E81 Rhea Liang and Simon Fleming

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Chad Ball  00:12

Welcome to the Cold Steel surgical podcast with your hosts Ameer Farooq and Chad ball. We’ve had the absolute privilege of chatting with some amazing Canadian as well as international guests over the past year. While the topics have been broad in range, whether clinical, social or political. Our aims for the podcast continue to remain the same. We hope to inspire discussion, creativity, scholarly research, and career development in all Canadian surgeons. We hope you enjoy our second season as we continue to highlight some incredible guests, deliver detailed masterclass sessions on a myriad of clinical topics and introduce some fresh new features such as debate and companion formats. We hope you relish the podcast as much as we do.

Ameer Farooq  01:12

On this episode, we’re joined by two guests who have made it their mission to combat bullying within surgical culture. Dr. Rhea Liang is a general and breast surgeon on the Gold Coast in Australia. And as the immediate past chair of the Operating with Respect education committee with the Royal Australasian College of Surgeons, Dr. Simon Fleming is a London based trauma and orthopedic registrar and is committed to combating bullying and improving diversity and equity in health care. We first heard both Rhea and Simon on the Royal College of Surgeons of England podcast, the Theatre. it was clear to both of us from chatting with them that we all have a lot of work to do personally. We hope that our conversation can be a stimulus for all of our listeners to think about their own cultures inside and outside the operating room.

Chad Ball  01:59

We were hoping today as you know, to talk about the topic of bullying, which again, you both become front and centre with, in terms of advocacy and just framing the issue in general. I was wondering if you could, maybe we’ll start with you Simon, tell us how you got interested in this topic? And then Rhea maybe the same question, as well as, how do you actually define the concept of bullying? Because I think there is some discrepancy and maybe some arguments from person to person as to what that term really is and when it should be applied.

Simon Fleming  02:33

Yeah, so it was really interesting. And again, I would never dare speak for Rhea because she’s my learned better. But five or six years ago, no one was really talking about any of this stuff. It was the toxic behavior elephant in the room. And through some kind of weird psychic link or Zeitgeist, the UK and Australia scene seem to start at about the same time. So, for me, I was Vice President at the time of the British Orthopedic Training Association, and we were having a lot of conversations about what I now recognize to be privilege. But at the time, I didn’t have a word for it. But it was conversations like, you know, people keep saying how dare I, as a straight white rugby playing male speak on behalf of a woman who’s a person of color, a member of the LGBT community with two kids doing her exam. And we would kind of get defensive as everyone does when they’re challenged in that way. And we would say, look, we have input, and we listen, and we were allies. But we really didn’t know what our membership felt. And the data that was available in the UK, things like the GMC survey, which the GMC are our regulator, and they send it out to all trainees every year. When they would ask about things like culture, if you wanted to raise any sort of concern around bullying, undermining harassment, or just poor-quality training, really in any context, you had to give up your anonymity. And then the first thing that that data was used for is it was then given to your boss. And your boss’s boss, who often were the people you were saying you had issues with. So, as you might imagine, that system didn’t really work. So, we did a census. And we asked trainees all kinds of questions. And when we were designing it, I kind of stuck my hand up and said, look, the hill I’d like to die on is culture and everyone was like, no, we want to know about learning objectives and career aspirations. And I was like, no, there’s something there. And so, we asked around, bullying, undermining and harassment and discrimination. They are all loads of definitions of bullying. And again, I’m always interested to hear different people’s definitions because certainly in the United Kingdom, which is different to Australia in a number of legal ways, but in the UK, bullying isn’t illegal. The only way bullying ever is made to be illegal is when it’s framed as discrimination or harassment. But for me, bullying is about power, and about silence. It’s about a toxic power differential, and your inability to speak out against that thing. Some definitions talk about it being repeated. I don’t think it has to be repeated, I’ve been bullied as one offs. And I would argue that if it’s repeated, it just means you’re being bullied more than once, you know? You can meet a consultant or an attending in a hallway, you can have never met them before. And they can be like, come with me and do this thing, or else. If they never do it again, you’ve still been bullied. But you know, there are other more robust legal definitions in countries where it has standing in law.

Rhea Liang  06:00

Yeah, and so I guess I get to speak to that, because Australia is one of those countries where bullying has a legal standing. And yes, it has to be repeated. And more importantly, in a legal sense, to prove it as a reason for a legal case, it has to be delivered with intent to annoy, harass, there’s a whole list of verbs about you know, the intent. It has to be delivered with negative intent. So that’s the legal definition. But the thing is, as it is operationalized, in surgical training, it doesn’t have to meet that legal definition. From our point of view, bullying is defined by the recipient of the behavior. And so, this is where the privilege comes in. You would be surprised, but a lot of the people who, you know, we get a little bit further into the formal process of addressing their bullying, and they can be entirely unaware that that’s the way it’s come across. But nevertheless, we believe that it has to change and that they should become aware of that behavior. So, the working definition of it and the legal definition of it are slightly different. But the thing is, trainees don’t want to go down the legal pathway. Actually, often they’ve gone legal because they have very little option. And we spoke about this in the Royal College of Surgeons, England podcast series. But the problem with the management of bullying right now in a lot of systems is that it’s binary, you know. You either choose to walk past it and let a lot of it slide because your alternative is to go world war three on it. And to escalate it down a number of formal pathways, as Simon was saying, you’ve had to tell your boss or your boss’s boss, or to kind of bring in some John Melot, to deal with it. And that’s been very damaging on both sides. It consumes a huge number of resources and often ends up leaving both the giver and the recipient damaged. So, a lot of the work that the Royal College of Surgeons Australasia has done is to try and fill in that gray zone in between to give people options to address this behavior without having to go formal with it.

Simon Fleming  08:05

And what’s interesting, of course, is it’s kind of like the chicken or the egg. Because Rhea is absolutely right people, people are often so reluctant to do something about it, because we have this amazing blame culture. And blame is all about power. Blame is all about pointing a finger and punishing someone and taking something away from them. And the narrative that has come out from both rears, work in Australia and mine in the UK is, well yeah, it’s easy to punish someone. You’re a bully, go stand in the corner, I’m going to hit you with a bigger stick to show that you’re a bad person versus let’s have a conversation and try and change your behavior. Your ideas, your attitudes. And Rhea is absolutely right. And it’s my experience as well. Most people when you talk to them are shocked and aghast that their behaviors have been perceived or experienced in that way. And one of my colleagues recently described it as the food in your teeth kind of dichotomy. Like if you had some spinach stuck in your teeth, you’d want someone to tell you, right? And if you were behaving in a certain way, you’d want someone to tell you. Even if you were mortified, even if you were embarrassed. Even if you realize that you’d had that food stuck in your teeth for weeks, you’d still want someone to go, look, this is really awkward for both of us, but there’s maybe something you want to do something about.

Ameer Farooq  09:30

You both had this great discussion on the theatre podcast where you talked about bullying, not just being about being impolite or uncivil. Can you expand on that? Like sometimes, you know, I think when you try to bring this up or talk about this subject, I think the perception that you can sometimes generate is that you’re telling me to be polite, and if you’re in a trauma situation or some high stress situation, sometimes it’s not easy to necessarily say something in the nicest phrase. You sometimes you have to be direct. Sometimes you even have to be a bit blunt. But I don’t think if I understand you both correctly, that’s what you’re saying. So, can you unpack that for me a bit more Simon? Like, how is bullying different from just being impolite or a certain way of speaking?

Simon Fleming  10:18

I was just gonna say earlier that I totally agree with Rhea. That all these behaviors are on a spectrum, right? You know, undermining is about a behavior that maybe subverts or weakens or wears away your confidence. Bullying might frighten you or again, is about that power differential. When you think about discrimination in the UK, we talk about the protected characteristics, which are, if I can remember them all, age, disability, gender reassignment, marriage or civil partnership, pregnancy, maternity, race, religion or belief, sex, sexual orientation. But actually, that the fact is, what we’re talking about is a spectrum of treating people like human beings, right? We’re not asking you to call them sir and mom and salute, we’re talking about basic respect. And when people talk about that spectrum between, say toxic bullying and incivility or rudeness, it’s still on the same spectrum, right? We know for a fact that, for example, if you’re rude to someone, you’re uncivil, which again, can be on the spectrum from that kind of undermining, or discriminatory or harassment, and they’re not mutually exclusive, they can happen one on top of the other. You can be both sexist, racist and undermine someone. And we know that if you’re on the receiving end of that, your quality of work, about 40% of people, their quality of work will drop. About 50% of people give or take will spend less time at work because of it. And about 25% of people who are on the receiving end of you just being rude, will take out their feelings or their anger or resentment or what have you on patients. Right? And what’s fascinating when you unpick what you said, to be honest is it’s one of those common push backs I get as well, I’m not really being rude, I’m under I’m under stress and other walks of life. Like the military will tell you that they have looked at human factors, they have looked at non-technical skills, and they have learned that stress, it’s a false dichotomy. Actually, if you create a culture that is respectful, and civil, then not only will your stress levels go down, but during stressful situations, your outcomes and performance will be better. When I do workshops of this, I love to do a graph. And on one axis, I do stress. And on the other axis, axis I do behaviors. And I say cool, right? Ameer, on this graph, I would like you to plot how stressed I need to be before it’s acceptable for me to make you cry. Or on this graph of stress, plot where a major hemorrhage is, and tell me how stressful a situation can be in major hemorrhage whereby to lighten the mood, I can tell a homophobic joke. Where does that come from? And it’s about understanding that you can be blunt, right? You can be task focused, and you can be an authoritarian leader, and still be respectful. In a major trauma, I don’t necessarily need to say please and thank you if I’m asking for diathermy and forceps. But I cannot throw stuff at you or use derogatory terms. Again, it’s the understanding that you can be, from my point of view, for example, I come from a MedEd background, I said, right, I’m doing my PhD in MedEd. You can give feedback and not be a bully. You can give really constructive, tough feedback and not be a bully. It is possible to do these things. But the challenge, of course, is most of us aren’t used to that. Right? We’re used to telling people, you know, you’re rubbish. That was awful, you know. Who taught you to suture? Where did you go to medical school? Back in my day, yada, yada, yada. And it’s an act of will, to understand the respect that Rhea was describing just makes everyone’s day better. The patient, the team, the unit. But it’s understanding that those things that culturally seem a bit soft and weak and wishy washy, actually are far more powerful than being shouty or abusive, or a bully.

Chad Ball  15:06

Yeah, I think that’s a very eloquent way to say that Simon and I like your description a lot. And if we sort of take a bit of a lateral walk down that rabbit hole, you know, one of the books that we’ve talked about, both with elite coaches previously on this podcast, as well as other folks is one called Legacy. And, you know, it sort of fits into your rugby background, not that, you know, being from England, and then spending time in Australia, you like the All Blacks. But you know that book written by Kerr is a superb example and description of a culture that creates accountability, and teamwork and leadership and how that all sort of works. I’m curious in that context, with you, for example, with a very, quite frankly, testosterone driven background in rugby, thinking back as to how you were trained, or you could say me in hockey, or Rhea in piano. I’m sure that, you know, not everybody was always, I guess I’m gonna I’m sure there was many episodes of bullying. I’m curious how both you and Rhea have framed those experiences in terms of your current outlook.

Rhea Liang  16:20

Yeah. So just further to what we were discussing before. And to elaborate it a bit more, we have to emphasize that when we agitate against bullying, we are not advocating for something called “nice culture”. So, respect is not the same as being nice. So, people who are superficially nice and insist that everyone in the team must be nice, and no one must ever raise their voice and no dissent will be entered into, you know, we must all agree and get along with each other. That’s just as disrespectful as nasty cultures. And it’s particularly prevalent in female dominant cultures. So, there’s a lot of that in, say, for example, female dominant professions, such as childcare and nursing. And so, we have to get away from that idea that that’s what we’re looking for, because that doesn’t help anyone improve or improve team performance either. So, what we’re looking for is psychological safety. Psychological safety means that you have, you know, the most psychologically safe team is one in which you are able to disagree. So, if you can think of those training relationships, I mean, I’m sure we’ve all worked on one where you were able to go well, actually, I was wondering why we did it this way. Because from what I’ve read, or in my previous team, we would have done it this other way, and be comfortable that you will not get your head bitten off for saying something like that. That’s psychological safety. And that’s actually the culture we’re heading towards, because that’s how we’re all going to improve. And so, it is with, you know, when I think about my piano, or I studied dance for quite a long time. And some of the training behaviors were really quite abusive in retrospect, but you always had those teachers who really made you grow and learn, and they weren’t sometimes particularly pleasant, but they did create that psychological safety where everyone had their voice, and you could disagree, safely. But it was a mutual thing, you know. If you could disagree safely with your trainer, then they could disagree safely with you as well and it was understood that you would take each other’s feedback. I mean, a good example, I think, is the distinction between what I would call Socratic questioning and pimping. So, it’s to do with the intent of it. So, this is a tradition that’s, you know, well established in medicine. But the intent is different. So, Socrates, of course, you know, the actual Socratic questioning was one of you are my future peer, I’m going to train you to become my protege or my future peer. And let’s dig into some really meaty, philosophical concepts and debate them back and forth. But I’m encouraging you to become just as hard edged and you’re arguing as I am, you know that that’s the sort of approach. Whereas pimping is often done with the intent to humiliate or embarrass, on the mistaken belief that doing so encourages people out of sheer embarrassment and shame to go and read up some more. So, you know, the pimping includes things like asking five questions on something that the trainee clearly doesn’t know anything about, and in order to really drum into them, that they are really so ignorant that they must go away and read something and doing it publicly often, to embarrass them. So, we have to make distinctions. It’s not so much about the behavior. Both of them are questioning behaviors as the intent and the way that it is operationalized and received. And as I mentioned before, the College of Surgeons Australasia is very much on the view that the intent of it should be determined by the recipient, how it’s received, because the giver may not necessarily understand the privilege they have.

Simon Fleming  19:58

You know, it’s interesting you use the rugby metaphor. The All Blacks are the ones who coined the no-asshole rule. The All Blacks are the ones who published the idea that you could be the best rugby player in the world. But if you don’t do what we’re talking about, if you’re not a team player, or a communicator, a listener, all those sorts of things, the fact that you might be a great sports person, actually still doesn’t outweigh the toxic impact you’ll have on the team. And, you know, when I think back to whether it’s the best days I had in my, albeit limited University sporting career, or, you know, my experiences as a surgical trainee, I’ve experienced it the best and the worst. And I’m the first one to admit, I’ve also doled it out. I undeniably role model the behaviors that I saw, because I wanted to fit in. This is how I behave, because this is how everyone else has behaved. And it’s part of the thing that Rhea was talking about. I talk about when we talk about creating this environment of psychological safety is you have to break through that kind of psychologically, very uncomfortable barrier of going, you know, am I the bad guy here? Not in a blaming way, but like maybe some of my behaviors do need changing. It’s famously non orthopedic, but it requires a huge amount of reflection. To accept that maybe your behaviors are not what they might be, you know, what Ria describes as pimping, which is very, you know, North American. We have in the UK, and the classic example of orthopedics is every morning, we have a trauma meeting, where the cases from the previous day and that day are described. Now, at its best, that meeting is one of the best things about orthopedics. Every morning, there is an MDT a teaching MDT with cases. And at its worst, it is a thing of fear, and humiliation and all the rest. And, one of the anecdotes I give is I remember, a case went up. And I hadn’t been in theaters for a while because I’d been doing my PhD. And someone said ah Fleming, you’ve got great hands, this is right up your alley, blah, blah, blah, off you go. And I said, you know, I don’t think that’s for me. Actually, I haven’t done a case like that in 18 months, and I just don’t think I can do it safely. Like you know, it was my first day back at work. I hadn’t had a chance to read up about any of it. I said, I can’t do it. And my boss, it was one of my best trainers said, “Oh for goodness sake, Fleming just man the eff up”. And I kind of sunk down into my chair and said, no to the case. And afterwards, he took me to one side, and he said, what’s wrong with you? And I said, right, you made me feel really small and really stupid. Like, I know I’ve been away for a while. And he said, look, I was just trying to tell you that I have faith in you, I believe you can do this case, you know that I’m not going to leave you hanging, I’ll be in the coffee room. We can talk about it beforehand, maybe do some drawings, do a bit of pre-op planning, we can come up with some cutoff points maybe where you can call me if you get stuck. And I was like, why did you say that then? And he was like, well, you know, we’ve got to get on with things. I was like, no, can you not see if you’d have said that I’d have actually felt really good about this case?

Chad Ball  23:27

You would have felt empowered, right?

Simon Fleming  23:30

Right. And it’s about reframing the way we talk to one another and engage with one another and educate because, you know, my mum and dad went to school and they were hit by their teachers all the time. They learned, they did well, they became successful at what they do. It’s simply that we now know better. And that’s the thing. We now understand human behavior, learning, all that stuff so much better that we just have to go, yah, you know what, that system that worked really well, that produced all the people I want to grow up to be like, it worked really well. But what we’re suggesting works better. It gets you better outcomes for less effort. And everyone’s generally happier while they’re doing it.

Chad Ball  24:17

Yeah, that’s a beautiful outlook by both of you. And you know, in particular, I think and it’s increasingly obvious that not only do we all have work to do on this, and not only can we all get better today, but we can get better tomorrow and the day after that by paying attention, drawing awareness to it, like you guys are. But I also believe it’s a clear skill set. And a lot of us that have trained maybe in the generation before you guys really, maybe don’t have it. To your point we’ve modeled off those that trained us from a very different era. I also think, if you go back to the rugby analogy and the All Blacks, their monitor of sweeping the sheds is a very important statement because it highlights not only what you’ve said, but it also brings us the concept of humility. And I do wonder if you know, more humility on a day-to-day basis and the way we communicate and interact, probably sets that stage of psychological safety that you talk about Rhea. And probably, you know, at least I can see it for myself, probably don’t think about it enough. And don’t engage it enough.

Rhea Liang  25:35

Yeah, I mean, just as a beautiful illustration of what you’re talking about, I’ve got no doubts that you mean very well, but you’ve just used the phrase you guys twice. And I’m not a guy. And people will say, oh, but that’s just a generic term, it just refers to everyone, you’re like, well if guy is going to be a gender-neutral term, then can I just walk in and say, hey all you girls? Gals, all of you today? Shall we talk about this? You know, and so it’s these little things that convey the impression, you know, what their system is I’m excluded. I’m not part of this conversation. And that’s been reported by a lot of people in surgery, because surgery has remained still quite predominantly male dominated. So, guys has become a term, a generic term, but we have to question that, and there are so many other things you can say, folks, people, team, Morning, everyone, you know, without using that terminology. But like I said, I have no doubt that you meant perfectly well, and didn’t intend to be gender discriminatory in that way. But this is what I mean by the spectrum, you know? We have to talk about these little micro aggressions if we’re going to deal with the nasty end of things as well.

Chad Ball  26:45

Yeah, I mean, I’m glad you brought that up. I typically use folks, but I think we also have to put some of these microaggressions in a cultural context with where you work too. You know, like, and where you live, and where you’ve been brought up. You know, there’s lots of different languages, lots different terms, I think that we probably all been exposed to traveling around the world training in different places, working in different countries, that if you took one and exported it to another, it might actually be even much worse than what you’re saying, it might be horrific. And I think that cultural sensitivity, that cultural and environmental awareness is critical. And you’re exactly right. Sometimes as my example just provided, we fall down in that, forget what environment we’re in and who we’re talking to. So, you know, I think, again, we all, including myself, have work to do continuously, with regards to that.

Rhea Liang  27:41

Yeah, but you see, the thing is, I felt psychologically safe to say that. And I think there are a lot of surgical teams where there might not be the case. You know, if you were the only woman on the team, you might not be the person to go, “I am not a guy”. So, it’s a kudos to you that you’ve created that space for us in this podcast. But what I’m saying is we have to take that out to our workplaces.

Simon Fleming  28:03

And it actually touches as well on what Chad raised around humility, which is the conversations we’re having are uncomfortable. Right? One of the things about being an advocate or an ally, is being willing to listen, which surgeons of all sexes and genders are famously bad at. Statistically, we interrupt people. Within our patients, within 60 seconds of them talking. Like we don’t like to just listen. And then you have that uncomfortable moment of like, yeah, you know what, I said that thing, or I did that thing. And, you know, Rhea and I again, we touched on it in the podcast, the Theatre podcast, around the Vanderbilt cup of coffee and having those difficult conversations. Statistically, over 90% of people will change their behavior if you just sit them down and go, look Rhea, I don’t know if you’re aware. But earlier today, you said this thing that you did this thing, and it made me feel like this. And I wonder what you think about that. And Rhea might say Fleming’s an idiot, he doesn’t know he’s talking about and then she’ll go away, and she’ll go, but you know what? Maybe I just won’t do that again. Or maybe…you know, I worked with a great boss. She said, I’m very aware that I keep using the male pronoun when I describe surgeons. So, we have pantomimes in the UK, you know, the “he’s behind you” type thing. And he said, whenever I use a male pronoun, I want everyone to shout out “or they” and eventually I’ll just stop doing it. I’m trying really hard, but I need you. I need you to challenge me on it. And it’s like, wow. Because that’s the thing. You have this bell curve of human behavior in healthcare, right? You’ve got the villains on one end, who are people going into Healthcare because they want power, and they want restaurants to make tables for them and all that sort of stuff. You’ve got the angels who will tell you that there is no such thing as sexism, racism, or bullying in healthcare. It doesn’t exist, they’ve never seen it. And then you’ve got the rest of us who screw up all the time. Right? I put my foot in it all the time. And I would hope that someone, politely, respectfully would go, Simon, you’re kind of an asshole today in a way that I can change and learn and not do it tomorrow. And that’s the bit that we’re really learning. That skill set of having those really uncomfortable conversations, where you don’t get your back up and go, how very dare you? You don’t know. And actually go, okay yeah, I guess I can do better tomorrow. Like, cheers. Thanks a lot.

Ameer Farooq  30:48

I think this ability to be able to talk to the person that’s teaching you, or instructing you is so critical, because I do think sometimes trainees misconstrue things as well. And I think that can happen. And really, there honestly, genuinely was no malice or bullying involved, it’s just that the trainee doesn’t necessarily perceive that or understand that – that the person that is training them is actually trying to get them better. Like, if you’re criticizing someone’s technique, that is not an indictment of you as a person. You know, I think sports are such a helpful analogy for this. Growing up, I did a lot of Taekwondo and our instructor, I mean, all my brothers and sisters were all in the same club. And so our instructor used to go around, and he would pick on me and my siblings constantly. Just be like, your form’s not right, you know, fix this, you’re not punching correctly, you know, you could do this better. And then he would walk past the next person and would not say a single word to them. And you’d be like, well, what in the world? And my younger brother, who’s now a lawyer, and he won’t mind me saying this, he was the only one who had the temerity to go to the instructor and be like, “Well, you know, that guy, or that girl is way worse than we are. And you didn’t say anything to them”. And he said, “well, I actually care about how you do, and I want to make you better”. And so sometimes, I think that if we create that space, then you can actually have those kinds of conversations. And also, that channel gets created both ways where, you know, your instructor also wants to get the best out of you, and you want to be the best that you can be. And sometimes I feel like that piece of that discussion is sometimes missing from all this. It’s this one-way street, where as the instructor, you’re feeling this pressure that, you know, I don’t want to say the wrong thing. But if we’re focused as you guys…you guys, there it is again. But if we’re focused on and what both of you are trying to do with the podcast, which is talk about culture, I think that we can really start to change things and move things along.

Rhea Liang  32:51

Yes, no, I would echo that. I recommend that all surgeons, because we are all used to being capable and competent at our game, which is surgery. And, of course, I’m a little bit further along. This is my 14th or 15th year of being a consultant, or as an attending, I think as you call it in Canada. And thankfully, due to Asian genes, I do look rather younger than that, but the thing about it is, I recommend that all surgeons take up new activities on an almost yearly basis to remind themselves what it feels like to be the learner. Because a lot of the misunderstanding about the intent of feedback occurs because we forget as teachers, how small and uncertain and exploratory our efforts are when we’re learning something new. And I don’t care what it is, you know, it could just be something simple, like underwater basket weaving, you know? But when you sit there, and sit there struggling with this thing that seems so simple to the teacher, you will remember what it’s like to be put on the spot, often in front of a class. So, you’re in public struggling along and to have very benign feedback given to you about how embarrassing it makes you feel. And so, then that sets up that negative cycle. And once you remind yourself of what it feels like to be a learner like that, then often you will adapt your teaching and surgery as well to understand to frame your feedback. So that it comes across better for a learner in that headspace.

Simon Fleming  34:25

It’s um, it’s also important because it reminds you how to be an ally. Because, you know, I’m a resident, right? You got to imagine having me as your trainee, right? Because I’m, I’m that guy. I am the guy who’s like, well, actually, Dr. Liang. Can we have a chat over a cup of coffee? Like could we talk about a thing today? And you know, I’m your younger brother in the Taekwondo class. So, I was always the guy like, but that’s not fair. And can we talk. But not everyone is like that. And I’m aware that some of that comes from my own privilege. Right, I have all the privilege of a straight white man. But also, I was raised by, like I said in the beginning, I was raised by a Holocaust survivor who literally, one of the few things he ever told me, he was like your job is always to try and stand up for people who can’t stand up for themselves. Like that’s the job of people with any kind of power, is to use it responsibly. And actually, there’s a huge piece of work about being an ally and an advocate for trainees because you know what, maybe your resident can’t tell their professor, but their professor is hurting them in some way. But maybe they can tell you. Maybe they can speak to you because again, you have created that psychological safety or that environment that allows them to feel a little bit more like a human being, a little bit less infantilized so that they can come up and go, hey, Dr. Ball, would it be okay to just tell you about a thing that I’m experiencing with Dr. So and So? And that’s hugely powerful. And it’s a massive privilege when someone comes to and goes, look, I don’t know who to speak to, but you seem really approachable and like you won’t hit me. So could I tell you about a thing that’s going on. And again, it’s really important to remind yourself that sometimes it’s not possible to speak up directly. And that’s when you need a bit of help.

Ameer Farooq  36:24

We’ve talked a lot I think now about bullying and try to understand what that means and how that might look. I’d like to talk to you both now about the work that you’ve done to try and combat this. And maybe we’ll start with you, Simon. You started a campaign in the UK called, Hammer It Out. What exactly was involved in that campaign? And how can you actually take concrete steps to change something as nebulous and yet, so crushing like bullying, and culture?

Simon Fleming  36:54

So, I mean, the campaign itself started, you know, we talked earlier about gathering data and stuff. So, the British Orthopedic Association gave the British Orthopedic Trainee Association a session at their annual conference. And normally, it’s a reasonably quiet affair, but we have all this data that I wanted to get out there. And so, I’d read loads of stuff around, you know, change models, and all this sort of change management stuff. So, I walked out to the front of the stage. And you will imagine that all the presidents of all the global orthopedic associations are there to see you know, the trainees do their shtick. And I say, I’m a bully, I’ve probably made people feel small and worthless, I’ve probably broken the law. Statistically, most people in this room have too, and we must do better. And then I go into my whole shtick. And I was kind of waiting at the end, for that moment you get in movies like with a slow clap, and then everyone starts to clap, and then you get like, carried out on their shoulders. And instead, as you might imagine, everyone lost their minds. And that was where the campaign was born. And at the time, again, much like Rhea, no one was talking about this. This wasn’t on anyone’s meeting agenda. It wasn’t in any of their core valuable values. It was, you know, it wasn’t a thing. It wasn’t a problem that healthcare had. And so, my goal in the early stages was literally to start the conversation. We need to talk about the fact that we have this problem in healthcare. And so the early years were primarily me advocating, sometimes face to face, sometimes big talk, sometimes emails, to both individuals, to teams to influencers and to organizations in going, will you support me in this work? Do you admit we have a problem? Can it be on a meeting agenda? Can we look at your data, your power, your access, and how we might change this? And at the very early stages, it was very much about just convincing people that it existed at all. And then once I got over that initial hurdle, which took some time, I came to that realization that physicians like to think of themselves as positivists right? Scientists, and data and graphs. But actually, when I looked at the literature, we had guidelines and data going back decades, showing negative behaviors, why bullying was bad, and no one had changed. And it’s because actually, changing culture is a completely different thing. It’s about changing people’s beliefs and attitudes. It’s not like changing how you manage DVTs. You can’t just put a poster up going we do this now. And everyone’s like, yeah, I guess we do this now. And so, it became a far more nuanced thing about changing people’s worldviews. And that I’ve done through everything from you know, heavily social media, but also quite vulnerably going out there and saying look, would it be okay if I speak to your organization, your President, your whoever, you know? I’ve literally spoken at one point to an auditorium with two people in it. Because I was like this is important stuff that we need to get out there. And if you look at culture change initiatives that have really worked like drunk driving or smoking cessation, you recognize that you need to have a kind of a gastroenterological approach of the top down and bottom up. You need legislation change. You need the rules to change. You need big, scary, powerful people to say, these are the rules. This is the standard we expect, do not walk past it. But you also need grassroots kind of marketing nearly like public relations stuff, to convince people, you know, on the day to day to maybe think twice before saying X, Y or Z. And it’s you know, I’ve been at it for literally the same time as Rhea, and it’s just about chipping away at things. And convincing people that it’s an iterative process. You can’t just do a culture change thing for a year, and then, you know, wash your hands and go do something else. Because people will always return to their baseline. To their mean. And the mean is, you know, if I could clap my hands and get someone to make me a cup of coffee, that’s cool. I would love that. And healthcare is the same. Its mean is hierarchy. Its mean is power. Its mean is the god complex. It is convincing people that we need to continuously chip away at this system that is inherently not great. And yeah, so it’s it started there. And I think it’s been five or six years now. And still, you know, people are still going, “So I’m told we have racism in healthcare. Is that true?” And you’re like, “Yeah”.

Ameer Farooq  41:56

Rhea, I’d like to get your perspective as well, with the work that you’ve done with “Operate with Respect”. Did you take a similar, you know, go out and talk to as many people as possible? I love that analogy of gastroenterology. As a Colorectal Fellow, it really is something close to my heart. But was that sort of the same approach that you took as well, Rhea, with “Operate with Respect?

Rhea Liang  42:04

No. And so, the thing fell into my lap and I was the beneficiary actually of some nice, positive, sexist and racist discrimination in that, when they’re looking for a counter to a straight white guy, they’re like, there’s that woman on the Gold Coast who’s always noisy about these things. And he’s a minority and she’s a younger fellow as well. So, let’s get her to heat this thing up. So, we were different. The Royal Australasian College of Surgeons had a sentinel event in 2015. And like all good surgeons, weren’t going to do things by halves. And so, we ended up by the end of 2015, with a program that has eight separate arms to it, that addressed everything from the complaint system, and diversity and inclusion right through to the Operate with Respect, in which the cultural change in which I chair. Heavily resourced, so you know, I won’t kind of put exact figures on it. But I presented the program recently to the Royal College of Surgeons England, who are thinking of doing something similar. And, you know, the mouths were open, because I said, you know, we’ve spent annually, more than a million Australian dollars on this. On the program. That is the level of resourcing that you require, if you’re going to do this properly, it’s not just something we just talk about. You actually need to get people out there: faculty trains, courses run, modules, you know, online learning modules done, and grow your complaints system so that it’s kind and compassionate, and can deal with all that gray stuff, and not just jump into HR. You know, you have to train people. That costs money. So, we came at it from a slightly different angle, but it’s amazing how similar we’ve ended up. You know, Simon and I of course, initially connected on social media, but all we do really is bounce tweets back and forth between us because we resonate so strongly. These things are the same everywhere. You know, it’s the same in Australasia, it’s the same in the UK, it’s the same in America and Canada, it’s going to be the same hierarchies dynamics as anywhere. Our philosophy is actually slightly more than gastroenterological. It’s kind of holistic medicine. So, we go for a top down, bottom up outside in approach. And there’s that saying, you know, culture eats strategy for breakfast. In other words, you can have as much top down as you like. Every organization I’ve worked for says, you know, we have zero tolerance for bullying and discrimination and blahdy blahdy blah. But what actually happens on the ground can be quite different. And we walk past a lot of those behaviors despite the organization saying, we have zero tolerance for it. So that’s where the bottom up comes in. You’ve actually got to convince people to change their behaviors on the daily. On the hourly, on the minutely, you know, just by little acts of speaking up by saying to people, you know that thing you said, that thing you did, this is how it came across. So that’s the top down bottom up. But the other thing is outside in. We have to recognize, and I think 2020 was particularly a watershed for us. We have to recognize that society is changing. General society is not willing to put doctors on pedestals anymore, they will not tolerate the power hierarchies. The “do as I tell you or else” sort of approach. We are not given the level of privilege that we once had, nor should we be. It should be possible for us to have respectful conversations back and forth that query our approach to things if we’re to truly improve. And so the feeling of the Royal Australasian College of Surgeons after our Sentinel event, which was a very terrible Sentinel event, you know. A trainee was frankly asked for a sexual favor by her boss, so terrible. But we have to appreciate that if we don’t put our house in order, our house will get put an order for us by external forces, and that might be quite unpleasant for all of us. So this is something that is beholden on all of us as surgeons to sort ourselves out.

Ameer Farooq  46:15

I want to ask you Rhea specifically about the specific challenges that women face in terms of bullying. You wrote a great paper in The Lancet about the challenges that female trainees face while in surgical training. Obviously, that that could be the topic for a whole other podcast. Could you talk a little bit about what you found about why women leave surgical training and specifically about how women might experience bullying differently than their male colleagues?

Rhea Liang  46:42

Yeah. So, the thing really, is that women don’t experience bullying differently so much, they just experience a lot more of it. And not just bullying but all the behaviors. So, when we did our prevalence survey, so as part of our Sentinel event in 2015, the Royal Australasian College of Surgeons did a large-scale survey of all our fellows, all our trainees, and all our specialists, International Medical graduates. And the findings were very striking for the differences between groups. So, for instance, our overall incidence of bullying, discrimination, harassment overall was 49%. So that’s terrible already. But when you break it down by gender, 34% of males experience bullying, but 58% of women, so almost two thirds. And the same with discrimination. Discrimination was 7%, across the board, but when you break it down by gender, it was 2% for males and 30% for women. So, the thing is, if you have a woman trainee in surgery, you can fairly well assume that if 58% of them are experiencing bullying, and 30% of them are experiencing discrimination, then it’s pretty much all of them. You know, like the groups will overlap slightly, but you can assume that they’re experiencing it on some level. And so, it’s universal for women just because it’s such a high incidence. The reasons for that are really complex and relate to a whole lot of societal things, you know, women are more likely to be doing childcare, the fact of pregnancy is unavoidable. You know, men don’t carry children yet, not that we’ve it figured out. So, that creates just an environment where those things somehow happen more easily in the environment that we have created in surgery, we have to address that. But the effects of bullying are universal. So, anyone regardless of gender, and of course, we have to be aware that there are more than two genders. So, we’re not just talking about a male, female binary, but about multiple genders. But everyone experiences bullying the same, in terms of its effects. So, we know that it decreases learning, we know that it decreases productivity. And that’s twofold because not only are you managing to do less work, because your ability, you know, when you’re being bullied, your ability to feel motivated and enthused about what you’re doing is decreased. But you’re also spending a lot of time on the associated other work of it. So, pursuing complaints, writing down, you know, that everyone’s like, well did you take contemporaneous notes? Did you write down what was happening? Can you send it to me? Have you created a portfolio? What pathway are you going to follow? Have you hired lawyers? You know, it creates an incredible amount of work. But quite apart from that there are physical health effects, you know. So, we know that it increases blood pressure and stomach ulcers and decreases mental health, affects sleep, blah, blah, blah. But then there are more widespread effects of that for women in particular, because due to ongoing societal dynamics, so women are still more likely to be the primary child-carer. Of course, this has been very much highlighted in 2020. So, the woman who is experiencing health effects, low productivity and low mental health, that feeds more often onto friends, family, children, then if it affects a male. And we know, for example, that more women are in that stage now, because of the way training is set up that the childbearing years coincide heavily with surgical training years. Whereas men are more likely to be single, and not have those effects. So, the effects of bullying don’t spread to quite such a large sphere. And the end result of all of that is what we call the “Tower of Blocks” thing. You know, if you stack up three or four blocks of stress sores, then you only have to give it a tiny wee nudge for the whole thing to fall down. And it’s an irreversible thing. So, you can’t just say, oh, you know, the pandemic was a very good example, I will just introduce this little thing of a pandemic. And even if it’s not particularly prevalent in your country, as it is, you know, we don’t actually have very much COVID in Australia, for example, but nevertheless, if you were already being bullied, and had childcare responsibilities, and perhaps were working with a boss who was quite unsympathetic to these things, then the additional work of preparing for a pandemic just pushed far more women over the edge than men. And we’re seeing that in a lot of things; in publication numbers, in ongoing ability to work, and so forth. So just to go back to the original question, it’s not that bullying has specific effects for women, much as it doesn’t really have specific effects for LGBTQI or rurally based people, or first in family, you know, the first in the family to go into medicine. It’s just that they experienced more bullying. So bullying, more or less has the same effects for everyone. But just that some subgroups experience it in a much higher incidence than other subgroups. And that gets back to our original idea of privilege. And we have to become aware of it if we’re going to address it.

Chad Ball  51:50

It’s been such a pleasure chatting with you Rhea and Simon today. Ameer and I are really, really grateful to hear your perspective on this issue and see the amazing work you’re doing both nationally, internationally to try and improve all of us. You’ve given us all a lot to think about it and work on for sure. Just in closing, I was wondering if you could give us an a sentence or two, what your vision is for the culture of surgery going forward? What’s your neo-utopic view of of how this all settles out? Maybe, you know, as Simon sort of mentioned in a proverbial sense to the point at which you know, parents aren’t, or teachers aren’t spanking their kids, per se. This sort of beautiful view that maybe we can all work to try and get to. Maybe I’ll start with you Rhea.

Rhea Liang  52:44

it’s hard to figure that one out, because we are making it up as we go along. If we feel badly about where we are, we can feel comforted that actually, the Royal Australasian College of Surgeons, when we looked around at other specialties, we were literally the first professional college anywhere internationally to institute such a widespread program. So, this is something that is new to all of us. And keep in mind that we like to consider ourselves as the best. We are the smartest, most highly achieving, you know, we’re a bunch of smart people. We should be able to figure this out. And yet we haven’t after decades of the same behavior. So, what’s my utopia? I don’t think there is… you can define one because the context will always be changing. But the principles will remain the same. So, the principles of justice or fairness of respect, and humility will remain the same. And that’s where we should head. It will be something that we co-construct. I don’t think it’s my place to determine, you know. Here’s my utopia, let’s all head for it. I think it’s something that we discuss together and figure it out as we go forward. My dearest hope of course is that I don’t just change the culture of surgery, that I actually can change the culture of medicine. Because we know this isn’t just a surgical thing. Every specialty that has done the research has found very similar incidences of disrespectful behavior. So, we mustn’t think it’s just a surgical thing. It is the whole setup of medicine, the structures that enable this thing, and we just have to keep working away at it.

Chad Ball  54:21

Well said. Simon?

Simon Fleming  54:24

So, it’s really difficult to speak after Rhea, A) Because she’s so much better at this, and B) Because we share so many worldviews. I agree with everything she says. I think my worldview is an acceptance that the system isn’t… So, I’m an orthopod, right? I’m a tool based individual. The system that we’re talking about isn’t broken. It doesn’t require fixing. The system we’re talking about was built this way. It was a system designed by old white guys to potentiate the careers of the younger white guys they knew. And even then, it was a toxic system. This is healthcare, not surgery. A toxic system of hierarchy, patriarchy, and power. And once we accept that, then we can start to look towards changing the system rather than fixing it. Because even fixing has an implication of sort of power and forcing things. And what we need to do is co-construct this – to change healthcare into something better. And there’s this great Maya Angelou quote, which is, “Do the best you can do until you know better. Then when you know better, do better”. And if we can hit that, we’re laughing, right? Because it accepts that nobody on this earth can be expected to do any better than what they know; than what they’ve been taught, what they’ve been shown, what they’ve had explained to them. But once someone sits down and goes, we’ve got a better way of doing things for our patients, for our peers and for our profession. Then you’ve got to take a deep breath a long hard look at yourself and do better.

Ameer Farooq  56:09

You’ve been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you’ve liked what you’ve been listening to, please leave us a review on iTunes. We’d love to hear your comments and feedback. So, feel free to email us at podcast.cjs@gmail.com, or connect with us on Twitter @CanJSurg. Thanks again.