Chair’s Column: Where We are Taking Action to Address Unprofessional Behaviour in the Department of Medicine

Oct 9, 2019
Author: 
Dr. Gillian Hawker

Gillian HawkerDr. Gillian Hawker In the last issue of DOM Matters we presented you with our 2019 Faculty Survey results. As in previous departmental surveys, the majority of our faculty report a collegial, respectful and civil work environment. As I hear from department members frequently, we are so very fortunate to work in such a wonderful department – with people who truly care about providing the very best patient care, learning experiences and highest quality scholarship!

Still, too many of us have witnessed or experienced unprofessional behaviours by faculty members, from eye rolling to blatant racism. Unprofessional behavior creates an unhealthy environment, contributing to physician stress and burnout, as noted by the following faculty survey respondent:

“Majority of the staff are excellent colleagues. However, there may be the odd one senior staff member who is a bully and can make a big difference to team dynamics. Fearing reprisal, more junior staff tend to compromise on their principles, align with the bully and try to please him/her constantly, even at the expense of gossiping against and potentially hurting others. A junior staff who tries to stick to principles and shy away from the gossip soon finds her/himself out of the "caucus" and starts getting targeted her/himself.  This sets the ground for a constant moral challenge for the junior staff: to stick to the principles of virtue one grew up with or to compromise with the principles and align with the bully to save her/himself from being caught in the crossfire.”

We have been working hard to address unprofessional behaviour but, fear of retribution and a sense that nothing will be done undermine our efforts:

“Despite encouragement and reassurances of any reporting of behaviour to be confidential and w/o reprisal - there is no way that trainees or junior faculty are going to report issues, as to do so would be career suicide. That is still an unfortunate reality. W/o specifics there is no ability to go back to an offending individual, and with specifics individuals are identifiable.”

“Although the intent is certainly that no retribution occur, it is challenging to enforce this. Retribution can take many forms many of which are passive and difficult to prove. Being the youngest recruit and still on probation, I don't feel comfortable to report acts of unprofessionalism from direct colleagues to the Division Director.  I discussed the issues with my mentor but it was received as an act to 'ventilate' my concerns.  One of these colleagues may be given a leadership position, which creates a moral dilemma whether to report my concerns to the Department Head and run the risk of personal negative consequences or to remain silent.”       

“…no point in speaking up (reporting) as nothing will happen…”

Encouraged by our departmental leadership, in this Chair’s column, I want to let you know that we are listening and taking action. So is the Faculty of Medicine; Dr. Pier Bryden has recently been appointed as Faculty Lead for Professional Values. Under her leadership, we will be working towards a common policy and procedures to address unprofessional behavior in the future.

Over the past five years, the department has received 50 formal reports of unprofessional behavior by members of our full-time faculty (6%):

  • 18 minor incidents: single, isolated events or micro-aggressions that are troubling to the individual who experiences or witnesses them, but for which a formal report may seem unwarranted.
  • 32 major incidents: behaviours, actions and/or micro-aggressions that are either repeated or so severe as to have a significant negative effect on the learner/faculty member and the work environment, and thus warrant formal reporting.

In addition to these, we have dealt with reports relating to faculty members’ cognitive abilities and complaints related to learner behaviors.

Addressing Reports of Unprofessional Behaviour

Allegations of unprofessional behavior have come from faculty members (n=28), trainees (n=11), or both (n=11). Complaints from trainees have come to us via program directors, division directors and site leads, as well as from the trainees themselves (in person, in writing/by email, and through egregious and persistent comments on teaching evaluations).

Two-thirds of complaints have been related to failure to be a role model, including:

  • Creation of a hostile environment: failure to work collaboratively in patient care; micro-aggressions; bullying; recurring outbursts of anger: shouting, throwing or breaking objects; hitting; and disparaging public remarks about the character or patient care of another physician, health professional or learner;
  • Intimidation & harassment: use of ridicule in the work environment or as an instructional technique; denying appropriate opportunities for learning and experience; and sexual harassment; and,
  • Research misconduct.

 Alleged Breaches of Professional BehaviourAlleged Breaches of Professional Behaviour An additional 10% of complaints related to violation of boundaries, and 8% each to failure to maintain a high standard of socially responsible clinical practice, including repeated failure to be available for scheduled duty or teaching, reporting for work when unable to perform required duties and questionable prescribing; lack of sensitivity to and acceptance of diversity; and failure to recognize, disclose, and manage competing interests.

Approach to Addressing Complaints of Unprofessional Behaviour:

From the Faculty of Medicine, the principles guiding the approach taken to address reports of unprofessionalism are as follows:

  • Complainant and patient safety is paramount.
  • Review and action must not be guided by an assumption of guilt.
  • Information regarding actions taken must consider issues of privacy and confidentiality. 

Putting these principles into action has been challenging, and we are well aware that we have not always got it right. This is difficult work! I want to thank our hospital leaders, in particular our PICs, as well as the Faculty of Medicine, in particular Dr. John Bohnen and Sara Gottlieb, faculty counsel, for their partnership in this journey. I am delighted to let you know that we are now working together with faculty leaders under the leadership of Dr. Pier Bryden, newly appointed Faculty Lead for Professional Values, to develop a common policy to address unprofessional behaviours in the Faculty of Medicine.

With the help of our hospital partners, the first steps taken when a complaint is brought to us have been as follows:

  • Ensure the complainant is safe from physical and psychological harm and that patient safety has not been compromised;
  • Ensure the complainant understands the processes and options involved in filing a report, including any limitations to our authority or ability to respond.
  • Encourage filing a report;
  • Obtain the complainant’s permission to share any potentially identifying information.

Concerns regarding research integrity are directed to the University’s Office of Research Integrity(research.integrity@utoronto.ca). Other types of complaints or issues, if they’ve arisen, would be directed to the relevant resources or bodies (ex. Community Safety Office, Sexual Violence Prevention and Support Centre, etc).

Minor Incidents of Unprofessional Behaviour

Our focus in these cases has been on the following:

  • Ensuring the faculty member understands that the behavior is unacceptable;
  • Setting expectations going forward, and providing the support required, e.g. education or coaching, to help address the behavior change;
  • Communicate that further action will be taken should the behavior recur or continue.

Major Incidents of Unprofessional Behaviour

A summary of findings and recommendations is prepared and presented to the faculty member. To date, actions taken have included one of more of the following:

  • Referral for coaching (diversity sensitivity, communications, leadership, etc.) 
  • Referral to the OMA Physician Health Program or other professional body (concerns about mental health and addiction)
  • Reallocation of trainee responsibilities, including suspension of learner interactions until professional behavior has been effectively addressed 
  • Reallocation of clinical responsibilities including clinical sites
  • Professional leave
  • Removal from leadership roles
  • Negotiated departure from the University
  • CPSO investigation & recommendations

Summary & Conclusion:

Let me emphasize once again that the vast majority of our faculty provide outstanding patient care and teaching to learners of all levels.The efforts described above are not in any way meant to persecute or punish faculty members who are dedicated to working and teaching in challenging circumstances. But we are an academic institution. As such, we have a moral obligation to all those who come to learn in our hospitals, clinics, and emergency departments to provide a safe and supportive environment. Further, as problematic interactions may stem from unusually high levels of stress in demanding work environments, addressing mistreatment is critical to addressing faculty and learner well-being. These efforts are part of an overall strategy to create an environment of safety, inclusion and wellbeing for all members of the Department of Medicine.

Resources for Faculty & Learners:

Clinical Faculty Advocate

Faculty of Medicine Code of Conduct for Clinical Faculty and Trainees

College of Physicians and Surgeons of Ontario (CPSO) document Physician Behaviour in the Professional Environment.

Parallels will be found in Sexual Harassment Complaints involving Faculty and Students of the University of Toronto arising in Independent Research Institutions, Health Care Institutions and Teaching Agencies 

Professional conduct extends to use of the internet and electronic communication in all settings. Useful guidance may be found in the Postgraduate document Guidelines for Appropriate Use of the Internet, Electronic Networking and Other Media, 2008