Bullies In Hospitals?

Theresa Brown’s New York Times op-ed, Physician, Heel Thyself, recently introduced hospital bullying into the national health care conversation.  (1)

In it, she recounted a hospital vignette while working as an oncology nurse.  A patient asked a doctor who should he blame for a late test result.  The physician, turning to Brown, said, “if you want to scream at anyone, scream at her.”

That type of boorish physician behavior certainly cannot be tolerated.  Brown was brave to bring hospital bullying to light in a national forum. 

But soon after her piece was published, many physicians, including myself (2), were defensive as Brown essentially singled out doctors for the bullying that goes on in hospitals.  

“Because doctors are at the top of the food chain,” she wrote, “the bad behavior of even a few of them can set a corrosive tone for the whole organization. Nurses in turn bully other nurses, attending physicians bully doctors-in-training, and experienced nurses sometimes bully the newest doctors.”

But I wonder if the issue is more complicated than simply blaming physicians.  Most doctors I know harbor nothing but the greatest respect for nurses, and realize how important they are to quality patient care.  It seems unfair to tar them with such a broad stroke.  

And besides, others in the hospital are responsible for bullying as well.  Like nurses themselves, for instance.

Last year on Well, the Times’ health blog, Brown herself wrote that “overwhelmed and angry nurses take their frustration out on the rest of us stuck in the corner with them, or on anyone they perceive as being less powerful than they are.” (3)

Indeed, 60% of new nursesleave their first position because of bullying from their colleagues, such as verbal abuse or harsh treatment. (4)

Brown calls for changes up top, such as hospital administrators adopting uniform standards of professionalism for every staff member, no matter how important they are, and having offending parties undergo civility training.  

But those policies are already present.  University of Pennsylvania bioethicist Arthur Caplan, in response to Brown’s column, points out that “hospitals are instituting courses about bullying, reporting systems are increasingly in place, and punishment is happening.”

Instead, change also needs to occur from the bottom up.  Consider how physicians are educated. 

The culture that perpetuates bullying can be traced as far back as medical school, when as students, future doctors are trained in a pecking order not unlike the military.  During the first two years, medical students have little exposure to patients and are exposed to the hierarchical tendencies and behaviors of their professors. 

This needs to change.  Medical students need to learn, from the beginning, how to work as members of a team.  They need to understand that patient care is not only about the doctor and patient, but about how doctors, nurses, and medical assistants form a cohesive unit for the singular goal of helping patients.  

That’s beginning to happen at some institutions, like Harvard Medical School, where patient care concepts are introduced in the first year.  Harvard student Ishani Ganguli, writing in the Boston Globe’s health blog, says “through role play and interviews with volunteer patients, we learn the vocabulary, even seating positions, that allow us to take detailed histories from patients and show empathy for them. We carry the skills from this course with us through subsequent years of medical school and no doubt beyond.”

She makes a point that such a curriculum should be expanded to teach medical students how to interact with nurses more collegially as team members, rather than as part of a superior-subordinate hierarchy.

Hospital bullying is often shrouded in silence, and Theresa Brown should be applauded for publicizing the issue.  But targeting the toxic culture that perpetuates the problem requires everyone to share responsibility.  Not just doctors, but nurses, hospital administration, and medical educators as well.  Only when every stakeholder is part of the solution do we stand a better chance of eliminating bullying behavior in hospitals altogether.

Kevin Pho, MD is a primary care physician in Nashua, NH, and is founder and editor of MedPage Today’s KevinMD.com.