Tackling workplace bullying

Medical Post
Helping Hand Column, October 16, 2007

If it remains unaddressed, it can have serious consequences for offender, colleagues and patient care

It is wonderful to see that physician health is becoming more of a recognized issue in our current health-care environment. I am gratified to see how much support, energy and momentum this concept has gained within the past 10 years. Initial work focused on improving the personal health of colleagues, and this continued to include advocating for a healthy medical workplace.

One of the key factors in ensuring a healthy workplace is to provide a safe and supportive collegial environment. This has led to increasing awareness of disruptive behaviour. Common sense tells us that it exists but the literature is just emerging and sparse. Disruptive behaviour is defined as poor communication behaviours, including intimidation, which create a negative impact on others in the workplace. There is usually a long-standing history, and it often goes on for years unaddressed. It is rarely one isolated incident, but rather multiple similar reports from a variety of sources emerge.

Types of bad behaviour
There are three main types of inappropriate behaviours, as identified by Dr. Richard Irons(author of The Wound Healer)in 1994. Inappropriate anger includes sudden and unpredictable outbursts, rude or abusive conduct toward staff, patients and patients’ families.

Inappropriate response includes verbal attacks on staff that can be personal, unfair or public; non-constructive criticism, slurs and belittling; unnecessary sarcasm or cynicism; profane or disrespectful language; blaming others; and sexual innuendos.

Inappropriate action includes sexual harassment, late or unsuitable responses to pages, imposing unreasonable expectations and demands on staff, throwing objects, bullying.

There are many contributing factors, including stress and burnout, especially in later stages; substance abuse; medical diseases; and psychiatric disorders such as depression, anxiety, mania, dementia, obsessive compulsive disorder and personality disorders.

This behaviour is unacceptable and needs to be addressed. It can have a negative impact on the health of the physician and his/her family and on heath-care colleagues, who may feel job dissatisfaction, reduced morale, helplessness, tension and anxiety. It also can have a negative impact on patient care.

However, it is not easy to address such behaviour. It makes us feel uncomfortable and tense. It is easier to avoid conflict. We may feel disloyal to the colleague, as if we are “tattling.” We worry we won’t be believed, have no power, will have the burden of proof, and risk liability and reprisal. Often, if this is long-standing behaviour, such people are charming, successful high-achievers and in senior positions.

Denial, rationalization
The typical response of medical colleagues who are intelligent, nice, caring and understanding is to deny(let it go), minimize(look the other way)or rationalize (hope it is temporary and will stop). Colleagues avoid any direct discussion but eventually they become frustrated and resentful.

To encourage and support reporting of such behaviour, many medical organizations have adopted a zero-tolerance policy for such violations. This is a great step forward.

However, there is a pattern I have seen emerging in recent years among colleagues working in small or rural communities in a health-care system with decreasing resources. These colleagues are dedicated and conscientious physicians who work hard to establish their practices, provide excellent patient care, make themselves available and soon shoulder a very heavy workload. As demands increase, they feel unable to say no and set limits. Often, there are few other resources, they may be doing one-in-two call and they may be the only ones who can do a specific procedure. So they agree to do more, with the justification that the ultimate goal is to provide the best patient care. However, this is not sustainable. These colleagues ask for help, but it is not available. They are tired, become resentful, have an angry outburst and then are identified as “disruptive doctors.” While they do have disruptive behaviour, they are not truly disruptive doctors.

I fully support the recent increased awareness of such behaviour as inappropriate and unacceptable. However, there are many causes of such behaviour, each of which requires different solutions. In the situation described above, such labelling is not only inaccurate but unhelpful, as it can prevent a successful resolution.

In fact, the colleagues in this situation are experiencing burnout due to chronic work stress and high workloads. They are victims of their own success, as they initially set a pace that was not sustainable. Any highly functioning healthy person placed in an unhealthy situation can become unhealthy. None of us are immune. While they do need to gain insight into their need for approval and difficulty in limit-setting, and learn to assert their needs in a calm and professional manner, it is also essential the institution understands their vulnerability to burnout, expresses appreciation for their work and actively supports them with the needed resources to maintain a healthy and sustainable work-life balance.

Outline a policy
Medical organizations can establish a policy for dealing with such behaviour, institute it and publish it. This will outline a transparent procedure to deal with such a colleague, offering explicit expectations and zero tolerance. The policy should establish a plan for early identification of such behaviour, clear documentation of all incidents and trends, and a fair and confidential reporting process. The first response to such reports would be to approach the physician in a safe and confidential manner, confront the behaviour firmly and specifically, and provide them a chance to explain and clear it up. There can be arrangements for clinical assessments, options provided for therapy and education, with clear consequences in the case of continued negative behaviour. This will require regular monitoring and followup evaluations.

The workplace itself will need to be accountable and offer confirmation that management is providing an optimal environment. I recognize this may be especially true in rural settings, where physicians have fewer resources. The ideal administration would be supportive of physician’s health needs, be alert to early warning signs of stress and burnout, and allow any required workplace accommodations. An initial orientation workshop for new doctors in the community could be created to define roles and expectations, understanding and avoiding burnout, effective communication skills, assertive training and conflict resolution skills. All incidents need to be identified and addressed early. Prompt assistance from workplace mediators and counsellors could avoid later resentments, complaints, lawsuits or dismissals.

Only by addressing both the unprofessional behaviour, as well as improving a suboptimal workplace environment, will successful resolution be fully achieved.

 

Mamta Gautam is an Ottawa psychiatrist who specializes in treating physician patients. If you have a question you would like addressed in this column, please contact Dr. Gautam at mgautam@rogers.com. Please include “Helping Hand” in the subject line. All inquiries will be confidential. Your questions will not be replied to, but may be selected to be answered in this column, which is intended to be educational, not therapeutic.