Andrew Garnham,1 Rachael Forsythe2
Some diseases are endemic and persistent. In this edition of the journal, the paper by vascular trainees Madurska et al points to bullying and harassment being such a disorder which is stubbornly resistant to intervention.1 Previous surveys have highlighted this problem and, although reported here in vascular surgery, it pervades much of surgery.
Why is this so important? Dysfunctional teams and poor behavioural markers are associated with inferior patient outcomes, which can be improved with appropriate team training.2,3 Well-established data around civility confirm that adverse behaviours affect not only those to whom they are directed but also witnesses.4,5 Both victims and bystanders experience decreased productivity and reduced engagement in work. Indeed, a significant number leave work altogether. The current workforce crisis mandates that we can ill afford to disengage trainees and allied health professionals with an interest in our specialty.
Why is this so difficult to change? Situational learning models and theoretical frameworks describe “cycles of abuse” where poor behaviour becomes learnt and normalised.6 Role modelling is important in many fields and, to an extent, we all model ourselves on those who teach us the craft of surgery. Previous trainee surveys highlighting similar issues resulted in responses from bodies such as the Vascular Society of Great Britain and Ireland (VSGBI), Specialty Advisory Committee (SAC) and the Royal Colleges and triggered letters to CEOs and MDs in all acute trusts. The VSGBI published an article in the European Journal of Vascular and Endovascular Surgery.7 The Royal College of Surgeons of Edinburgh developed a training module addressing bullying and harassment which was recommended to all those consultants involved in vascular surgical training.
Given all that has been done, the results of this latest survey provoke predominantly feelings of failure, disappointment and dismay. Whilst we must accept that the response rate is low, it signals that issues are likely to persist. How can we explain the results of this latest work? It appears to confirm that the diagnosis endures and the disease is endemic as it affects units throughout the UK. It is positive that the issue is being examined in an open way and perhaps the apparent increased rates of reported poor behaviour may represent colleagues feeling able to speak up. Apathy may have contributed to the poor response rate. The COVID pandemic presented unprecedented working challenges often outside our control, usual activities and comfort zone, resulting in additional extraordinary stressors for both trainees and trainers. Having now entered a phase of so-called recovery and faced with the Herculean challenge of “clearing the backlog” in an NHS that is far from ready, tensions will inevitably escalate. Are these pressures reflected in the outcomes of the present survey?
So what about the pathophysiology? Data from the Royal College of Surgeons of Edinburgh website8 confirm that the most commonly examined webpage is entitled “Am I a bully?” Self-reflection and personal inquisition may be necessary to become aware of distress provoking actions and behaviors. We must all place ourselves and our professional interactions under the microscope.
Further work is certainly required in order to more fully understand this disease. Its aetiology, environmental contributing and confounding factors, early indicators, prevention and management all merit further investigation. How can the problem be further dissected? Perhaps a range of real-life examples of these behaviours for discussion and thematic analysis with trainees and consultants together would be valuable? It is hoped that discussion and exploration of situational feelings and emotions in a safe environment will guide management strategies. Perhaps compulsory targeted training in emotional intelligence and stress management will provide trainers with effective “medicine” for this disease. As with any disease without a thorough understanding of the aetiology and careful dissection of the pathophysiology, we will be scratching around in the dark for suitable effective treatments.
November 21, 2022
1. Consultant Vascular Surgeon, Royal Wolverhampton NHS Trust; Training Programme Director and Deputy Head of School, Health Education West Midlands; President Elect, Vascular Society of Great Britain and Ireland
2. ST8 Vascular Surgical Trainee, NHS Education for Scotland; President, Rouleaux Club
Consultant Vascular Surgeon, Royal Wolverhampton NHS Trust, 12, Corporate Services Centre, New Cross Hospital, Wolverhampton WV10 0QP, UK
Email: [email protected]