was published on May 28, 2011 in FoxNews.com.

Theresa Brown’s New York Times op-ed, Physician, Heel Thyself, recently introduced hospital bullying into the national health care conversation.

Hospital bullying requires everyone to share in the blame and solutionIn it, she recounted a hospital vignette while working as an oncology nurse.  A patient asked a doctor who should he blame for a late test result.  The physician, turning to Brown, said, “if you want to scream at anyone, scream at her.”

That type of boorish physician behavior certainly cannot be tolerated.  Brown was brave to bring hospital bullying to light in a national forum.

But soon after her piece was published, many physicians, including myself, were defensive as Brown essentially singled out doctors for the bullying that goes on in hospitals.

“Because doctors are at the top of the food chain,” she wrote, “the bad behavior of even a few of them can set a corrosive tone for the whole organization. Nurses in turn bully other nurses, attending physicians bully doctors-in-training, and experienced nurses sometimes bully the newest doctors.”

But I wonder if the issue is more complicated than simply blaming physicians.  Most doctors I know harbor nothing but the greatest respect for nurses, and realize how important they are to quality patient care.  It seems unfair to tar them with such a broad stroke.

And besides, others in the hospital are responsible for bullying as well.  Like nurses themselves, for instance.

Last year on Well, the Times’ health blog, Brown herself wrote that “overwhelmed and angry nurses take their frustration out on the rest of us stuck in the corner with them, or on anyone they perceive as being less powerful than they are.”

Indeed, 60% of new nurses leave their first position because of bullying from their colleagues, such as verbal abuse or harsh treatment.

Brown calls for changes up top, such as hospital administrators adopting uniform standards of professionalism for every staff member, no matter how important they are, and having offending parties undergo civility training.

But those policies are already present.  University of Pennsylvania bioethicist Arthur Caplan, in response to Brown’s column, points out that “hospitals are instituting courses about bullying, reporting systems are increasingly in place, and punishment is happening.”

Instead, change also needs to occur from the bottom up.  Consider how physicians are educated.

The culture that perpetuates bullying can be traced as far back as medical school, when as students, future doctors are trained in a pecking order not unlike the military.  During the first two years, medical students have little exposure to patients and are exposed to the hierarchical tendencies and behaviors of their professors.

This needs to change.  Medical students need to learn, from the beginning, how to work as members of a team.  They need to understand that patient care is not only about the doctor and patient, but about how doctors, nurses, and medical assistants form a cohesive unit for the singular goal of helping patients.

That’s beginning to happen at some institutions, like Harvard Medical School, where patient care concepts are introduced in the first year.  Harvard student Ishani Ganguli, writing in the Boston Globe’s health blog, says “through role play and interviews with volunteer patients, we learn the vocabulary, even seating positions, that allow us to take detailed histories from patients and show empathy for them. We carry the skills from this course with us through subsequent years of medical school and no doubt beyond.”

She makes a point that such a curriculum should be expanded to teach medical students how to interact with nurses more collegially as team members, rather than as part of a superior-subordinate hierarchy.

Hospital bullying is often shrouded in silence, and Theresa Brown should be applauded for publicizing the issue.  But targeting the toxic culture that perpetuates the problem requires everyone to share responsibility.  Not just doctors, but nurses, hospital administration, and medical educators as well.  Only when every stakeholder is part of the solution do we stand a better chance of eliminating bullying behavior in hospitals altogether.

Kevin Pho is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitter, and LinkedIn.

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  • XrayQueen

    Don’t Stop at Doctor’s bullying Nurses! What about how some/most Doctor’s & Nurses Bully other Valuable Co-worker’s. Especially Radiologic technologists which is my profession. Without us there would be no surgery or diagnosis in which required Radiology to find the cause or to locate that fracture via C-arm to repair. In my 30 years of working in this field it has always amazed me how inconsequential most Doctor’s & Nurses feel we are. I’m always please to work for and harder with the Doctor or Nurse who is appreciative of my work and recognizes my value! Medicine should be about Teamwork not Hierarchy! We all need one another to perform an Excellent Job!!

  • http://www.PhysicalTherapyDiagnosis.com Tim Richardson

    The culture that perpetuates bullying will take more to change than courses about bullying, reporting systems and punishments.

    Bullying arises from an asymmetrical power relationship that is codified in law, not qualification or skills. I’m talking about the only unlimited license in healthcare, the physician.

    Teamwork will be slow to evolve when one profession enjoys unlimited license to decide or overrule a plan of care based on their credential. In some cases, the physician may be less qualified to make the decision than the nurse being overruled.

    Healthcare is not inherently a bullying, aggressive or violent culture. There is no reason bullying behavior should evolve among caregivers – except that one caregiver has fiat decision-making authority.

    I don’t know how to make this change. But, I do know that I’m not the only one that recognizes the physician license as a barrier to quality improvement in healthcare:

    “…the physician continues to be relied upon as a repository of knowledge and a vehicle for information processing…The primary barrier to this cultural change is graduate medical education and credentialing.” – Lawrence Weed, MD

    Tim Richardson, PT

  • Justin

    I agree that role playing difficult professional interactions in medical school (and RN and PA school, etc.) would be helpful.

  • mdstudent

    Nah, any med student would tell you that nurses and PA interactions are very weird. Even more so amongst med students, NP students, and PA students.

    The interaction changes from intern, to junior, to chief to attending

  • Nimish Purohit

    What about Hospital CEOs and their appointees (puppets-physicians and other administrators) bullying doctors? Some of my colleagues and myself have been subjected to this humiliation and find ourselves alone as our medical organizations appears to have ‘kept mum’. some have sought legal counsel and may have settled for compensation but this does not solve the fundamental problem and these arrogant administrators go unpunished.

    • angelina

      In some hospitals, there exists an incredible arrogance, a group mentality of the CEOs, department heads, VPs, IT department heads, etc. pushing multimillion dollar hospital wide EMR systems to the end-user physicians….what the physicians are not aware of is what goes on behind the curtain…

  • Kristin

    My perspective on this, after a long damn time in Experimental Psych–not counseling, so don’t expect the warm fuzzies–is that research indicates pretty clearly that power corrupts. Nobody wants to think of themselves as a bully, but pretty much everyone given the opportunity to, will. (See: Zimbardo, everybody’s body of work on that since Zimbardo pissed everyone off.) People who can get away with bullying, bully. If you want to end bullying, there needs to be a clear system for reporting and punishment. Preferably a social structure that inhibits bullying responses. The way that comes about is confrontation–typically, any sign that something is socially unacceptable is a powerful deterrent. But as long as the people who might do the confronting are in positions where it’s advantageous for them, for whatever reason, to ignore it, it will be ignored.

    Economics models with people as “rational actors” are kind of hysterical. We’re rational to a point, and that point is our immediate self-interest. So if the tired nurse who’s watching a charge nurse bully a new hire just wants to get out and get off that shift without a fight, there will be no confrontation. If an administrator knows a doctor is a problem but also knows the doctor brings in money and would take a confrontation poorly, there will be no confrontation.

    Would classes help? Would more emphasis on interpersonal skills be useful? Maybe. It depends on the quality of the course. It has to be designed and implemented carefully, or else it will look like–and be–an attempt to control from the outside, by people who care more about the appearance of correct actions than actually carrying out the correct actions. Students are particularly well-versed in the idiotic hypocrisy of bureaucrats: think back to “Just Say No” and contemplate its abysmal lack of efficacy.

    And, hey, just sayin’–changing medical school admissions emphases might help, too. My MCAT may tell you how smart I am, but it’s not a great indicator for whether I’m a psychopath. Maybe add something like the MMPI to the mix. People will howl, but it will tell you who’s a pathological liar and who’s likely to get violent.

  • http://www.transparenthealth.wordpress.com Tracy Granzyk Wetzel

    Kevin,
    Great post and insights! There are wonderful people working to change this type of culture in medicine. I shared this post with the group of faculty and students who participated in the 7th Annual Telluride Patient Safety Educational Roundtable on a related post at our Transparent Health blog (http://transparenthealth.wordpress.com/2011/06/19/bullying-in-hospitals-whats-the-solution/). Would love to hear more of your thoughts, as well as your readerships thoughts, on this topic.

    For example, what actions can C-Suite leaders, as well as medical educators, take to change the disruptive behaviors in medicine and turn toward a culture of respect for all involved? Ultimately the patient (or customer) loses when there is a disrespectful culture within a hospital (or organization).

  • R Ryan

    Until bullying is recognized as a defense mechanism, it will never be resolved. Employee behavior always starts from the top in all situations. If the top management does not stop the bullying, there is nothing that can be done at the bottom. Why from the top? Because they have the power to do something about it, they are leadership, and they are the first example. The problem is top management does not value their employees at all levels. Money and business is the ultimate goal and civility to each other is just a buzz word. I challenge first top management in hospitals and health care facilities to take civility training and behave as such.

  • Annette

    I find this article interesting and true; however, it not only applies to the hospital environment but any industry. Anywhere, someone may feel superior over someone else. People in this day and time have no respect for others. We can date that as far back as anyone can remember. There is an old saying “Respect thy neighbor as thy self” that has long been done away with. PS-I to work for a hospital.

  • xrayted

    I came into the allied health field later, ( a laid off Mechanical Engineer) as a Radiologic Technologist. I found the nurses as bad as the doctors. The nurses would try to dictate how I was to run my CT room (order of patient’s, etc.). They had no knowledge of the procedures and protocols, and I also found they had very little working knowledge of anatomy. They are suppose to be the backbone of medicine, I find it hard to believe.