Junior doctors hesitate to speak up over unprofessional behaviour, study finds

Authors: Matthew Limb 

Publication date:  05 Jun 2017

New doctors are less likely to speak up about a colleague’s unprofessional behaviour than they are about traditional threats to patients’ safety, even when they perceive high potential for harm to patients, a US study has found.

The study found that junior doctors reported “fear of conflict” as a barrier to speaking up about unprofessional behaviour. The authors said that their findings, published in BMJ Quality and Safety,[1] showed “important safety deficits” and the need to provide more supportive clinical environments to foster open communication.

The research involved 837 interns (doctors in the first year of postgraduate training) and residents (those in second year or above of postgraduate training) at six US academic medical centres between 2013 and 2014. It was carried out by a team of researchers from institutions including Vanderbilt University Medical Centre, in Nashville, Harvard Medical School, and the University of Texas.

Open communication about concerns is vital to keeping patients safe and preventing errors, the authors said. However, although speaking up about traditional safety threats, such as inadequate hygiene, has been promoted and incorporated into medical curriculums, speaking up about unprofessional behaviour remained “relatively underemphasised,” they said. Safety threats perceived to be professionalism related, such as failure to disclose an error or disrespectful behaviour, may be harder for trainee doctors to recognise and to raise, especially by young doctors who already faced substantial barriers to “speaking up the hierarchy,” the authors added.

The study sought to compare interns’ and residents’ experiences and attitudes and the factors associated with speaking up about traditional versus professionalism related safety threats. It involved survey questions and analysis of responses to two “vignettes,” scenarios that were based on actual cases and designed to assess the likelihood of speaking up about different safety threats.

The study participants were asked whether they had observed a patient safety breach or example of unprofessional behaviour at least once during their most recent month working in an inpatient setting. Those who reported observing an event were then asked whether they discussed any of the unprofessional behaviours or patient safety breaches with the persons involved. Patient safety breaches might typically include improper sterile technique, while unprofessional behaviour could include covering up an error, falsifying documents, or insulting colleagues.

Respondents more commonly observed unprofessional behaviour than traditional safety threats, the authors found, but they reported speaking up about unprofessional behaviour less often. The three most commonly cited barriers to speaking up about patient safety breaches and unprofessional behaviour were getting someone else in trouble, fears of conflict or eliciting anger, and alienation from team members.

Respondents more commonly reported fear of conflict as a barrier to speaking up about unprofessional behaviour than about traditional safety threats. Respondents were also less likely to speak up to an attending physician in the professionalism vignette than the traditional safety vignette.

The authors wrote, “Speaking up about unprofessional behaviour was more commonly perceived as confrontational, more likely to cause self-alienation, less likely to be efficacious and less of priority than speaking up about traditional patient safety breaches.”

Most interns and residents perceived little support for speaking up about professionalism related problems. The authors said that the results reinforced the importance of fostering collective accountability, caring and capable leadership, and cultivating a supportive clinical learning environment.

They wrote, “Simply offering training on speaking up without addressing the organisational and cultural elements that influence speaking up is unlikely to succeed and may increase the moral distress of participants by raising behavioural expectations without providing a supportive environment.”


  1. Martinez W, Lehmann LS, Thomas EJ, et al. Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents. BMJ Qual Saf  2017;bmjqs-2016-006284. [Link] [Link] .

Matthew Limb BMJ Careers

Cite this as BMJ Careers ; doi: