Issue 36 / 17 September 2012

INCIDENTS of aggression from colleagues in clinical medical practice are surprisingly high in Australia, according to findings from the first nationwide study into medical workplace aggression.

The authors of the research, published in the latest MJA, said the results of the cross-sectional study of Australian medical clinicians indicated that workplace aggression in medicine “is a significant professional, occupational safety and public health issue”. (1)

The research found that co-workers were the third most common source of aggression towards clinicians after patients and patients’ relatives.

“Prevalence rates for co-worker verbal aggression (14.8%–44.3%) and physical aggression (4.3%–13.0%) were much higher than for United Kingdom clinicians, where less than 5% experienced verbal aggression and less than 1% experienced physical aggression from co-workers in the previous 12 months”, the researchers wrote.

They surveyed 9449 doctors between March 2010 and June 2011 in the third wave of the Medicine in Australia: Balancing Employment and Life (MABEL) survey to determine how often doctors were subjected to verbal or written and physical aggression from patients, patients’ families and carers, colleagues, and other people external to the workplace.

Overall, 70.6% of doctors had experienced verbal or written aggression and just under a third (32.3%) had experienced physical aggression from one or more sources in the previous 12 months.

“Of particular importance is the finding that workplace aggression prevalence for the primarily hospital-based, younger and less experienced hospital non-specialists and specialists in training was up to twice that for GPs or specialists”, the researchers wrote.

International medical graduates (IMGs) in general practice appeared to be more vulnerable to workplace aggression from patients, the authors wrote.

Associate Professor Leanne Rowe, of the University of Sydney, told MJA InSight that she hoped the study would serve as a catalyst for action by the medical profession.

“This very significant study confirms the need for formal training on aggression minimisations skills, particularly those at higher risk including international medical graduates, junior doctors, and women. The issue of co-worker violence is of concern and requires further exploration”, Professor Rowe said.

Dr Will Milford, chair of AMA Council of Doctors-in-Training, was surprised at the high rate of verbal, written and physical abuse from co-workers.

“I wonder whether, particularly with the higher rates for hospital doctors, this reflects the high stress environment in which these doctors work. How much of this is driven by public hospitals under pressure, with too many patients, not enough beds, not enough staff and too few resources?”

However, Dr Milford said caution was required when comparing these data to data collected by other research groups. “Differences in the methodology of the study will reflect different results, and unless the studies were identically run it would be premature to assume the difference reflected a true difference between health systems”, he said.

The study authors wrote that previous research showed doctors exposed to aggression reported a loss of confidence or enthusiasm for treating patients, and increased medical errors.

“Clearly, greater institutional efforts are required to enhance the aggression minimisation skills of doctors who are new to clinical practice, and to reduce both the prevalence and impact of workplace aggression”, they wrote.

Dr Milford said raising awareness of bullying and harassment in the medical profession was an important step in the process of eliminating the problem.

“The AMA encourages doctors’ employers and the medical colleges to have their own anti-bullying/harassment policy.”

Dr Milford said he hoped this research, and research like it, could drive change and improve the workplace for all staff in the health system.

Professor Rowe said it would valuable to look at evidence-based strategies implemented by other professional groups.

“For example, in response to a number of prominent cases of physical violence, formal training is provided routinely to nurses in Victorian public hospitals. It is time for the medical profession, perhaps led by the AMA, to develop a similar program of training for doctors of all specialties. More information about responding to medical workplace violence may be found at”, she said.

– Amanda Bryan

1. MJA 2012; 197: 336-340

Posted 17 September 2012

25 thoughts on “Alarm at aggression in medicine

  1. Richard Shiell says:

    I do not recall any “bullying” during my Residency at Ballarat in the years 1965-66. I received my share of verbal criticism from senior colleagues but it was not undeserved. I wonder how the modern graduates define “bullying”?

  2. Sally Cockburn says:

    Thanks for this article Amanda 🙂

    Hi Richard, It didnt happen to me either but just that doesnt mean it wasnt happening then or isnt now. It’s always been there. While some of this may be misinterpreted “management” I have mentored a number of DITs over the years whose experiences were nothing short of horrific and even though bullying is a subjective thing these were not just their interpretations.
    I suspect there is only a minute percentage of “perpetrators” who really mean to bully (then again, sadly, sex for advancement is still being offered) most probably just need some help with communication skills or a few weeks holiday. The victims (who are definitely not all female!) should be able to speak up early to help identify where its been a comunication issue and stem it, but they are scared about who to talk to. They know it’s no myth that if they choose the wrong person “they will never get another job in this town”. Yes we’ve seen it happen.
    Often the “bully” is probably just over worked and stressed and the “victims” lack resilience – the latter may well be our parenting – we have brought this generation up to believe they are perfect – and that has its drawbacks when facing criticism. Every doctor needs a mentor so they can debrief – I think GPs need to be more active in looking after colleagues (stressed potential bullies and victims alike). These doctors need safe places to debrief.

    As a profession we need to take this seriously and not be bystanders when it comes to bullying – are you up for it Richard?

    PS it’s not just DITs either and some have tragic endings – but we cant speak about that – can we …..

  3. RayT says:

    There was some pressure to work long hours back in 1968 when I was a first year RMO, and to get everything raised at one ward round done before the next one in 2 days time. I don’t know that I saw it as “bullying” so much as unreasonable expectations. I had to prioritise. I was on duty from 90 to 130 hours a week depending on which unit I was working in, which was excessive I believe.

    When one of my consultants was a little terse because I hadn’t got some minor thing done between rounds, I said, “My days only have 26 hours, how many do yours have?!” We got on well after that…

  4. Anonymous says:

    Well the results underestimate the true extent of bullying by senior staff including administrative officers in our hospitals. Our hospital and administrative systems promote and reward social psychopaths who flourish. I have seen others and been victimised and bullied myself and am witness to how ineffective the systems for protecting myself and colleagues have been. My attempts to protect myself or speak out about the way others have been treated have led to further victimisation.

  5. Anonymous says:

    I have seen this aggression among midwives. As an obstetrician, from the outset I must say I have a very positive attitude towards midwives, feel they are an equal part of a team, and I have maximum respect for what I call a “seasoned midwife”, the traditional midwife (ie, not College trained) who has forgotten things I may still have to learn in obstetrics. [Admittedly if occasionally I am perceived as being abrasive, it is always only in the name of optimal patient care when something has or has not been done on behalf of a patient.]
    Suddenly, about 5 years ago when I started helping out doing rural locums in O&G, I have run afoul of a few “radical midwives” in 4/>30 hospitals I’ve worked at. It appears nowadays any staff member with access to a hospital computer terminal, can file one of these reports full of venom (sometimes) or other false claims against one about something or other. As an example, I had to perform an emergency D&C for an incomplete miscarriage and had to consent the patient immediately before in the anæsthetic bay. On the form for her signature I described the operation as “EUA / D&C” and was carpeted for using two of the most common abbreviations in all of Medicine in the rush to operate. The superintendent was most apologetic about it but was forced to act since one of those formal complaints had been made.
    The doctor is handed a printout of such complaints. The complaints are even graded, would you believe, by the author? It is a form of bullying since each and every complaint has led to my complete exoneration by hospital CMO, DON or medical board with recommendations of counselling of the complainers.

  6. drphil says:

    I too do O&G rural locums and for some years have been describing to the juniors the accuracy of consent forms describing the procedure. It should be “suction curettage for evacuation of retained products of conception” (or ERPC if you will). In this day and medicolegal age, it’s prudent to be accurate.
    I was at a recent ASM where George Pell was an invited guest speaker, and after making my position clear re his relevance to a women’s reproductive health scientific meeting, was told I’d be “crash tackled” if I wasn’t “respectful”. In the end the convenors “did a Howard” and left no time for serious discussion.

  7. Richard says:

    Bullying takes many forms and it is enlightening to do a google search on terms such as ’10 signs of bullying’.
    The results can surprise but will be of some great use to many who are probably wondering ‘Why is this happening to me? What have I done wrong?’
    The answer is probably ‘nothing to justify this’ but they have come to the attention of a sociopath and a bully.

    The loathsome (through grotesque misuse) ‘RiskMan’ that Anonymous@11:14 refers to is a piece of software pushed by a private organisation. Of course, they benefit as more people ‘use’ it to ‘manage risk’ . I have heard staff discussing this and they are encouraged to post on even the most insignificant events, if it ‘could pose a risk’.
    In the clear absence of adequate training on what constitutes a risk, this is management gone completely mad and/or is obviously used to harass by proxy.
    The more and more lesser trained ancillary and various support staff are encouraged, by the airheaded egalitarian brigade, to believe their input is as important as that of an experienced clinician, the longer this nonsense will go on.
    Some management, Medical and otherwise, like it because it gives them an excuse to show their authority and keep their uppity colleagues in their place.
    This bullying can be seen in its most egregious form in the frequently unrestrained and appallingly biased behavior of the medical board.
    Perhaps the AMA would have a bigger membership if it were to show some backbone in dealing with serious issues such as this??

  8. Dr Julian Fidge says:

    Modern graduates define bullying the same way everyone else does, Richard.

    I’m glad you weren’t bullied.

    It is fairly typical of older graduates that they think that anecdote = evidence. But that is not actually the case. Perhaps if you had a broader education, like a modern graduate, with more than one degree and some life experience, you wouldn’t use your personal experience to minimise what is obviously an important issue for the entire profession.

  9. Richard says:

    I think, if you were referring to my post@11;56, you misunderstand (deliberately or through failure to read carefully) where I stand on this. I loath bullying and have had more than my fair share of it. I have also spent some considerable time with people whose careers have been blighted/destroyed by bullying.
    “.. broader education, like a modern graduate, with more than one degree and some life experience..” Are you really serious or just stirring??? Such a daft comment aimed at somebody you do not know, is actually bad manners and could be seen as an attempt to silence i.e Bully.

  10. Andrew G says:

    Uh oh! Is Dr Julian Fidge (11:57am) now bullying Richard Shiell (9.30am)?

    Anyway, when I was a boy, I had to get up in the morning at ten o’clock at night half an hour before I went to bed, drink a cup of sulphuric acid, work twenty-nine hours a day down the mill, and pay the mill owner for permission to come to work, and when we got home, our Dad and our mother would kill us and dance about on our graves singing Hallelujah. (Okay, it didn’t really happen to me but a Yorkshireman once said that.)

  11. Sim says:

    Ask me about bullying because I am living it!!!!!
    Bullying is systemic and condoned by professional bodies.
    I am IMG/OTD and I am on treatment by a psychiatrist at the moment. My employers are laymen actually the medical superintendent has never been at medical or nursing school but was promoted because he was a police superintendent. Together with my fellow professionals, we were policed like criminals with aggression, bullying and abuse. Being voiceless and powerless I broke down. I have worked in 5 countries for 25 years with two Masters degrees and two Bachelors degrees in medicine but but being OTD was like being cheap OTC.
    God bless the system.

  12. Anonymous says:

    I would like to make two points. First, it is an over-simplification to equate bullying with aggressive behaviour. It appears that the latter is what the MJA article reports. Aggressive behaviour is just the tip of the iceberg. This is the most overt form of bullying, and (in comparison) fairly easily recognised and remedied. There are much more insidious ways of bullying that occur when some people in the workplace (often from the sociopathic and/or psychopathic spectrum of personalities) effectively undermine and subvert other people’s work and professional existence by more subtle (but often very effective) strategies that avoid overt aggression. Second, I have knowledge of a particular Australian healthcare workplace where bullying is so rampant that it is the norm of interaction rather than the exception. The interesting thing is that this place is literally riddled with anti-bullying policies, guidelines and codes of conduct (and other formal documents and initiatives). This makes it look so fantastic and water-tight that one would assume that bullying cannot occur. My conclusion? These documents are not worth the paper that they are written on (or: the electronic format they are saved in). My other conclusion? It is a dangerous fallacy to assume that policies and codes of conduct alone can remedy such problems. If anything, they create a false sense of having acted. It equates to paying lip service. Also, it is unclear to me what “evidence-based strategies” in this context means. This would have to be elaborated upon. I must admit that I do not know of any good solutions, but I am inclined to think that this is connected to overall workplace culture and ethos (any role models coming forward?), but not to the number and volume of policies and codes of conduct and strategies present in a place.

  13. discus49 says:

    “Perhaps if you had a broader education, like a modern graduate, with more than one degree and some life experience, you wouldn’t use your personal experience to minimise what is obviously an important issue for the entire profession.”

    In a sentence, Dr Fidge, you devalue the skills, and (life) experience of all of your colleagues who qualified before you. Rarely have I seen such arrogance on-line at a professional level. It’s as well the public do not have access to this board.

    Did you ever ask yourself who trained you to these high standards?

  14. John Raftos says:

    The MABEL questionnaire did not ask about the source of the bullying in hospitals. I think you’ll find that the majority of the bullying is by administrators and little by medical colleagues.

  15. Anonymous says:

    My thoughts to all who are being harmed by the system of intolerance and lacking of respect diversity of people bring. A culture of risk managing based on fear and control crushes the spirit of those who love their job.
    Rural obstetrics is a challenge especially if you are up to date and current but you are belted around if you don’t ‘conform’ to our way. Love locums. Special people that love the challenge of change. I am old school midwife but passionate about reform, returning to the way I knew it where women are spoken to with respect and time. The old school O&G that gave news well are few now. It s all about risk managing and fear. No beds, no respect, no time for anything as hospital managers only care about $$ & through put.

  16. Anonymous says:

    I congratulate you for bringing this matter up. One has no objection to constructive criticism provided it is delivered in an objective manner.I myself have worked in a public teaching hospital for more than 20 years under various departmental heads. Their working styles were different and issues if any were handled in a mature manner.I was forced to leave my job as Professor after 24 years when there was a change in the departmental head.Despite having good organizational skills and many other strengths,she herself was so insecure she would make an issue of anything however trivial. It reached such a stage that you were damned if you did and damned if you didn’t either. She would publicly humiliate everybody from senior staff, nurses, resident doctors and students. Most people would go along since she was responsible for the appraisals at the end of the year. I myself decided to take up another position since the atmosphere was so vitiated.

  17. Richard says:

    Statements of “Vision” and “Objectives” (blah blah) are commonplace nowadays. Unfortunately, few live up to these grandiose documents, which are more often than not, used as yet another tool to harass and intimidate “Can YOU work within our vision? (waves exotic glossy document at senior practitioner, all the while asking irrelevant and provocative questions..)” John@17:20.. Certainly, much bullying comes from admin but many of the worst of medical admin I have met have either been fellow medics OR supported by those amongst our ‘fellows’ with their own interests closer to their own hearts.

  18. Anonymous says:

    I have experienced several instances of verbal aggression as a DIT in recent years, and from one person this developed into bullying as a fairly sustained campaign to manipulate unit staff and belittle me publicly. All instances for me have been from colleagues at the same or slightly senior level. With benefit of hindsight, these were generally due to an unfortunate combination of personality styles, insecurity, highly stressful jobs and poor coping skills, in which their frustrations were externalised (and mine somewhat internalised).

    The hierarchical system of medicine does make it difficult to raise and deal with these issues directly – we are still rather expected to be subservient and just cope, no matter how large the workload or how unreasonable the demands. Though I found that people, rather than policies, were the best solution in the instance mentioned above. Due to a wonderful and approachable head of unit, I was able to voice my concerns and although the issue was never quite ‘resolved’ (personal insecurities are hard to heal) I was at least heard.

  19. Iain Esslemont says:

    Aggression in medicine is often kept hidden. My own experiences, one of which almost led me to taking my own life, are described in my autobiography, “Life is what you make it” (Melrose Books). It has been suggested that my description of the debilitating personal effect of practice dysfunction and inter-doctor enmity is painfully frank and could be used as the basis of a postgraduate case study on this all too common, but rarely discussed, happening.

    Doctors are human beings and a medical degree does not confer immunity from being a human being, and in fact, because of the possibility of being authoritarian, supplies ammunition which can be used to be a bully, whether as a consultant surgeon or as a means to pursue a different aim in the use of a medical practice.

  20. anon says:

    My experience of internship and residency was very much full of “bullying” in a wide variety of manifestations. Where to start!?! Most of my bad experiences came from registrars who were overworked, stressed and having trouble coping so heaped blame and abuse on more junior doctors. But there was also bullying from fellow interns or residents, nurses, consultants, medical admin, even ward clerks. Most of the bullying was in the form of threats of complaints or threats of bad reports, snide comments about your work or flat out calling you stupid or incompetent or lazy. Surgical registrars especially are specialists at using sarcasm and rudeness to deflect consults. I’m sure most of it is fatigue related. As a junior doctor you’re taught to do whatever your told, keep your head down and never complain. It’s horrible sometimes and you just have to get through it. I really don’t think I was considered below average nor am I an IMG. I really felt for those people sometimes, they had it WAAAYYYY worse than me.

    More worryingly is the bullying of junior staff by consultants, also seems to be more common in surgery. In Dubbo, where I was a student, it was well known that one particular consultant there hated women and Asian registrars. He had a female registrar once and he didn’t speak to her the entire 6 months she was there. Another surgical consultant told me that 8/9 of his last registrars had put in bad reports or complaints about him yet they still kept sending him trainees. I have personally witnessed another consultant yell continuously at his registrar throughout a surgery, as stream of comments such as, “what are you doing, don’t cut there, you’re hopeless, hopeless, my god you’re hopeless, WHAT ARE YOU DOING?? Cut there no not there here, no there, my god you’re hopeless, what are you doing, my god, it’s a bloodbath! a bloodbath in there….”, for 45 minutes straight. I was appalled at this behaviour. It wasn’t just bullying, it was dangerous to the patient. Complaints are virtually impossible because everyone’s trying to get onto a training program or afraid of getting kicked off one, and having a reputation as a complainer is something no one wants.

    I thought everyone knew junior doctors were virtual slaves to the system, no control over hours or colleagues or rotations etc, just have to get through it and enjoy the good terms with nice people when they come and get through training ASAP. Sigh.

  21. Sim says:

    Doctors and other pseudo-leaders are never trained to be leaders at Uni. They become leaders by default or corrupt instead of by design. In their failure to lead, they blame others with rage to silence their them.

    Some of the causes of hate and conflict are self-inflicted. Those who are insecure,hate themselves and cannot love anyone else. Those who cannot achieve the expected standards at work or in life tend to hate those who have achieved. The failures tend to blame others for their failure with rage.

  22. anonymous says:

    I worked at a hospital where a known serial bully (or likely sociopath) doctor with no credentials other than his MBBS worked himself up the administrative and clinical ladder with clever use of deception, smoke and mirrors. Even after 4 woman, (it was the women that were the brunt of the more easy to see overt bullying) sought help from the administrators, even when, after scratching up past history found he had been asked to leave another hospital due to bad behaviour, it ended up all 4 female doctors had to either leave or change shifts. He had ingratiated himself to administration so well (socially, personally – going on holidays with them – and professionally) that they all sold out or simply did not wish to see or believe the clear and damning evidence.
    During the investigations and complaints, in typical fashion of a serial bully, he was suddenly “depressed” when faced with being caught out or asked to show cause……(as the books say, what mature adult runs out of a room in tears when asked to be accountable). For the four of us, he managed to evade accountability for each case and then, in keeping with being a book perfect bully, placed a complaint that he was being bullied.
    Only one visiting senior Dr. smelled a rat with him…interestingly, he asked him for specifics with respect to his training and credentials – this man unfortunately did not find his work extended. All the nurses that saw or had experienced his lies and deception (with everything from patient (mis)management to colleague powerplays) became complicit to the wrong doing after seeing the 4 doctors lose their battle.
    For the sociopath or serial bully, mediation is the last nail in the coffin for the victims…the HR people just don’t get it. The behaviour of a serial bully is incomprehensible for a normal empathetic person. As a medico-legal forensic psychiatrist told me “it’s too abstract for most people” “it takes direct experience”.
    It’s not easy to pick the serial bully or sociopath. Con people are sociopaths. To become a doctor assumes some intelligence therefore the sociopathic doctor will be a formidable foe. What is easy is to know is, by middle age if there is a repetitive history, if there are “crazy-made” people around then go get help from a medico-legal forensic psychiatrist to help you out…and whatever you do, never mediate with a serial bully.

  23. anonymous says:

    Discus49 cites Julian Fidge’s comment as a case of arrogance and possible bullying. I, too, think that Dr. Fidge’s comments are delivered very poorly and I hope that this was an impulsive emotive error of Dr. Fidge as he has been prominent in the media addressing the typical and well known bullying by Defence towards its members. At least Dr. Fidge shows more courage than the rest of us “anonymous” writers.

  24. Dr Nemo says:

    Whereas classic cases such as that posted by the anonymous obstetrician won’t disappear any time soon, bullying can also take the form of subtle denigration to the victim (such as someone in a teaching hospital who has been singled out for not being given a training position despite getting the primary first go) by social exclusion, inappropriate labelling such as management indicating to the victim’s peers that the victim suffers a major psychiatric complaint when none exists, and other forms of emotional debasement. These often take the form of oral (i.e. spoken) one-off comments) but may on occasion be written such as across personal property of the victim. Both of these forms of verbal abuse (i.e. abuse by using words) constitute a form of bullying endorsed by departmental directors and other senior medical personnel employed by hospitals to give the victim the “hurry along, get lost and keep quiet”. As I subsequently observed in a different public sector setting management usually encourages and endorses such behaviour. The only time it even brings the attention of a former victim is when the management culture supporting you evaporates and new enemies appear (as is always the way).

  25. RayT says:

    Perhaps I should add to my comment at the top that I do not say the hours I worked are OK, nor that bullying should be tolerated. My year took the SA government to the Industrial Court in 1968 and won a limit of 80 hours for future generations, and penalty rates for anything over 55 hours. A small step at the time, but…

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