As we continue our third year of the pandemic, there have been reports of hostile treatment directed at public health officials and medical personnel. This is escalating a crisis of burnout among health professionals, but there is an insidious, chronic hostility that lurks within hospitals between those who are supposed to be on the same team.

Bullying within health care has been a longstanding challenge. It is pervasive enough that the American Medical Association chose to adopt a policy on the issue, creating a formal definition and providing guidelines to address bullying within the medical profession.

The AMA defines bullying as “repeated, emotionally or physically abusive, disrespectful, disruptive, inappropriate, insulting, intimidating, and/or threatening behavior targeted at a specific individual or a group of individuals that manifests from a real or perceived power imbalance and is often, but not always, intended to control, embarrass, undermine, threaten or otherwise harm the target.”

Bullying exacerbates the challenges of a stressful profession and contributes to burnout and moral distress among health care staff. The Joint Commission, in a 2021 updated statement, refers to workplace incivility as an epidemic and a serious risk to patient safety.

The hierarchical nature of medical training contributes to a culture of bullying. We are trained in an environment of individualized achievement, often directly competing with each other, then expected to work as part of a team. I have heard many of my colleagues refer to their training experience as “hazing.”

Bullying is an embarrassing secret many in the profession prefer to ignore. Institutions fear losing the income from high-producing specialists or managers and the perceived prestige they might bring.

Bullying is a shocking betrayal of professionals who have dedicated themselves to their field. It occurs in myriad ways, between physicians and their trainees or nursing staff, coworkers, and between administration and staff.

Bullying is not leadership, although many confuse the two. Abusive supervision describes repeated expressions of hostility directed at those being supervised. It involves public criticism, such as embarrassing trainees on rounds. It includes angry outbursts, rudeness, and coercion, such as insisting someone perform duties not in their original contract or demanding a “positive attitude” from staff while refusing to hear their concerns. Other less overt examples would be a manager who is never pleased with the employee, contacting staff only when there is a problem, repeated calls to unplanned meetings, or excluding staff from meetings. In the context of health care, it might mean denigrating the expertise of medical personnel and excluding them from major decisions that impact patient care.

Abusive supervision results in lower individual and group morale, reduced psychological well-being, and impairments in executive functioning. Targets experience higher rates of depression, emotional exhaustion, and work-family conflicts. Other potential detrimental impacts of workplace bullying include PTSD, anxiety, depression, sleep disturbances, and even suicide.

Factors that contribute to a culture of bullying and abusive supervision include poor management skills, lack of leadership training, work overload, stress, and a lack of organizational fairness. We might initially imagine the targets as weak performers, but often the targets are skilled staffers who are perceived as threatening to those who bully.

Bullying is exacerbated in a culture that emphasizes the higher-producing specialties and dismisses other vital but less profitable specialties, such as primary care. Providers in these fields are labeled as low producers and devalued in an environment that focuses on procedural income. The crisis in primary care serves as a good example of a specialty that offers high value with cost savings but little respect. Thus, we can anticipate major shortages as practitioners shy away from these specialties.

The costs of bullying and abusive supervision to an institution include loss of trust in the organization, loss in prestige, low productivity, high rates of absenteeism, and employee turnover, something we can ill afford in today’s climate. It can lead to lawsuits, loss of profits, and higher disability costs.

Ultimately, patients, often the most vulnerable, pay the price. Patient care is a team-based endeavor; we must rely on each other to meet the needs of patients and families. Bullying can impact these dynamics, making people afraid to speak up even to prevent patient harm, increasing the risk of medical errors and the costs of care.

Moving forward, we must be honest about the existence of bullying, harassment, and abusive supervision within our culture. We need to recognize the cycle of violence we pass along through training. It is unprofessional conduct, putting both patients and medical staff at risk. Changing the culture will not be easy. It will require a multidisciplinary approach across institutions; to encourage individual and bystander resistance.

Recommendations to address bullying include a strong institutional ethos of mutual respect, with civility as a core value. We must create a culture where bullying and abusive supervision are not tolerated with widespread educational initiatives for all staff, providing them clear definitions and behavioral expectations. Confidential surveys of staff will aid in assessing the prevalence within the work environment. There must be procedures in place for reporting prompt responses to concerns. Targets must be assured if they come forward, their concerns will be addressed without “backlash.” Mediation is generally not recommended; bullies will simply deny their actions.

A commitment to leadership training is critical, with an emphasis on communications skills, anger management, and conflict resolution. Our goal should be developing a true collaboration with mutual respect between leadership, staff, and providers.

The pandemic has crystalized for many that staying in a toxic work environment is not worth the price. Medicine is stressful in the best of circumstances; the pandemic has exacerbated a crisis of burnout and moral distress within the medical professions. A culture of bullying contributes to these stressors impacting the physical and mental health of those targeted. If we want to stem the flow of people exiting medicine, we must confront the embarrassing secret of bullying in our ranks.

This essay is cited in the KevinMD record on violence against health care workers.

Aldebra Schroll is a family physician.