Bullying in the workplace occurs in every sector of industry. The healthcare landscape, including radiology, is not exempt from a problem that can have devastating effects for talented physicians who feel they have nowhere to turn. Unprofessional behavior that amounts to bullying is often difficult to identify, prevent and stop — and who does it, what they do and why they do it may surprise you.

Bullying behavior may involve abuse, humiliation, intimidation or insults. Victims are often on the receiving end of this behavior repeatedly, at the cost of great distress that may impact their mental and physical health. Workplace bullying is more common in healthcare than in other industries and can prove detrimental to the delivery of quality patient care.¹

People find it difficult to talk about bullying. When you hear the word, there tends to be a focus on the physical aspect, says Aine M. Kelly, MD, FACR, professor and clinical educator of radiology at Emory University. But there are many forms of bullying that go unrecognized and are underreported.

“In medicine, including radiology, it can be embedded in social interactions,” Kelly says. “Some examples of bullying that I have seen, and sometimes unfortunately experienced in a previous academic workplace and other radiology settings such as national societies, encompass a great many things. There may be a denial of privileges, like the amount of time allocated to academic pursuits. Some radiologists with qualifications equal to their colleagues may be prohibited from performing the same tasks they are trained and able to do.” Undesirable shifts or duties are sometimes given only to certain staff. Denying or delaying promotions for an extended period with insufficient explanation or justification can also qualify as bullying.

Other examples include repeatedly declining to put someone’s name forward for a leadership position or preventing certain radiologists from sitting on or chairing committees. Radiologists with extensive experience may be told to answer phones or complete other tasks that traditionally are not part of their job. “These assignments may be regarded as demeaning and could make staff feel small,” she says.

Women, people of color, trainees, residents and younger radiologists tend to be the most frequent targets for bullying, Kelly says. Trainees need a degree to qualify as doctors, and residents need someone at a higher level to sign off on their certificate, for example. A person in a position of power can affect whether someone gets that degree or certificate. Younger radiologists who are not familiar with a working group’s culture may have fewer support options or allies than more seasoned colleagues. They may have no one to champion for them, Kelly says.

Powers Shift

A huge obstacle to coming forward as a victim of or a witness to bullying is that the issue must be raised by someone in a perceived position of power — or at least in a stable position that doesn’t make them feel vulnerable, Kelly says. “Anyone should be able to put their hands up and say, ‘Wait, something is not right here,’ and leaders must lead by example with a zero-tolerance policy,” she says. “Unfortunately, in a previous workplace, I saw leadership move perpetrators sideways into a similar or equal position to get them out of the limelight. In some cases, they promoted them to create distance from a victim.”

This way of dealing with bullying is not uncommon. “That is sometimes referred to as ‘passing the trash,’” says Carolyn C. Meltzer, MD, FACR, dean of the Keck School of Medicine of the University of Southern California (USC). “Someone exhibiting unprofessional behavior is simply moved from one workplace environment to another. Once there, that person is likely to exhibit the same unacceptable behavior and have the same impact on staff. It is vital that this practice is taken seriously and investigated.

“I have witnessed intimidation in the workplace,” Meltzer says. “I have seen radiologists use their influence to promote some people and marginalize others. We see a lot of gender segregation, especially in academia, when women are not given the same opportunities for mentoring or teaching. They are frequently passed over for more powerful committee appointments and may be excluded from other staff support roles.

“Many forms of intimidation go unreported,” she says. “If you are junior to the person, you may feel that you don’t have a voice. I have so much more opportunity to speak out — to be an active bystander or upstander — if I see someone being intimidated because I am senior and have more perceived power.”

Bullying of radiology residents goes largely underreported by victims and witnesses. A significant percentage of radiology residents are unaware of zero-tolerance harassment and bullying policies in their workplaces, for instance, or rules protecting people from retaliation.² Building camaraderie can help residents share their experiences with trusted colleagues who may offer encouragement and support — or speak up on a victim’s behalf.

“When I was early in my career, it was very hard to speak out,” Meltzer says. “There was always the fear of retaliation and being labeled as ‘difficult’ or someone who ‘can’t take it.’ In medicine, we have this drive to not show weakness. We are there to serve patients, so we are told to toughen up and not complain.

“I had an experience years ago in a new position with someone who was quite a bully,” Meltzer recalls. “He repeatedly intimidated others from a leadership role. I asked him to step out of that position, and I received a lot of flak for it. Regardless, it set the tone for what was acceptable behavior and what was not right — and that it didn’t matter who it was.

“In an environment where everybody on the team is respected for what they bring to the table, regardless of their identity or seniority, they are more likely to speak up and prevent an error,” Meltzer says. This includes radiation oncologists, RTs and support staff who contribute to the radiology value chain. “That fair and just culture needs to be part of everything we do and actively promoted.”

Consequences Manifest

The consequences of bullying should not be taken lightly. “Sadly, I have seen victims of bullying resign and move on to another institution or practice,” Kelly says. They can suffer exhaustion and burnout, develop health problems, struggle with substance abuse, and see relationships with colleagues, partners and family deteriorate.

“Then there is the issue of diminished patient care and the reputation of the radiology group or practice when word gets out about workplace bullying,” Kelly says. It is also costly and time-consuming
to replace a radiologist who abruptly leaves because of bullying. “You may be losing a talented radiologist with valuable skills,” she points out.

Today it’s important to keep in mind that not all bullying happens in person. “Outside of the workplace, one thing we don’t talk enough about is cyberbullying,” Meltzer says. “In social media around radiology, we see anonymous Twitter handles, for instance, used to engage another through demeaning posts.”

Malicious responses to someone’s tweets can be especially painful for victims because they don’t know who is making the belittling statements. “It is nearly impossible to undo these things,” Meltzer
says. “We have seen terrible outcomes from this type of bullying in education among younger people, and physicians are just as at risk.

“If your health and performance are compromised as a result of bullying, there can be a direct impact on the quality of patient care you deliver,” Meltzer says. “It is incumbent upon leadership to ensure the safety of patients. Those in positions of power need to set the tone for professionalism, inclusion and flattening the hierarchy. As leaders, we should strive to create a welcoming and less formal environment. Ultimately, that will better serve our patients.”

Those in positions of power need to set the tone for professionalism, inclusion and flattening the hierarchy. As leaders, we should strive to create a welcoming and less formal environment. Ultimately, that will better serve our patients.

Causes Differ

Tracey H. O’Connell, MD, a musculoskeletal radiologist who left private practice five years ago and now does teleradiology, says she coaches physicians, including radiologists, who are being gaslighted and bullied. Gaslighting is a form of psychological manipulation that involves abusers seeking control over other individuals by making them question their own judgment and intuition.

“Bullying is more overt — behavior or actions that people can see from the outside,” O’Connell says. “For instance, most people in a meeting can witness bullying behavior and recognize that something isn’t right. Gaslighting is more subversive, but still a type of bullying. It dismisses a person’s reality, making them feel like they are making things up or being too sensitive. It depends on having a gaslighter, who needs to be right, and a gaslightee, who needs the gaslighter’s approval.”

Bullying can take the form of spreading rumors and planting seeds of doubt. Trainees and early-career radiologists are vulnerable to anyone trying to undermine their expertise. Often, bullying or gaslighting is done subconsciously as a response to feeling ‘not enough’ — not smart enough, not fast enough, not skilled enough. Ironically, shame is often what causes bullying and gaslighting,
and shame is also the result of such behaviors, O’Connell says.

“When someone needs to feel more secure, they bully or gaslight. They feel threatened and want to maintain their position in the hierarchy,” she explains.

“They may be afraid of anyone who is in a position of power over them,” O’Connell says. “Medical students may be afraid of residents and everyone above them. Residents may be afraid of fellows and attendings, and those people afraid of the chair, and the chair afraid of the administration. This vertical power structure limits an individual’s ability to speak out about what’s OK and what’s not OK.”

The competition never ends in radiology, with partners competing with each other for RVUs, number of cases read and perceived dedication — or competing for referrals with another radiology group in town.

“Sometimes all it takes, for example, is someone commenting offhandedly to others, ‘I hope this person doesn’t come in late tonight, because they were late yesterday.’ Then others in the group may say, ‘Oh yeah, I noticed that, too. They are often late.’ Little comments like this can put that person in the crosshairs,” O’Connell says. A similar result may happen if someone tells residents they aren’t going to pass boards.

Another common way gaslighting shows up in radiology is through differences of opinion. A different interpretation is not always a “mistake” because it’s possible to have many interpretations of the same study, particularly when reading MRIs, O’Connell says. Sometimes even the same radiologist will read the same case differently weeks after rendering an initial interpretation. Yet, such disagreements can be used to “rank” radiologists based on nuanced language around who is “right,” which can be arbitrary unless surgically proven.

“People can work in bad situations for a long time, until they can’t anymore,” O’Connell says. “You can sacrifice your well-being for decades, until it becomes unsustainable. I’ve seen very qualified people quit after many years of practicing radiology in a psychologically unsafe environment where no one is speaking up or offering support. Some radiologists, when they have had enough, realize they don’t need to tolerate bullying — that they can go work somewhere else where they are valued and can have relationships with colleagues based in mutual trust.”

Speaking Validates

When radiologists experience bullying, they have to decide how to handle the situation — and that brings up a whole new set of stressors. “Raising concerns in isolation may not always be the best approach because of potential adverse effects,” Meltzer says.

Institutional leaders at many places have established multiple lines of reporting, she says. “One way is through trust lines, an online or phone-based resource that allows someone to anonymously draw attention to another person’s behavior. The person raising an issue does not have to be the victim — the reporting can be on behalf of an ally who doesn’t feel senior enough or comfortable enough to speak up.”

There are ombudspersons in many academic environments who can help with resolution. “As a chair and now as dean, I have relied on these ombudspersons to meet with me on a regular basis and make me aware of where there may be bullying or other professionalism issues that truly warrant an investigation,” Meltzer says. It is also important that residents and younger radiologists have mentors who offer guidance about interpersonal situations.

“At my institution, we have processes in place for important milestones — academic promotions or a move to a leadership position. We use search committees, for example, which are comprised of staff trained in anti-bias techniques,” Meltzer says. “I don’t make decisions about promotions or filling senior leader positions without a search committee reporting to me, collecting feedback from other sources and compiling that information in an objective manner.”

When it comes to leadership’s role in preventing and eradicating bullying in the radiology workplace, first and foremost they must have the desire to do so, says Daniel B. Chonde, MD, PhD, a radiology resident at Massachusetts General Hospital. “If a leader does not see an issue with the bad behavior, nothing will change. Despite there being more momentum in efforts to stop bullying, some leaders will still tolerate it — especially if the perpetrator provides a great deal of value to a program.

“Assuming leadership is committed to reducing and eliminating bullying, they need to be involved in the goings-on of their department,” he says. “If they rely on intermediaries, they increase the
likelihood of bias distorting the information they are given.” Fortunately, there are some promising changes on the horizon, Meltzer says. With more women than men now in medical school, for example, there is a stronger and more diverse pipeline to the specialty. Diversity has become top of mind for many radiology groups, she says.

“When there are more of you, and diversity becomes more normalized, these situations are less likely to occur,” Meltzer says. “But when you feel different or isolated in your position — when people don’t look like you or they see things from a different professional and cultural perspective — unfair treatment and discrimination can become commonplace. Scrutinizing or singling out one individual or a likeminded group is less acceptable under diverse leadership.”

As workplaces grow more diverse, things are starting to change — but it will take conscious effort, Meltzer says. “I think we are moving in the right direction. The last thing you want is a monolithic leadership team who have similar cultural interpretations and who view all staff performance and behavior through a singular lens.

“It is critical to know what’s going on with your people at the ground level in any organization,” Meltzer says. “There is nothing that keeps me up at night more than not knowing someone is suffering. If they are not reporting a case of bullying or another form of harassment, they are living and working in isolation — sacrificing their own well-being and potentially the safety of patients.”