More Than One in 10 UK Cardiology Trainees Report Being Bullied

Bullying is common among cardiology trainees in the United Kingdom and disproportionately affects women as well as those who trained outside the country, according to new survey data.

With several previous surveys illustrating contentious work environments in the field—most recently female electrophysiology trainees as well as a broader international cardiology cohort—it is well established that cardiologists have much to learn about fostering positive workplace cultures.

But after hearing many anecdotes from colleagues, lead author Christian Fielder Camm, MBBCh (Oxford University, Oxford, England), told TCTMD this study, published online this week in Heart, is “an attempt to sort of demonstrate this beyond any reasonable doubt that there really is a substantial issue with bullying within cardiology training in the UK.”

Among 1,358 responses to a British Junior Cardiologists’ Association survey from UK cardiology trainees between 2017 and 2020, 11% reported bullying with both women (OR 1.55) and non-UK medical school graduates being more likely to be on the receiving end.

Though many studies have been published in this space, Harriette Van Spall, MD, MPH (McMaster University, Hamilton, Canada), who was not involved in this survey but published a systematic review earlier this year looking at bullying in medical settings, stressed to TCTMD that “knowledge about a problem doesn't necessarily mean that the problem is tackled effectively.”

She defined bullying as a “toxic behavior that's aimed at debilitating the victim and that has an adverse impact on his or her career. It includes overwork, destabilization, isolation, and threats to their professional status. It also has an element of shame where the person who's being bullied often feels that there's something that they have done to elicit the bullying behavior.”

Notably, this survey allowed respondents to self-determine what bullying meant to them, because “bullying takes such a myriad of different shapes and forms and trying to predefine it means that we may invalidate individuals’ experiences that are still substantially problematic to them,” Camm explained. But the survey did attempt to collect more objective data as well.

Specifically, women were more likely than men to report sexist language (14% vs 4%; P < 0.001), and non-UK medical school graduates were more likely to report racist language (UK 1.5% vs European Economic Area (EEA) 6% vs other locations 7%; P = 0.006). Also, one-third of respondents identified at least one inappropriate behavior, with 8% indicating they had been shouted at or targeted with spontaneous anger. In 82% of cases, cardiology consultants were accused of bullying by the trainees.

Looked at regionally, rates of bullying varied between 3.8% to 21.8% across various UK deaneries. When broken down by year, rates of bullying were consistent in 2017 (10%) and 2018 (10.9%) but jumped to 14.2% in 2019 then fell to 9.1% in 2020.

It’s likely that the drop in bullying complaints in 2020 was a “blip” Camm said, but since surveys were filled out in March and April, it’s possible that a “collective feeling of camaraderie” at the start of the COVID-19 pandemic led to a decrease in bullying. “Being an optimist, I hope that [the pandemic] would make people less apt to bully given that we've all been through a collective experience that you'd hope would bring people together,” he said. However, greater workplace pressures that are now an everyday stressor for clinicians might possibly “exacerbate” the tendency to bully, Camm added.

By publishing these data, he said he hopes that not only will those who have been bullied feel less alone, but also that those who do the bullying will be dissuaded from doing so going forward. “The key thing is that this can only really be a first step,” Camm said. “Highlighting a problem is important, but I think how we move to try and deal with this problem is more vital. . . . A national strategy is probably required to try and deal with what is clearly quite an endemic cultural issue within cardiology, at least within the UK.”

No Simple Fixes

In an accompanying editorial, Resham Baruah, MBBS (Chelsea and Westminster Healthcare NHS Trust, London, England), and Emma Sedgwick (Sedgwick Coaching, London, England), confirm the size of the problem. “The consequences of workplace bullying can be catastrophic for the individual and system, with increased levels of sickness, an impact on learning, reduced retention, reduced patient safety and even increased suicide risk,” they write. “Trainees who have been the victim of bullying are 10% more likely to drop out of training.”

Nick Curzen, BM, PhD (University Hospital Southampton NHS Foundation Trust, England), president of the British Cardiovascular Intervention Society (BCIS), told TCTMD that while bullying is “undoubtedly a problem,” the solution isn’t simple.

I doubt it's the case that most people in this survey who would have been labeled as bullies got up in the morning and went to work intending to be difficult or unpleasant to other people. Nick Curzen

“There's obviously been a huge change in culture in interventional cardiology and cardiology in particular over the last 20 years, so the way that junior doctors’ expectations are in relation to how they're treated and what they expect from their working environment is very, very different,” he explained. “And the reason that's important is because many of the people who are mainly being labeled as the perpetrators, who are consultant cardiologists, grew up in a completely different culture, so they were subject to a completely different environment when they were training.”

Pointing a finger and calling a group of people “bullies” will not be effective, Curzen continued, “because I suspect that the majority of them don't realize that they're causing this perception of bullying to their colleagues. Therefore, if we're going to reach a solution to this problem, then it's going to need to be done with everyone involved and it's going to require a lot of education of the trainers who are being labeled as bullies.”

This is imperative to avoid disengagement of qualified trainers in the cardiology space, he said, as well as to maintain good morale. “If we keep seeing this type of adverse publicity without very constructive potential solutions being offered at the same time, I think some doctors are going to come to the conclusion that their lives would be better if they try and avoid this interaction as much as possible,” Curzen said. “And I think that would be very sad and it would be a tragedy for training in the UK, which has always been based around an apprenticeship-type model.”

Further, Curzen said, what the survey is likely highlighting is that clinicians are “not coping well with the stress that they're working under and [so] they may be a bit short with people, they answer them in angry or frustrated tone and these behavior patterns are things that we need to learn and educate ourselves not to pursue. But I doubt it's the case that most people in this survey who would have been labeled as bullies got up in the morning and went to work intending to be difficult or unpleasant to other people.”

While those who are knowingly bullying others should be disciplined for their actions, Curzen said those who may do so unwittingly need encouragement to learn new behaviors. “The way they're interacting is the way they've interacted for their whole career. And so to expect them overnight to suddenly act in a different way because these surveys are now highlighting that it's not received well is quite a big ask,” he commented.

In response, Van Spall specified that bullying is “a specific effort to target someone” and that this needs to be better understood. “That's different form an anecdotal exchange that might potentially have been better if there was less of a workload or less stress or less pressure in the moment,” she said.

Call for Culture Change

Success within cardiology has often come to those with “alpha” personality traits, but these can also be “destructive” as they often aren’t balanced out with a human way of dealing “with diverse ideas and diverse people,” according to Van Spall. “While it may be that [bullies] lack self-awareness, they often have no incentive to change and there's nothing at risk, so they continue on with business as usual getting away with things because they're protected by virtue of their status or the funding that they bring or the assets that they provide a university,” she said.

To change the culture in the short-term, Van Spall suggested that “the reporting mechanisms and the ways in which we respond to bullying behaviors should not rely on the victim to fix the problem.” Rather, enabling bystanders to report bullying will help break the cycle, she said. And in the long term, “choosing leaders that demonstrate emotional intelligence, particularly under stressful situations, is another way of changing culture.”

Baruah and Sedgwick agree. “Both perpetrators and victims need to be involved and supported in order to bring about organizational behavioral change through reflection, counselling, training and coaching, with an avoidance of placing too much onus on the ‘victim’ and their supposed resilience.”

They call for everyone working within the field of cardiology to change the culture. “We have the opportunity not just to have an impact bullying but, if we work collectively, to improve wider working conditions and job satisfaction,” they conclude.