Introduction

Complaints to the Medical Council are becoming more frequent today than ever before.  There was 308 complaints made in 2014, 369 complaints in 2015 and 411 complaints 2016 showing an increasing trend in complaints (1). Patients are more informed of their rights, while also having greater access to medical knowledge through the Internet than ever before. Patients want to be part of the decision making process of their treatment and want to feel listened to by their doctor. As of such, doctors must now display excellent communication skills to convey medical terms in simple language for the patients to understand.

We are also living in a time where more than ever, employees seek a safe environment to work in, free from discrimination and bullying, to be treated equally and fairly.  It is in the patient’s interest and the hospital’s interest, that good practise working conditions are implemented to enable staff to perform their work to the best of their abilities without added stresses of any nature.

In the following essay, I will highlight two examples of unacceptable behaviour and describe a solution for one of them.

Workplace Bullying

Example A. A consultant frequently verbally abuses his intern during ward wounds for not knowing a diagnosis.

The Workplace Bullying Institute gives a definition of bullying as “ repeated, health-harming mistreatment of one or more persons by one or more perpetrators.’ Bullying can be in the form of intimidation, humilication, threats, verbal abuse or even work interference (2). In the healthcare workplace, bullying is a challenging and common problem. It has serious negative consequences on the employee involved and is strongly correlated with burnout in the profession (3). It is most frequent in those aged 40 and under with women being more likely to be targeted (2).

Bullying is most common in emergency departments, intensive care units and in behavioural health units. It is also fairly common in the operating room, recovery room, pre- anaesthesia area and in preoperative area. There has been a culture among some surgeons in particular, who have been known to intimidate their lower ranked colleagues especially in stressful situations such as emergencies and the use of new equipment (2). Vogel noted in his paper on bullying in medicine, that it’s something that has existed in medicine for a long time, and that some medical trainees have seen it has part of the “hidden curriculum”(4). Pan et el. analysed the work environment of 540 junior doctors in Australia, 27% reported experiencing workplace bullying (5).

It is important to note that bullying is not just common among doctors in the hospital but also among all healthcare professionals.  Trépanier et al. noted in their paper that up to 40% of nurses are frequently exposed to bullying behaviours at work (6). It is one of the reason’s being suggested for the current nursing shortage. In their study, they highlighted 7 job characteristics that were found to significantly correlate with bullying in the nursing profession. These include:

1. Workload
2. Organisational constraints
3. Bad and stressful work situations
4. Negativity related to job control
5. Promotional opportunities
6. Reward
7. Structural Empowerment.(6)

Bullying impacts patient safety directly as those who are bullied, are made to feel apprehensive and will most likely diminish their performance due to the increased anxiety. With the diminished psychological functioning will also result in a higher rate of absenteeism (6).

Bullying in the workplace tends to happen in organisations that do not have a good support system and to employees who feel unable to defend themselves from their attackers. Several factors can contribute to bullying in the workplace:

• A culture of bullying in the organisation
• Staffing shortage
• Excessive workloads
• Power imbalances
• Poor Management skills
• Role conflict
• Stress
• Lack of autonomy (7).

In example A, which I have highlighted above, it is clear that the consultant is bullying his intern. As has been highlighted in the literature, it is quite common that junior doctors suffer bullying and in the past, there has been a culture of “this is the norm”. This intern would likely feel anxious and stressed every morning going to work. As this is their first medical job, the intern is at their most vulnerable.  With an experience like this, it may lead to burnout and the young doctor leaving the profession.

As has also been mentioned, the work environment healthcare professionals work in can contribute heavily to the culture of bullying given the high stress and demands of the job. Creating positive job characteristics and high quality interpersonal relationship have been shown reduce likelihood of bullying occurring in the workplace (8).

Improper Communication

Example B. A doctor not involving a patient in their treatment plan, prescribing medication without informing the patient of it’s purpose and potential side effects.

It is imperative that healthcare workers have good communication skills. Most patient complaints and dissatisfaction is due to the breakdown of the doctor-patient relationship (9).Patients need to feel listened too, feel they are being informed clearly and precisely of their illness and feel it is they who should be making the decision about their healthcare. Communication skills of a doctor are important for making good relationships with their patients. It is also essential in the diagnosis and treatment of a patient. It is called the heart and art of medication (9).

A physician’s communication and interpersonal skills include the ability to gather information in order to facilitate accurate diagnosis, inform the patient appropriately, give therapeutic instructions, and to establish a caring relationship with their patients.  The ultimate goal of the doctor- patient communication is to improve the patients overall health (10).

Biglu et al. in their study of the communication skills of physicians and patients satisfaction concluded that there is a strong correlation between patients satisfaction and the communication skills of physicians (devoting the appropriate time for visiting the patients, explaining diagnosis and treating procedures.) (11)

There are many reasons for ineffective communication in the doctor patient relationship. Examples include doctors workload, fear of litigation, fear of physical or verbal abuse, patients anxiety and fear, and unrealistic patient expectation (9).

It has also been noted that doctors have been found to discourage patients from voicing their concerns and their requests for further information. This can leave patients to feel disempowered, have poor understanding of their diagnosis and the patient may not follow through with their treatment (12).

Interestingly, it has been observed that during medical education, communication skills of students decline. Also, doctors in training tend to lose their focus on holistic patient care, empathy supresses likely due to the emotional and physical brutality of medical training (12).

In example B, which I highlighted above, it is clear that there is a poor doctor-patient relationship. The patient is not informed of their illness and does not feel involved in the decision making process, they are unlikely to follow through with the treatment. This may mean repeat visits from the patient or even the patient not returning to the doctor due to lack of trust. As is well mentioned in the news, there is chronic crowding in emergency departments around the country. Initial failure of a doctor to explain a patient’s illness clearly, involving them in the treatment plan, means there is a likelihood of this patient ending up in the emergency department if the illness is serious.

Remedy for Poor Communication

We are not all born with excellent communication skills. For the doctor in question who’s communication skills are not up to the expected standards some of recommendation I would make include:

Encourage attentive listening – A patient wants to feel that they have a doctor’s undivided attention, that they are being listened to and understood.

Empathy – Empathy is one of strongest ways of providing support to reduce a patients feelings of isolation and letting them know that their feelings or normal and to be expected (13).

Use open-ended questions – This encourages the patient to talk, to give more detail, which enables a better diagnosis.

Build a relationship with the patient – Knowing a patients perspectives, medical knowledge and expectations, can enable a doctor to break bad news in better way (13).

For long-term effective communication among healthcare professionals, it is vital to incorporate communication skills teaching in medical education. As has been noted by Aspegren, communication skills can be taught in courses, learnt and with adequate practise, students can be as effective as their teachers (14). Iqbal et al. in the study of the impact of focused training on communication skills of final medical students, found a 92% improvement in their performance after training (15). They concluded that training plays a very important role on improving communication skills.

Conclusion

As highlighted in the Medical Council’s code of ethics (16), medical professionalism is a core element of being a good doctor. Doctors at all times should act in the best interests of their patients.  I have highlighted just two of the issues that could impede that priority and given remedies to one of them to prevent such an action happening. If doctors adhere to the guidelines outlined in the code of ethics,  it will help for medical professionalism to me upheld during the course of their careers.

1.  [Available from: https://www.irishtimes.com/news/health/medical-council-sees-complaints-against-doctors-rise-20-1.2768116.

2. Pellegrini CA. Workplace bullying is a real problem in health care. Bull Am Coll Surg. 2016;101(10):65-6.

3. Livne Y, Goussinsky R. Workplace bullying and burnout among healthcare employees: The moderating effect of control-related resources. Nurs Health Sci. 2017.

4. Vogel L. Doctors dissect medicine’s bullying problem. CMAJ. 2017;189(36):E1161-E2.

5. Pan TY, Fan HS, Owen CA. The work environment of junior doctors: their perspectives and coping strategies. Postgrad Med J. 2017;93(1101):414-9.

6. Trepanier SG, Fernet C, Austin S, Boudrias V. Work environment antecedents of bullying: A review and integrative model applied to registered nurses. Int J Nurs Stud. 2016;55:85-97.

7. Rayner C, Hoel H. A Summary Review of Literature Relating to Workplace Bullying. Journal of Community & Applied Social Psychology. 1997;7(3):181-91.

8. Balducci C, Cecchin M, Fraccaroli F. The impact of role stressors on workplace bullying in both victims and perpetrators, controlling for personal vulnerability factors: A longitudinal analysis. Work and Stress. 2012;26(3):195-212.

9. Ha JF, Longnecker N. Doctor-patient communication: a review. Ochsner J. 2010;10(1):38-43.

10. Duffy FD, Gordon GH, Whelan G, Cole-Kelly K, Frankel R, Buffone N, et al. Assessing competence in communication and interpersonal skills: the Kalamazoo II report. Acad Med. 2004;79(6):495-507.

11. Biglu MH, Nateq F, Ghojazadeh M, Asgharzadeh A. Communication Skills of Physicians and Patients’ Satisfaction. Mater Sociomed. 2017;29(3):192-5.

12. DiMatteo MR. The role of the physician in the emerging health care environment. West J Med. 1998;168(5):328-33.

13. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302-11.

14. Aspegren K. BEME Guide No. 2: Teaching and learning communication skills in medicine-a review with quality grading of articles. Med Teach. 1999;21(6):563-70.

15. Iqbal N, Mookkappan S, Basheer A, Kandasamy R. Impact of focused training on communication skills of final-year medical students in a medical school in India. Australas Med J. 2015;8(10):325-32.

16. release]. Medical Council.