An independent report commissioned by the Royal Australasian College of Surgeons (RACS) released yesterday has found bullying, sexual harassment and discrimination are commonplace in the culture of surgeons. Apologising and committing to genuine action to address the “toxic culture” is a positive step, but the actual detox will require more radical surgery to some deeply held beliefs and a transplant of new attitudes about who is, and what it is to be, a doctor.
After reading news of the report in the morning, I found myself later in the day listening to a second-year medical student – let’s call her Jessica – describe the humiliating bedside teaching methods of a female clinician she’s nicknamed “The Trunchbull”*. She said:
The most offensive part was that this all occurred in front of patients. You could even see the looks on the patients’ faces, willing us to get the questions right, as they knew the humiliation that was to ensue.
We already know that 74% of Jessica’s peers have had similar experiences. And we now know that if her training leads her down the surgical path, there’s a 58% chance Jessica will continue to be bullied and a 30% chance she will be sexually abused or assaulted. This figure is tragically in line with the 33% chance of such abuse described in earlier studies.
And we know that if Jessica chooses to take action against her tormentors, she faces a 30% chance it will continue unabated.
‘Toxic culture’
The events of this year have left no doubt the culture of medical training in Australia is toxic. That toxicity is killing doctors and it’s killing patients.
The release of the RACS report was accompanied by contrition and an apology from the college about its own part in enabling this “toxic culture” to flourish. But demanding cultural change is one thing. Achieving it is quite another.
The college should be congratulated for taking the essential first step towards cultural change: acknowledging the existence and scope of the problem. They’ve also identified that there are still some surgeons who don’t believe these problems exist.
This mirrors much of the commentary of denial and victim-blaming around this issue in recent months. The deniers say, “It didn’t happen to me, therefore it doesn’t happen.” The victim-blamers suggest trainees are “whingers” and need to toughen up, or that they’re using their “feminine wiles” to get ahead.
Despite accepting all the report’s recommendations unequivocally, the next step for the RACS is much harder. It requires not just a new willingness to hold surgeons to account against revised policies and procedures, but also a frank scrutiny of the culture itself, especially its institutionalised norms and privileges.
Social exclusion
There’s a disturbing similarity between the statistics about negative health outcomes and experiences of abuse in medicine to those seen in other populations that experience high levels of social exclusion. Two notable examples are Indigenous Australians and people from sexual and gender minorities. Social exclusion – the negative consequence of stigma and discrimination – causes mental distress, substance abuse, reduced access to health care and poorer health outcomes.
Surely doctors, especially surgeons, are not a marginalised or stigmatised group? They’re revered, trusted and highly valued by society.
Actually, what matters most within a culture is not how doctors are perceived by society, but how they perceive each other. And within the society of doctors, not all doctors are equal.
Medicine today is a complex, increasingly diverse, but still very hierarchical culture. But as recently as the mid-20th century, it was much more mono-cultural: predominantly white, Caucasian, affluent, heterosexual and male. That is no longer the case.