9 8 | THE QUARTERLY Q1 2023 Towards Better: Why We Need to Reculture Medicine Now The latest Medical Training Survey makes for sobering reading, prompting the need for senior doctors to do more to stop bullying, racism, discrimination and harassment, in the profession, writes Dr Jillann Farmer. The results of the 2022 Medical Training Survey were released in February and paint an increasingly negative story for our earlycareer colleagues. They point to an environment that is repugnant to cultural safety, one that holds an uncomfortable mirror to the profession and details impacts on workforce retention. For RACMA Fellows, there are two perspecives to consider – that through the lens of system leaders and managers, and that of supervisors of our own candidates. Both perspectives warrant further reflection. The headline data are as follows: 30% of prevocational or specialist trainee doctors witnessed bullying, harassment, racism, or discrimination in the workplace in the 12months preceding the survey. For RACMACandidates this percentage was 36%. 22% of the general population and 24% of RACMA Candidates reported experiencing it themselves. The combined overall total of those who experienced or witnessed these adverse behaviours was 34% in the overall survey group. The rates were lower for Trainees in General Practice, with 19% witnessing bad behaviour and 16% experiencing it. For non-GP specialties, 34%had experienced these behaviours and 23% had witnessed it. Breakdown by category Bullying – 12% experienced, 21%witnessed (RACMA – 16%, 24%) Harassment – 8% experienced, 13%witnessed (RACMA 13%, 17%) Discrimination – 9% experienced, 13% witnessed (RACMA 8%, 15%) Racism – 6% experienced, 13%witnessed (RACMA %, 14%) Racism If we look at the data from the 191 respondents who identified as Aboriginal or Torres Strait Islanders, there are some confronting differences. 20% of our Aboriginal and Torres Strait Islander colleagues have directly experienced racism in the workplace. 30% of them have witnessed it. That compares with 6% experiencing racism and 13% witnessing racism for non-Aboriginal and Torres Strait Islander respondents. While 85% of the overall cohort agreed that their workplace did not tolerate racism, only 69% of Aboriginal or Torres Strait Islander respondents agreed. This suggests that we need to ameliorate the way we recognise and acknowledge the lived experience of racism – those who do not experience it are more likely to believe it is not there. So, who is responsible for this bad behavoiur The survey helpfully outlines the answer to this highly pertinent question. 50% of respondents identified senior medical staff 40% identified a patient, family or carer 33% identified nurses or midwives, and 30% identified a registrar or other doctors in training Respondents were able to identify more than one perpetrator, as the report was an aggregate of a year’s experiences. This means that 80% of respondents saw other doctors engage in bullying, harassment, discrimination, or racism. Half of them senior doctors, who should be their role models, engage in these behaviours. 79 respondents were RACMA Candidates. They had negligible levels of reported bullying, harassment, racism or discrimination. However, for the 24% who experienced it, it was perpetrated by their supervisors- likely to be Fellows of this college- 23% of the time. Although these overall numbers are low, this should give us all pause – and a renewed awareness of our impact as role models. The full report can be downloaded here, and you can create a report that details your specified areas of interest by using the website’s interactive features. A culture of bad behaviour The Medical Training Survey produced similar results in 2021, and as a consequence of those results, the Medical Board of Australia convened a “Culture of Medicine Symposium” on 27 May 2022. While the COVID-19 pandemic and its associated workplace stressors may have exacerbated levels of manifest distress in the workplace, it cannot explain the totality (or even the majority) of this picture. The 2019 Survey, collected before the pandemic, showed that 22% of respondents had experienced bullying, harassment or discrimination, and 27% had witnessed it. What can we do? Some key challenges for change include: the complexity of our close working relationship with other stakeholders the split responsibilities between the States (who operate the health services that employ almost all non-GP specialist trainees) and the Colleges (who accredit training positions, set curriculum, conduct training programs and associated assessments, and confer Fellowship), and the finding that non-medical health professionals and patients/ families were identified as a very significant proportion of perpetrators. This is not an exclusively medical problem, but the medical profession must own its slice of this unsavoury pie. We have tolerated egregious behaviours for too long. Some of the Specialist Medical Colleges have taken concrete steps to address these issues, others are still at the policy and discussion stage. Whilst acknowledging our contribution, it is also clear that the Colleges alone cannot fix this and dealing with it as a professional conduct issue dooms us to failure. The Medical Deans Australia and New Zealand Inc have published a series of case studies of their interventions to address these harmful behaviours. These case studies are sobering reading, with several entrenched and recidivist attitudes among senior colleagues who, quite frankly, should know better Psychosocial Hazards Bullying, harassment, discrimination and racism are psychosocial hazards, recognised variously in different state legislation, but nonetheless, they are workplace hazards. As a working GP, I saw many patients whose acute mental health decompensation was directly associated with workplace experiences, and amongst those were medical practitioners, nurses and allied health professionals. The AMA Council of Doctors in Training has published an excellent briefingpaper on this topic, which shouldbe readby all those aspiring to or currently holding leadership roles in healthcare (in medicine or in other disciplines). Whilst Doctor wellbeing and workplace psychosocial hazards are related, they are not the same issue. Poor individual health and wellbeing can be one contributor to adverse workplace behaviours, and psychosocial hazards can (and do) contribute to poor health. These programs of work complement one another, but it is time to move beyond a belief that doctors can fix this by ourselves. Fixing the problem Doctors are, by and large, a privileged group. This contributes to a perception that doctor behaviour will not be addressed. That does not negate our need for safe, healthy workplaces. However, it does mean we have an opportunity to use our privilege to benefit all health workers, to contribute to the creation of better workplaces, better culture, and in turn, better patient care. We need leaders (Health Ministers, Directors General, Commissioners, and consumer advocates) who acknowledge that this is a shared responsibility, with employers having a duty of care to their staff that cannot be abrogated to medical training entities. In return, those leaders need us, as professionals, to step up. They need us to challenge hazardous behaviour, to ensure that those who report it are supported and protected, and to set clear boundaries around what constitutes professionalism in the 21st Century. It is only by harnessing the cohesive efforts of all parties that we will finally create healthy workplaces. The Royal Australasian College of Medical Administrators has started a 2-year project to boost us on this journey. I am privileged to lead that project team, with a firm belief that together, we can reculture medicine. To date, there has been extensive stakeholder liaison with invitations to speak at some College Conferences. Branding and website development will be finalised next month, and a governance structure has been established with the convening of an Advisory Board to commence shortly. Communication around branding and websites will be made available to all RACMA Members in the coming months. There will be ample opportunity for Fellows and Candidates to become involved in this work. There will be working groups to produce content, and these will be supported by an array of reference groups, each one focusing on a different perspective. This will ensure that voices not usually heard at leadership tables in medicine are amplified effectively. These reference groups will be co-chaired by RACMA Candidates and nominees of other colleges. I invite you to connect with the project and join us on this journey towards a better culture. *A version of this article was published in Issue 10 of Insight+ on 27 March 2023
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