By Mikkael A. Sekeres, M.D. June 14, 2018 Years ago, when I was a medical student trying my hand at a variety of specialties, I spent two months on the surgery service. The days were rigorous, starting before 5 a.m., when I was expected at the hospital to round on patients who had recently undergone surgery. I then scrubbed in to the first operating room case of the day, at 7 a.m. Depending on the complexity of the procedure, we wouldn’t emerge from the O.R. for hours, biologic needs such as going to the bathroom or eating be damned. Another case, more rounding, and I typically surfaced from the hospital at dusk, completely exhausted. Unless I dared to inquire when we would be done with rounds. “Whenever you ask me ‘When will we round out?’” the surgical fellow told me and the other medical students, more than once, “I will make it one hour later.” This was said unsmilingly, and he delivered on his promise. Our supervisor’s behavior was a form of bullying, and not the last time in my career that I would face it. Bullying involves an imbalance of power between the perpetrator and the victim: in our case, between a fellow or staff physician and a resident or medical student. It occurs repeatedly over time. A victim’s inability to defend him- or herself is also part of the equation — we feared any grade less than high honors, which could compromise the type or quality of residency we might obtain, and would be determined largely by the fellow. Finally, the intention of bullying is to cause harm or distress — our fellow seemed to delight in our fear.
pernicious, even tragic, repercussions of bullying in school-age children have been well documented. But bullying is also far more common than we acknowledge in health care workers and can cause similar harm to body, mind and career. In one recent study of 635 doctors and nurses working in neonatal intensive care units in Greece, more than half of both doctors and nurses said they had witnessed bullying in their workplace or been a victim of bullying themselves. Doctors were more likely than nurses to label themselves as victims. Dr. Ilias Chatziioannidis, the lead author of the study, said there were three main types of bullying: personal bullying, for example, having insulting or offensive remarks made about your habits or background, attitudes or private life; workplace bullying, such as being pressured not to take a sick leave or holiday; and personal intimidation, including threats of violence or physical abuse or actual abuse. Rates may be even higher in America. In another study that included 1,387 American medical students in their final year of school, 42 percent reported having experienced harassment and 84 percent experienced belittlement during medical school. Most commonly, the bullying behavior came from the residents and professors supervising them. American medical students in a similar survey spoke of comparable examples of harassment and belittlement in the workplace. They included abusive stereotypes (“You females and your pea-sized brains!”); sexual overtures (“The chief resident asked explicit questions about my sexuality/experiences/practices. He could not be discouraged and continued doing so throughout the entire rotation.”); and inappropriate touching, including “patting the posterior, pinching the waist, stroking hands, rubbing and massaging.” Toward the end of my surgery rotation, I scrubbed in on a patient undergoing coronary artery bypass surgery, an intricate procedure in which the heart is actually halted from its inexorable beating for a time as the surgeon attaches new vessels supplying it with blood. The cardiac surgeon had spent the majority of the case berating me for my inadequacies, from how I held a retractor to the way I was standing or had tied my surgical cap. Eventually, he called me over to his side of the operating table. “I want you to hold this heart for me with your hands,” he said. Ever so gingerly, I eased my hands underneath the patient’s heart, cradling it as delicately as if it were a Fabergé egg. “Jesus Christ!” he shouted at me. “What the hell are you doing? You almost tore it out of this man’s chest when I just fixed the damn thing! Get out of here!” I sheepishly left the O.R., and any passing thoughts I had of a career in surgery. But the consequences of bullying, as we all know, can be even more dire, leading to anxiety, depression, burnout, drug abuse and worse. In a recent essay in the New England Journal of Medicine, Dr. Michael Weinstein, a trauma surgeon, opens up about his own spiral into depression and burnout, after silently enduring feelings of inadequacy for years while working in a culture that wouldn’t allow him to share those feelings. He recounts how, during his residency, he was “rewarded” for having been on call for 24 hours with being allowed to scrub in to the operating room post-call, extending his shift to 36 hours. He reflects on how he considered a colleague “weak” because he took a leave of absence for a nervous breakdown. He eventually plots his own suicide, and it is only at his wife’s urging that he finally gets the help he needs. How many others have been driven to such despondency with the mixture of sick or dying patients, whom we sometimes can’t fix, and an unforgiving work environment? It is a cruel irony that doctors and nurses are drawn to medicine to care for others, yet the majority have been bullied by their colleagues and superiors. We should all be able to turn to one another for support, to be able to admit that we are hurting, and to ask for a system that allows for missing work in the event of illness, without suffering castigation for being weak. It’s in our patients’ best interests, and in ours. Dr. Mikkael Sekeres (@MikkaelSekeres)