In Practice: Reflections from NPs and PAs

Harrison Reed, PA-C, practices critical care medicine in Baltimore, MD.

Susan Fowler’s first day on the job did not go well. She had just joined the ride share company Uber as an engineer in late 2015 when the messages arrived. Hours into her first official assignment, Susan’s new manager contacted her over the company’s communication system to ask for sex.

Susan was so struck by the audacious advances that she saved screenshots of the conversation and reported her supervisor to the human resources department. Expecting swift punishment for her boss, Susan was shocked when Uber’s upper management came to his defense. It was his first offense, they argued, according to Susan’s account of the events, and he was “a high performer,” a status warranting leniency. The abuser kept his job while Susan found a different team.

Last month, Susan’s online description of her experiences at Uber set off a firestorm for the transportation company. But while sexual harassment is one of the more troubling (and illegal) forms of workplace abuse, it is far from the most common. More subtle offenses often fly far below the legal radar and rarely grab similar headlines. But, as in Susan’s experience, organizations often absolve abusers they view as talented or highly productive.

The healthcare industry is certainly no stranger to toxic work culture. Surveys of healthcare executives indicate that the vast majority of healthcare workers experience, witness, and/or report destructive behavior on a regular basis. These attacks often flow down a perceived power gradient when more powerful employees bully their less-influential colleagues. Punishment for this behavior follows the same lopsided rule, as prominent employees are likely to avoid punishment for the same offenses that would have “lower-ranking” colleagues fired.

Perpetrators of toxic behavior rarely reveal themselves in a single, explosive episode but choose more subtle tactics that, over time, erode the morale of their targets. These include degrading comments, public humiliation, destructive criticism, sarcastic insults, work disruption, and team sabotage. The consequences of these actions can ripple through an entire organization as the victims themselves adopt similar aggressive tendencies for protection.

A single jerk can cause staggering damage. Direct victims of workplace abuse—or even those who merely witness such behavior—are far more likely to skip work, call in sick, or take vacation. When they do show up, victims are less invested in their work and productivity drops. Ultimately, employees who deal with abuse on a regular basis do what any reasonable person would do: they quit.

The estimated cost of replacing employees ranges between 1.5 and 2.5 times their annual salaries. Toxicity from the most prolific surgeon or productive administrator can easily rack up a debt that surpasses any profit he may bring. If five or six coworkers are driven to find new employment by the behavior of such a person, the cost of rebuilding a team could reach into the millions of dollars.

Of course, the true cost of an abusive workplace is never limited to a few resignations. Well-intentioned employees waste countless work hours running interference and buffering jerks. A nurse once told me that she expects to receive fewer orders for her patients when certain administrators are in the building since medical providers are likely to be occupied appeasing an inflated ego. Mistakes made under abusive supervisors are less likely to be reported for fear of punishment, and thus systemic errors are less likely to be caught and corrected. Employees in these settings are reluctant to perform tasks “above and beyond” their duties in favor of maintaining a low profile. Entire workforces can disappear into defensive foxholes.

It should come as no surprise, then, that hospitals peppered with toxic jerks are also linked to lower patient satisfaction. Far more disturbing, some studies have connected a negative workplace culture to increased patient mortality, a prospect that should have hospitals shoving bullies out of their doors with bulldozers.

Organizations claiming to value evidence-based methods must face the hypocrisy of harboring jerks. With so much evidence of such widespread harm, anything less than a zero-tolerance policy toward toxic behavior and workplace bullying defies science and reason. Rooting out poisonous personalities is, no doubt, an unpleasant experience, but it is one that offers both immediate and long-lasting rewards.

Much like the dawn of the “Moneyball” era in professional baseball, healthcare organizations must rethink the basic assumptions of team building. Talented jerks—even superstars—don’t bring a financial advantage; they destroy it. Administrators wishing to build the most effective organization at the most affordable cost should prioritize intangibles such as temperament and teamwork far above marginal differences in experience or productivity.

Of course, workplaces aren’t just filled with accounting spreadsheets. Whether it is employees or the patients for whom they care, toxic cultures do incalculable damage to real human beings. If healthcare leaders are to claim the dual responsibilities of running business and saving lives, they must make a healthy work environment a top priority.