Not so innocent bystanders

Joanna M Flynn
Med J Aust 2015; 203 (4): 163. || doi: 10.5694/mja15.00685
Published online: 17 August 2015

It's time for all of us to accept responsibility

“The standard you walk past is the standard you are prepared to accept.” With this wake-up call in June 2013, Lieutenant General David Morrison challenged all those serving in the Australian Army to take responsibility for the culture and reputation of the army and the environment in which they work.1 He made this call in response to an emerging scandal of sexual abuse and harassment in the army. At the 2015 Australian Medical Association national conference in May, James Lawler, President of the Australian Medical Students’ Association, named bullying, harassment, sexual harassment and their mental health as the biggest problems affecting medical students.2 He explained that he could not tell his peers to take a stand against the perpetrators because “the hierarchy is too high and too strong”. Quoting David Morrison, he called on those present to help change the culture of medicine.

Discrimination, bullying and sexual harassment are illegal and breach both published and implicit codes of ethics and professional standards in medicine.3 Yet they are prevalent in medicine and health care, not only in Australia, but in many other countries and cultures and in other professions, notably law.4 Both men and women perpetrate this behaviour, but the most common pattern is a male perpetrator and female victim. The behaviour affects the individuals involved and the organisations they work in, reducing individual and team morale and performance and, in health care, ultimately diminishing patient safety.5

Most incidents are not reported. Reasons for this include lack of confidence in complaint processes, fear of adverse consequences, reluctance to be viewed as a victim and cultural minimisation of the problem.6

Hierarchies lend themselves to misuse of power. Our profession remains hierarchical, and the further one advances up the hierarchy in many parts of the profession, the greater the imbalance between the sexes. This is particularly so in surgery, where only 10% of fellows are female, and few women hold office.7

In this issue of the Journal, Walton points to the profound power imbalance that exists for junior medical staff8 and Mathews draws attention to the system of patronage where trainees depend on powerful senior colleagues for advancement.3 These articles go some way towards explaining why victims cannot be expected to solve the problem or even to take primary responsibility for identifying and naming it.

What can the rest of us, the bystanders, do?

How can peers and colleagues not notice inappropriate behaviour going on around us? Or do we notice but feel disinclined to become involved or reluctant to act? And how do we respond if a student or trainee comes to us for help and support? Or if we are part of a formal complaints mechanism?

Those who are perpetrators, whether their behaviour is deliberate or unconscious, need to know that their peers do not accept and will not tolerate it. The behaviour needs to be recognised and condemned as and where it occurs.

The lack of confidence in complaint processes and fear of reprisals is a sad reflection of the hidden curriculum in medicine, the cultural norms and expectations that run counter to the explicit curriculum of professionalism.

The way forward

“Good medical practice”, the code of conduct issued by the Medical Board of Australia outlines the professional values on which all doctors are expected to base their practice.9 These values include integrity, truthfulness, dependability, compassion and self-awareness. Bullying, discrimination and sexual harassment are incompatible with these qualities.

Problems of discrimination, bullying and harassment are not new, but they are increasingly at odds with the standards expected in the 21st Century. Other institutions are facing up to the darker aspects of their history and culture, bringing them into the light of day and committing to eliminating abuse and exploitation. It is time for all of us to accept responsibility for the culture and reputation of our profession and work to create environments in which respect is the dominant quality of relationships with our colleagues, trainees and patients.

Provenance: Commissioned; externally peer reviewed.

  • Joanna M Flynn

  • Medical Board of Australia, Melbourne, VIC


Competing interests:

I am Chair of the Medical Board of Australia and a member of the Expert Advisory Group of the Royal Australasian College of Surgeons on bullying, discrimination and sexual harassment.


remove_circle_outline Delete Author
add_circle_outline Add Author

Do you have any competing interests to declare? *

I/we agree to assign copyright to the Medical Journal of Australia and agree to the Conditions of publication *
I/we agree to the Terms of use of the Medical Journal of Australia *
Email me when people comment on this article

access_time 10:11, 17 August 2015
Ethnic Medica

It is encouraging to see an open discussion on bad behaviours within the profession. So far the discourse has been focused on gender, specifically the inequitable treatment of women. Most of the studies have also been by women. What is less discussed is the same discrimination faced by non-White doctors of both genders. There are publications on effect of racism on patients, but what about on doctors? What are the emotional and mental impacts of covert racism on doctors by patients, other White doctors and the bureaucratic administration? There are strong anecdotal evidence by those aggrieved that it has a negative impact on them. So the silence on the topic is deafening.

Competing Interests: No relevant disclosures

Dr Ethnic Medica

access_time 09:32, 21 August 2015
Ulf Steinvorth

Thank you for reminding us that we are all personally involved in bullying and harassment in the medical fraternity, if only by looking the other way.
The article raises the critical question what we can do about it while the institutions and complaint mechanisms are falling short.
It stops short of offering us new ways of dealing with the abuse we witness, highlighting the need for our community to get together and find new, more effective and acceptable ways to combat and eradicate abuse of power.

Maybe we can learn from similar experiences in our military and Church and adopt some of the measures that have been employed in their field?

Competing Interests: No relevant disclosures

Dr Ulf Steinvorth
General Practice

Online responses are no longer available. Please refer to our instructions for authors page for more information.