Bullying has significant, far-reaching consequences for all health professionals, students, trainees, patients, their families, and organizations. Bullying is antithetical to healthy organizational culture, patient safety, and professionalism. A culture of safety and respect in sites of healthcare education and work is foundational to the well-being of everyone in health care. This commentary on a case recommends individual and collective responses to bullying that express fundamental clinical and ethical values and what it means to be a professional.
Dr S is a second-year surgery resident who is apprehensive about a last-minute assignment to assist Dr T in an aortic valve replacement for the patient, JJ. Dr T often condescended to many students, trainees, and colleagues and repeatedly made public, belittling remarks about Dr S's performance, specifically. During JJ's surgery, Dr T ordered Dr S to get a 28 mm St Jude mechanical valve. Dr S paused, however, recalling from JJ's patient record a prior episode of intestinal bleeding. Dr S wondered whether Dr T knew about this detail in JJ's history, which would influence evaluation of prospective risks and benefits of long-term anticoagulation therapy that standardly follows mechanical valve placement. Dr S felt intimidated by Dr T and hesitated, wanting to ask whether a bioprosthetic valve, which would not necessitate anticoagulation therapy, might be more appropriate for use in JJ's case.
Dr T shouted, “What are you waiting for, S? Get the valve or get out!” Members of the surgical team looked away, including Dr A, an anesthesiologist who has often witnessed Dr T's outbursts and their effects. Dr S retrieved the valve and was distracted throughout the rest of the surgery. Hours later, Dr S reminded herself to make sure there was a plan for evaluating the patient's need for long-term anticoagulation.
Professionalism is the conduct, values, and qualities that characterize members of a profession and guide decision making in ethically challenging, rapidly changing clinical practice environments.1 Health professionals have duties to maintain competency and skill standards in their fields, practice self- and group-regulation,2 and express enduring commitment to reliable, safe, equitable care for all patients. Clinicians also commit to practice with empathy, compassion, respect, collegial engagement, and teamwork. Quiz Ref IDHigh-functioning teams demonstrate defining characteristics of professionalism: sharing core ethical values, modeling respect for fellow professionals, and promoting cultures in which everyone feels safe asking questions.3 When well-functioning professional teams are partnered with health systems with shared goals and values—and when leaders are committed to building systems that make it easy for team members to do the right thing—a culture of safety is possible.
Safety Culture Undermined
Quiz Ref IDThe American Medical Association (AMA) defines workplace bullying as “repeated, emotionally or physically abusive, disrespectful, disruptive, inappropriate, insulting, intimidating, and/or threatening behavior targeted at a specific individual or a group of individuals that manifests from a real or perceived power imbalance and is often, but not always, intended to control, embarrass, undermine, threaten, or otherwise harm the target.”4 Bullying can affect anyone regardless of gender,5 occupational status,6 or nationality7 and is more frequently reported by women7,8 and members of some racial and ethnic groups.9,10
Quiz Ref IDDisrespectful behavior, including bullying and aggression, directed toward colleagues and learners diminishes their vigilance and willingness to share concerns or ask for help and threatens team performance.11,12 Disrespectful behavior contributes to errors, patient dissatisfaction, and preventable adverse outcomes.12- 16 Patients who receive care from surgeons like Dr T are more likely to experience complications (eg, surgical site infections, cardiac arrest, septic shock, and stroke).16,17
Quiz Ref IDTeam members subjected to behavior like Dr T's report diminished professional satisfaction, isolation, burnout, distress, depression, anxiety, and suicidal ideation.18- 22 Those regularly exposed or subject to patterns of disrespect can experience pain, fibromyalgia, and cardiovascular disease.23- 27 Bullying contributes to increased absenteeism19,28 and can undermine organizations' attempts to build respectful, safe workplaces.13,29 Reputational damage, legal costs, and turnover are other organizational consequences of bullying and disrespectful behavior.30- 32 When single incidents go unaddressed over time, they forge dysfunctional practice patterns.33 As a seasoned observer of Dr T's abusive behavior, Dr A, for example, also regularly lets colleagues down by remaining silent, further eroding trust, undermining effective communication, and threatening patient safety.11,13,18,28,29,34- 36
Everyone Is Responsible
When team members model courage by speaking up in the moment and reporting incidents when needed, they reinforce desirable, safety-oriented clinical and ethical values (eg, respect, equity, inclusion) and help strengthen organizational cultures of safety. As health care practice continues to evolve and care delivery trends change, addressing disrespect and bullying will require collaboration among clinicians, professional societies, health professions schools and their admissions committees, and health care organizational leaders. Preventing bullying begins with recognizing the need to promote self-reflection and self-regulation opportunities during professional development, before patterns of dysfunctional, unprofessional behavior emerge. To help organizations achieve a workplace safety culture, the AMA established guidelines, among which the following are key4:
Describe organizational leaders' “commitment to providing a safe and healthy workplace.”
“Outline steps for individuals to take when they feel they are a victim of workplace bullying.”
“Provide contact information for a confidential means for documenting and reporting incidents.”
Establish “procedures and conduct interventions within the context of the organizational commitment to the health and well-being of all staff.”
Establishing and maintaining a system-wide peer reporting and feedback mechanism improves accountability and enhances professional self-regulatory capacity and can help motivate self-reflection.33 For example, professionals should consider the following questions:
Do I understand relationships between disrespect and adverse outcomes for my patients?
What should I do to make it easier for others to collaborate with me to care well for our patients?
Do I understand how to respond to someone expressing disrespect toward a colleague, patient, or myself?
How should I partner with organizational leaders to support my colleagues effectively and sustainably?
Organizations have duties to patients and staff to promote safety, to promote awareness of threats to safety that bullying and other forms of disrespect create, to establish clear processes by which incidents that threaten safety can be safely reported (eg, by minimizing vulnerability to or fear of reprisal), and to review and respond to incidents and patterns of unprofessional behavior equitably and effectively. In our experience, responses to reports of incidents are not well coordinated or consistently or equitably applied to all team members, especially when abuse is committed by individuals like Dr T who, despite being viewed as “high value” in terms of having cultivated an exclusive skill set or capacity to generate revenue, enact behaviors corrosive to collegiality or the reputation of the organizational workplace.37- 40
The pursuit of a high-functioning professional team begins with steadfast confirmation of shared clinical and ethical values expressed through professional collaboration with active organizational leaders with the courage and authority to offer consistent reinforcement of values and consistent messaging and enforcement (eg, in performance reviews) of behaviors and practices that are incentivized (or penalized). Quiz Ref IDTo promote a culture of safety and professionalism, leaders should hold everyone equally accountable, recognize professionals who exceed expectations, employ and effectively utilize reporting systems, and provide sufficient resources to individuals and teams to build and maintain these efforts.41 It is through this commitment to a better culture focused on safety that all health care workers and trainees, organizational leaders, administrators, patients, and families can stand up for medicine and be vigilant advocates for the medical profession.
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The AMA Journal of Ethics exists to help medical students, physicians and all health care professionals navigate ethical decisions in service to patients and society. The journal publishes cases and expert commentary, medical education articles, policy discussions, peer-reviewed articles for journal-based, video CME, audio CME, visuals, and more. Learn more
AMA Journal of Ethics
AMA J Ethics. 2021;23(12):E931-936.
AMA CME Accreditation Information
Credit Designation Statement: The American Medical Association designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.
If applicable, all relevant financial relationships have been mitigated.
Conflict of Interest Disclosure: The author(s) had no conflicts of interest to disclose.
The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.
Lindsey E. Carlasare, MBA is a research and policy manager at the American Medical Association in the Professional Satisfaction and Practice Sustainability business unit in Chicago, Illinois. Her research work focuses on identifying and evaluating elements of physician practice that contribute to burnout, stress, depression, and other factors affecting the well-being of the physician workforce. She has also collaborated on research to study practice dynamics, such as behavioral health integration, changes in payment models, and electronic health record use, and how these factors affect the practice of medicine and physician well-being; Gerald B. Hickson, MD is the Joseph C. Ross Chair of Medical Education and Administration and founding director of the Center for Patient and Professional Advocacy at Vanderbilt University Medical Center in Nashville, Tennessee. He serves as a member of the board of directors of the Institute for Healthcare Improvement and previously served as chair of the board of directors of the National Patient Safety Foundation. Since 1990, his research has focused on why certain physicians attract a disproportionate share of malpractice claims, how disrespect affects team performance and outcomes of care, and how to identify and support high-risk clinicians.
Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:
It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.
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