It’s Friday morning in any operating room, USA. Nurses and techs are scrambling to get everything in place before the surgeon arrives because if not, there will be hell to pay. The first patient arrives late, the second patient needs to use the bathroom, the third patient needs blankets before the IV is started … and here he comes … and we’re not ready. The fear is palpable.
Down the street, in another operating room, a tech has called out sick. The nurse manager springs into action, adjusting staffing assignments and calling out to her team. “OK, you go scrub in OR 3, and you scrub with me in OR 2. As soon as we finish in OR 2, you can relieve the tech in OR 3, and then she can scrub into OR 1. If we do this right, there will be no delays. Quick, Quick!”
And they do it right, and the doctor isn’t delayed. But he finds out the team is down one tech. So, he hunts down the nurse manager and waits for the surgeon to leave the OR where the manager is caring for a pediatric patient undergoing an airway procedure. Then, he bursts in during the critical moment when the patient is being extubated. He screams at this nurse so loudly and with such insults that she later states she cannot remember his words. “It was too traumatic, I guess.”
Bullying involves behavior that targets a person with the intent to intimidate and harass and can cause risk to the health and safety of the targeted person. In the world of health care, it can also cause risk to the health and safety of the patient, too.
“I remember looking down at the patient, she was just 12-years-old, you know? And I looked at her to make sure she was OK. And I looked at the monitors, and her vitals looked good. And then I started to cry, which is very unusual for me. I don’t usually cry when the doctors yell at me, you know? I’m used to it. Doesn’t matter. But he got me that morning. And I cried. And the thing is, he wasn’t delayed at all. I knew if he was we would all be in trouble, but my plan worked and there was no delay. I just don’t understand.”
This nurse and others like her suffer from so much constant bullying by physicians — they often don’t even know it’s not supposed to be like that. After all, leadership knows the abuse happens routinely. They fear surgeons, if reprimanded, will move their surgery cases to another health system and “everybody on the team will lose jobs.” She is told that she “should have communicated better with the physician.” And then, sadly, she is forced to apologize to the doctor that screamed at her. That’s followed up with several apologies to the surgeon by members of senior leadership.
This nurse manager is strong. Most nurse managers are, especially those who work side-by-side with surgeons every day. She says she stays for her team and the patients. She is doing good work for the community. Is there a health system out there that won’t tolerate bullying from physicians? They all have a zero-tolerance policy on paper, but that’s all it is, a token piece of paper.
Bullying the surgical team reduces performance and decreases their desire to learn, grow and engage in their work. Bullying reduces morale and increases staff turnover. Eventually, the most confident and accomplished team members resign, leaving behind the least competent workers — those willing, like battered spouses, to stick around.
John B. Pinto describes three types of surgeon bullies:
1. Episodic/improvable. In a moment of stress, the surgeon lashes out, uncharacteristically, at others. We are all prone to this to varying degrees, and in the mildest cases, the episodic bully rapidly pulls back from the brink, recognizes the pain and harm he has caused in others, and quickly apologizes. Over time he improves his behavior. The established surgeon who loses it once or twice a year is easy to forgive once an apology is made.
2. Chronic/escalating. This kind of sociopathic, narcissistic surgeon bully gets worse over time. The newness of each professional relationship may keep the bully at ease at first. But over time, the boundaries come down and the bullying behavior escalates until the new member of the team feels the sting just as much as the veterans. The lack of serious consequences teaches this bully to continue the poor behavior freely.
3. Secondhand bullying. Bullying is largely a learned behavior. Those who are part of a team led by a bully may start to become bullies themselves. After all, the motto goes: see one, do one, teach one.
I have one more type to add:
4. The accomplice bully. This is the team member who allows the bullying to occur repeatedly and, in the worst cases, attempts to make the bully’s target(s) believe the bullying is their fault. This bully retaliates on behalf of the chronic bully by warning targets they will lose their job if they speak up, forcing targets to apologize to the bully, and minimizing the bullying event(s).
The history of tolerance to intimidating and disruptive surgeon behavior allows bullying to go unchecked in health care. Previous generations have made great strides to educate about bullying. My generation has to do more than educate and write policies. We have to act, and we have to do it to protect future generations, workers and patients.
Bullying in health care poses a critical problem for patient safety. The Institute for Safe Medication Practices found that almost half of health care personnel surveyed would rather keep silent than question a bully physician about a medication order. The Joint Commission cited the role of bullying in medical errors and warned of a decline in trust among hospital employees.
What can be done to stop bullying by surgeons in operating rooms across the country? Report all incidents per your organization’s policy. Understand that this action takes strength and bravery. Know bullying is not the fault of the bully’s target. Realize your identity may be revealed, by accident or on purpose, after you report bullying event(s). Some will use your complaint to win the physician’s trust. “She lodged a complaint, but don’t worry; I’ll fix it for you.” This is classic accomplice bully behavior. If your organization doesn’t handle the event(s) appropriately, report it to their accrediting agency such as The Joint Commission and the Centers for Medicare and Medicaid Services.
Know that there is truly strength and safety in numbers and unity — find health care leaders, surgeons, nurses, techs and anesthesia providers that you can trust. Band together against bullying by promoting dignity and respect. Bullies try to divide and conquer to force their agenda. We must demand that health care organizations stop bullying.
The author is an anonymous physician.
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