Issue 2 / 25 January 2016

THE bullying and harassment of junior doctors was perhaps the dominant issue of 2015. Significant efforts are now underway by groups such as the Royal Australian College of Surgeons to address an issue that has been demonstrated to affect up to 50% of trainees.

Anecdotally, I have heard many stories of senior clinicians reaching out to juniors in overt demonstrations of empathy and support. Horror stories from consultants’ own training have been shared with a common theme pervading: as careers progress things do improve.

While it is very difficult to quantify, there is little doubt that bullying has always existed in the medical profession. Publications on bullying and harassment in various forms first appear in the literature in 1988 but as Shem illustrates in The House of God, punishing residencies were an established part of medical training in the 70s.   

Indeed, teaching by humiliation is an art that was unfortunately perfected in hospitals with a sort of Faustian bargain struck. Endure the torment and, eventually, the hazing would finish and a consultant would emerge. Today, this sort of behaviour is rightly deemed completely inappropriate. Yet it clearly persists. 

So why, in 2015, did bullying and harassment erupt as an issue? Is the bullying of today any more sinister and insidious than in the past? Why is it boiling over?

Certainly, today’s trainees are more diverse than they have ever been. Women, international medical graduates and ethnic minorities are all more likely to suffer bullying and harassment. However, it should not be forgotten that anyone can fall victim to it. Indeed, even in homogenous groups, bullies will find victims.

Related: MJA InSight — Tim Lindsay & Harris Eyre: Career crisis

There is an established dose–response relationship between workplace bullying victimisation and mental health outcomes. Additionally, it is known that those most likely to be bullied and harassed in the hospital setting are juniors. It is therefore logical that the longer a junior doctor remains a trainee, the more likely it is that they will be bullied and, by extension, the greater the toll the bullying will take on their wellbeing. 

Unfortunately for vulnerable juniors training times are longer, and less certain, than ever. In 2014 alone, 1600 applicants to GP and surgical training missed out on places. With an unprecedented number of medical graduates, this backlog is expected to compound in the next few years. By and large, these applicants are cycled back into resident or unaccredited registrar positions of questionable developmental value. This elongates training and means that juniors persist in susceptible positions for longer than ever before.

Further, with such an oversupply of juniors relative to training positions, there is little guarantee that persisting will result in the reward of a training place and subsequent fellowship. This uncertainty compounds any bullying and harassment and drives further negative health outcomes.   

It is therefore clear: the rules of the Faustian bargain have changed, but the downsides of medical training remain.

To date, the response to bullying and harassment has focused on the behaviour of individuals. A zero tolerance policy has been announced, or reiterated, by numerous colleges and there appears to be genuine momentum to generate lasting cultural change. This, of course, should be encouraged. But surely such a complex problem deserves a multipronged approach. With some specialities in Australia now approaching the longest and most inefficient training times in the world perhaps it is time for training reform as well.

Dr Tim Lindsay is an Australian junior doctor and PhD student in the department of surgery, University of Cambridge, UK, supported by the Cambridge Commonwealth Trust.

14 thoughts on “Training crisis means more bullying

  1. Lilon Bandler says:

    Please – let us not confuse two very different, though linked, issues.

    It is absolutely clear that bullying is entrenched in the medical culture; it begins from the moment a junior medical officer (PGY1) asks the first year medical student a question in their first week on the wards, and belittles them for not knowing the answer, thus providing a boost for their own shaky confidence.  Dr Lindsay is absolutely right – this will need a multi-pronged approach, including a completely different mind-set from senior clinicians and medical educators.

    It is also true that we have long training times, though I have never seen evidence that this is “inefficient”.  Impatience with the duration of training is also long-standing.  However, what often fails to be acknowledged is that the level of responsibility we ask of consultants takes maturity, and maturity (particularly for some people) takes time.  I suggest that the duration of our training is not “inefficient” but is a safety net, reducing the number of immature consultants, with huge responsibilities that they do not have the emotional skills to manage.  Reduce the training time if you wish; but make sure that you find some alternative way of ensuring the emergence of mature clinicians.  That too, might help reduce bullying.

  2. Monash University Publisher Packages says:

    Who are these people bullying junior doctors-or others in training places? They are doctors as indicated in many reports. Society put doctors on high horse or doctors pretend or claim to be on the elites can not be trusted on their behaviour. Can not condone this behaviour in whatever form it comes. Train juniors as  they come-perhaps lack of knowledge if anything should be blamed to the educational institution and their lack of fundamental teaching through their business model.

  3. Dr. Balaji Bikshandi says:

    Why don’t we just get rid of Internship. I doubt that it makes them smarter RMOs. Oh well, then there will be no ‘issue’ to beat-around-the-bush about! Where will the politicians and beaurocrats go if issues are resolved? In my humble opinion, the politicisation medicine is the single biggest threat to healthcare in Australia – be it a minister in the registration body, beaurocrats compromising lives of patients interfering with provision of care citing their moronic ‘cost-benefit analysis’, vilification of doctors of international background regardless of their merit and issues such as internship training. Perhaps this is why some countries create, in addition to a legislaltive, exective and judiciary, an independent Medical council. Ah well, we can only dream.

  4. Dr. Balaji Bikshandi says:

    I guess what is required is a proper definition of “Bullying”. What about the rampant employer bullying that happens to practicing doctors and not just trainees? Listen to the stories of the Medical defence organizations, how do you think they run so profitably?? Trainees need to know that the beaurocrats (and doctors associated with them) are rampantly bullying practicing doctors utilizing various fake disciplinary actions such as ‘clinical privileges’ and ‘suspension without notice’ and agencies like ahpra having biased members against good practicing doctors start unnecessary investigations on them. It is perhaps such undercurrent of financial and reputational bullying that the member of the profession are subject to is why they exhibit it towards the trainees (that is not a justificaiton but a fact of life). As is mentioned earlier, the ‘politicisation of medicine’ where merit had been overtaken by sinister groups of doctors, beaurocrats and politicians is to blame, ultimately. Groups of doctors establish ‘territories’ to practice and are unwelcoming to newer practitioners unless they ‘conform’ to their mandates – isn’t that not bullying?? Institutions like AMA are very well aware of these – situations that threaten the autonomy of the professional – but just do nothing. Issues like trainee bullying are a much smaller one in my experience (having suffered) when compared to the passive bullying that the sytem does to a practitioner and their family. Wake up!

  5. Andrew Jamieson says:

    Bullying is everywhere starting as soon as humans can vocalize and move ie. at about two years of age. It is part of life, unpleasant or even catastrophic but will always occur where humans interract. It is certainly more prevalent in a competitive environment. The definition of bullying has to be subjective and be dependent on the perception of the one bullied. I saw and/or suffered much more bullying at school both public and private than in my whole medical career. Bullying of medical students and junior docs when I saw it was sporadic, usually in response to shortcomings and when it happened to me it was always a stimulus to do better. I can’t believe that reducing training time will result in more bullying, if anything less as more training means better competence and less reason for complaint. I don’t think it was any worse in the ’70s  than more recently. On the other hand the vast majority of the senior doctors were friendly and kind and I never saw overt discrimination on the basis of gender, race or colour. Female surgical trainees were encouraged as were males if they showed motivation and talent. 

  6. Dr. Balaji Bikshandi says:

    Bullying might have been everywhere but never in history has it been so systematised and institutionalised as it is now. Take for instance the various names the bullying groups take on: medical administrative committee, clinical review committee, Credentialing committee, selection committee and the medical board! All of them function without a well researched evidence of proof of their benefit. They only feed the medical defence and the lawyers. The issue of bullying popularised by press gives them more ways to bully practitioners with this new clause. I guess the bullying practitioners are only trying to impart the training needed for real world practice! The bullying committees would ask them to do much more than sucking something after their training is finished. Perhaps what is needed is a cost benefit analysis of the above bullying committees and the eventual abolition of them. That ought to remedy the issue altogether. 

  7. Anonymous says:

    Actually A/P Bandler, inneficiency within the Australian training system is well known and worsening by the year due to terrible training backlogs. I suggest that you read the excellent article by Mitchell et al ( that further explains this gowing problem. Unfortunately since its publication in 2013 very little has been done to address the mismatch between the number of applicants seeking training positions and the limited number of positions available.   

  8. Andrew Jamieson says:

    I suggest Anonymous gets onto some of the “bullying committees” to find out what their function is and what the attitudes of their members are and yes, a lot of the time these committes do not achieve much however someone has to take on their functions and it is infinitely better that a group of usually unpaid but interested and motivated doctors make decisions on say selection or medical orgaizational matters than a single doctor with possible biases or even worse a bureaucrat who knows little or nothing about  medicine and its practice. 

  9. Dr. Balaji Bikshandi says:

    Dear Surgeon about to retire,I had been on them. Although we all have that general perception that a single person may be more biased, I have realised that the collective intellect is even more biased! Every member of such a committee is interested in driving only their selfish agenda. Not all of them are cost free (at least they cost that fine wine to amuse themselves). But certainly all of them and their actions need validation. Beaurocrats do participate in them and affect many practitioners with popularised issues such as bullying. Their favourite way of bullying is to strip a practitioner of all legal income. All through human history, the single most commodity a non-free person wanted was not gold but the others’ freedom. So we have to analyse why the bullyer is bullying the bullyee – it is simply because they are bullied themselves. A free man always defends the other’s freedom while a non-free one seeks to devour it. I am not the great Sartre but wish he was alive to analyse the scourge of bullying within this ‘noble’ profession. Cheers.  

  10. Sue Ieraci says:

    WHile Australian post-graduate training HAS been described as “inefficient” in comparison to that in the US, that does not mean it is inferior. Once registered, doctors are employed professionals, working their way through the system, as all professionals do. Baby lawyers don’t defend people accused of murder – we all need to accumulate experience, judgement and wisdom. 

    The article appears to consider working in a hospital as a “non-job” – (“positions of questionable developmental value”). ON the contrary – all clinical experience is of “developmental value” – the broader the better. We don’t need to emulate the US system where one goes straight from internship into specialty training, at a time when we need more generalists than ever before.

    Our growing number of frail elderly with complex illness don’t need more sub-specialty surgeons – they need good doctors with solid clinical skills and judgement – both in the community and in hospital.

    Bullying can never be condoned, but de-valuing clinical experience that is not directly related to passing specialty exams is yet another form of “bullying”, in my view.

  11. Jennifer Bradford says:

    It is a worthy endeavour to try to reduce bullying, but I have to agree with Surgeon about to retire, that it will never completely stop.  Therefore, as well as attempts to reduce bullying, we also need to empower juniour doctors to resist it.  Bullies know intuitively who to pick on.  It is possible to train juniour doctors to behave in ways that make it less likely to be bullied.  It worked for both my nieces at their high schools!

  12. Tania Rogers says:

    When I was in training I found the worst behaviour was quite often within the trainee / medical student cohort.   The intense competition, the cult of personality that exists in the medical system (those that are able to display the most sparkling, confident and witty conversation are are falsely assumed to be the best candidates / clinicians / whatever) and the perception that only a percentage will pass inevitably leads to some bullying by exclusion.

  13. 6403@amamember says:

    At least Faust got his reward up front.  In medicine, the bullying in all its subtle forms may never end; becoming a consultant is not necessarily the Nirvana you wish for (sorry for the mixed metaphors).  You always work for someone, and your colleagues can be the worst perpertrators.

    The current system of employment with stacked interview committees and pre-selected candidates needs change.  Where is the AMA and ASMOF?

    There are doctors who have been black-balled informally with no recourse and no prospect of “rehabilitation”; no procedural fairness.  

    The fear is real.  To wit Dr Anonymous’ many posts.

  14. Dr. Balaji Bikshandi says:

    Stunning metaphor, anonymous. It is the shocking lack of transparency with all the committees that is the core problem. Not AMA or ASMOF, but an anti-corruption watchdog is what is required to raid them all. Yes the ‘selection committees’ are plain fraudulent. In fact, that is the key point where they start to bully trainees (“I will make sure you can’t get a job anywhere”). Hope someone out there listens to these if they really want to eliminate the bullying menace. 

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