Chair's Column: Fostering a Climate of Inclusiveness and Civility: Results from the 2017 Faculty Survey

We have a wonderful department full of talented, caring and creative individuals. But, we work in an increasingly stressful academic and clinical environment and this can take its toll. Each of us copes with the stresses of our various professional and personal roles differently. While the stresses affecting our lives as academic physicians increase, so too, have the expectations of us as physicians and leaders.

As faculty members, we are expected to maintain a high standard of socially responsible clinical practice – to demonstrate honesty, integrity, empathy, humility, compassion, and altruism at all times. We are expected to be role models – to be collegial, act with courtesy and respect, communicate effectively, and demonstrate sensitivity to, and acceptance of, diversity. Further, we are expected to have insight into  the impact of our actions, using the Faculty of Medicine, University of Toronto, Standards of Professional Behaviour for Medical Clinical Faculty, College of Physicians and Surgeons of Ontario (CPSO)and hospital codes of conduct as our guidelines.

How well do we answer these expectations? The 2017 Department of Medicine Faculty Survey provides some clues. When asked their level of agreement with the statement, “The people I work with interact with them in a respectful and civil manner,” the vast majority – 87% – of the 414 faculty members who responded (an overall 52% response rate) ‘somewhat’ or ‘totally’ agreed.

Still, lapses in professionalism inevitably occur.

Almost half (48%) our survey respondents reported having witnessed what they perceived to be ‘unprofessionalism’ by faculty members towards others (their peers, those junior and those senior); 38% indicated they had personally experienced such behaviours. Some respondents attributed these behaviours to their sex/gender, race/ethnicity, religion and other attributes, including their age, medical specialty and professional role. Most often the behaviour was described as disrespectful, but other behaviours were also reported (bullying, eye rolling, explicit favoritism, exclusion from activities, ageism, unwillingness to pitch in clinically, swearing, and name-calling).

Every one of us is entitled to the occasional ‘bad day’, but persistent unprofessionalism in any one individual cannot – and should not – be tolerated. As Department of Medicine leaders, we are truly committed to cultural change, but we cannot take action to address incivility or unprofessionalism unless we know about it.

As a former physician-in-chief and now Chair, I am well aware that there are major barriers to dealing with unprofessionalism in our department that must be addressed. Our survey results underscore these barriers, which include: 

1. Lack of confidence (trust, belief) that action will be taken

We have a strong tradition of excellence in research, teaching and clinical care at the University of Toronto. And, we have tended to celebrate faculty members’ achievements in one of these areas – especially in research – irrespective of the individual’s overall contribution to the community in which they work. Respondents’ comments indicate that there is a perception that some faculty members are ‘untouchable;’ that is, that their long history of unprofessional behaviour is overlooked due to the prestige and/or money they bring to the institution. Our culture has also promoted the ‘selfish’ academic, putting relatively less emphasis on the value of collegiality and team work.

This must change.  

2. Lack of clarity regarding what to report

Respondent comments suggest there is a lack of clarity regarding what behaviours constitute ‘unprofessionalism.’ Indeed, when unprofessional behaviour is exhibited and not addressed ‘in the moment,’ we may send the message that the behaviour is ok – or at least tolerated. However, there is very clear policy in this regard. In brief, clinical faculty members must not:

• Create a hostile environment
• Intimidate, harass or discriminate
• Fail to identify, disclose, or manage conflicts of interest
• Have inappropriate relationships with industry
• Violate boundaries
• Repeatedly fail to be available for scheduled duty, including teaching and chronic lateness or report for work when unable to perform required duties
• Fail to fulfill academic obligations (e.g., inadequate supervision, be unavailable to learners, or fail to hand in evaluations in a timely fashion)
• Fail to complete professional obligations such as required clinical records and reports in a timely fashion
• Fail to cooperate with investigation and management of alleged breaches of professional conduct

For examples of what constitutes each of these behaviours please take a look at the Faculty of Medicine, University of Toronto, Standards of Professional Behaviour for Medical Clinical Faculty.

3. Fear of reprisal

And, of course, there is fear of reprisal. How on earth is a medical student or resident – or even a junior faculty member –  expected to challenge a more senior individual of whom they may be relying on for a positive evaluation, faculty appointment or reference letter for promotion? When asked why they had not acted on unprofessionalism experienced or witnessed, a common response from survey respondents was that they were simply too afraid – that there was insufficient support and protection for the complainant.

When asked how confident they are that they could take action to address unprofessionalism without concern for reprisal, only 51% of our survey respondents indicated being ‘very confident’ (43%, 58% and 66% for assistant, associate and full professors, respectively). Perhaps it’s not surprising, therefore, that only 26% of those who reported having personally experienced unprofessionalism had taken any action to report it.

We have work to do and we need your help. If we truly want to affect cultural change, we need to create a community in which you feel comfortable and confident to speak up, and supported when you do so.

Moving forward – educating our faculty and trainees about how to address unprofessionalism

As a self-regulated profession, it is our responsibility – our obligation to patients and society, as well as to our peers and trainees - to behave in a manner consistent with expected standards (i.e., code of conduct) for our profession. But practically, how do we do this? How do we address unprofessionalism when it arises?

First, if you have witnessed unprofessional behaviour, respectfully and quietly speak to the individual themselves, if possible. Let them know how the behaviour made you feel, even if unintended. Listen to them as well. It is possible that the offense was not only unintentional but unconscious, and they may be completely unaware of the impact of their words or actions. If you do not feel comfortable addressing unprofessional behaviour with the individual themself, ask someone senior to you to have the conversation on your behalf. (This is where good mentorship comes in – ask mentors for advice on how to handle the situation. If this is not possible, contact departmental leadership for confidential advice.)  Often this is all it takes.

If the behaviour continues despite your best efforts, take your concerns to the hospital department/division chief or the university department chair (that’s me), depending on the nature of the issue. Provide them with specifics. If the leader is the problem, go to their leader – there is truly no one beyond reproach. Students or residents with concerns about the behaviour of a clinical faculty member should bring them to the course or program director or, in a clinical institution, to the site director, VP of education or equivalent. Every effort will be made to protect you from retribution.

When a complaint is made there is a formal process that unwinds – it is thorough and fair. The goal of this process is to help the individual to reflect on their unprofessional behaviour and its impact on others, and to learn how best to prevent recurrence. There are many explanations for unprofessional behaviour; among these are physician stress, burnout, and personal/family issues. Where root causes are identified, these too must be addressed. While these may contribute to unprofessional behaviour, this is not meant as an excuse. 

For this reason, while confidentiality is critical to maintain – we function on a “need to know” basis.  Anonymity is not possible except where complaints are found through review of teaching and rotation evaluations. Fairness demands that a physician asked to respond is entitled to know the identity of the complainant. We recognize this poses a major barrier to reporting, but imagine it was you about whom a complaint was made. If the behaviour has been witnessed or experienced by more than one person, a group complaint may be made, which may empower reporters. A number of conflict resolution strategies will be used, depending on the nature of the complaint – the most effective one is usually communication. Sometimes a conversation is sufficient, at other times a coach may be required, and still others, a referral may be made to the Ontario Medical Association’s Physician Health Program. If the unprofessionalism persists despite these interventions, we must – and will – take action.

One needs to remember that reporting results of investigations into unprofessional conduct can be tricky; the desire to respect the need for privacy of the parties involved must be balanced with an equal need for transparency of process and knowledge that action has been taken. The complainant is not entitled to a detailed report, but simply a guarantee that the behaviour has or is being addressed and observation that the behaviour has improved.

The Faculty of Medicine Clinical Faculty Advocate

We recognize that a conversation about the concern with a neutral party may be helpful to determine what action to take. It is for this reason that the Faculty of Medicine Clinical Faculty Advocate (CFA) role was established. The CFA serves as a neutral party to approach for advice and input. Dr. Carl Cardella, a member of our department, holds this position. However, only 39.4% of our survey respondents indicated that they were aware of this role and relatively few contacted the CFA. Dr. Cardella may be reached through his UHN email and we have provided a link on our departmental website as well. UHN has also put in place two faculty member ‘ombudspeople,’ Lorretta Daniel and Flavio Habal,  as “go-to people” in the department who can be approached to confidentially discuss professionalism issues. Please spread the word!

What else have we done to address unprofessionalism in the DoM?

We have taken a number of steps to promote a culture of respect, inclusiveness and civility in our department. To note a few:

• Consistent demonstration of professionalism (adherence to the Faculty of Medicine code of conduct) is now required for continued faculty appointment (successful three-year review), senior promotion, and receipt of departmental awards.
• Leadership evaluations are being conducted routinely at the level of the University department and hospitals. Feedback from these evaluations is being reviewed carefully and individuals who may benefit from additional education, coaching or other support are being proactively identified. 
• Faculty survey results (2015 and 2017) have been shared with our PICs and departmental division directors to identify areas in need of improvement – and, to enable us to learn from those groups who have got it right!
• Professionalism is a criterion for all senior leader recruits.
• Faculty development in unconscious bias and diversity and equity are ongoing. Only one in five respondents (19.1%) reported having received unconscious bias training, while one in three (32.9%) had received equity/diversity training in the prior three years (unconscious bias training: 11.1% lecturers versus 30.7% full professors; equity and diversity training: 16.7% lecturers versus 48.9% full professors). Through the work of our Mentorship, Equity and Diversity committee, led by Sharon Straus, we aim to ensure all faculty and trainees receive such training.

To summarize what we have learned from the 2017 Faculty Survey:

• The vast majority of colleagues and trainees are amazing to work with;
• There is a culture of ‘selfishness’ in academic medicine – need more emphasis on collaboration and collegiality;
• The is a concept of the ‘untouchable’ who is beyond reproach – who will discipline the very powerful/most senior/academically accomplished who are abusive?
• Clarity is needed with respect to expectations regarding conduct: role modelling appropriate behaviour and understanding the consequences of unprofessionalism
• Recognition that physician unwellness may be manifested as unprofessional behaviour
• A multifaceted approach to addressing professionalism is required;
• Leadership engagement in promoting culture change is critical; and,
• Leaders must be held accountable

I realize there may still be many of you who are skeptical that these strategies will have an impact. Sometimes hard-wired behaviours are difficult to change. Let’s try.  A culture of support and inclusion in this department depends on it.