Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Breaking the Silence—How to be an Active Bystander


Everyone should speak up when witnessing unprofessional behavior. This supports learners, advances health equity, and improves patient outcomes.

Derogatory behavior is an action that undermines an individual’s merit or personhood and is unfortunately all too common in the medical profession. Derogatory behavior includes mistreatment, discrimination, sexual harassment, and bias. While derogatory behavior can be directed towards all participants in a medical setting, it’s often directed towards those lower in the hierarchy of medicine, like students, trainees, and medical team members from historically marginalized groups. Those marginalized include female medical students, underrepresented groups in medicine (URiM) (for example, African-American and Latinx), Asian, and LGBTQ+. These groups disproportionally experience higher rates of learner mistreatment.



Derogatory behavior has many negative effects. Mistreatment of residents is linked to negative perceptions of the learning environment, burnout, and depression. In addition, racial workplace discrimination experienced by physicians is associated with higher job turnover and lower career satisfaction. Physician dissatisfaction and poor well-being are associated with medication non-adherence and other patient safety errors. Discrimination and mistreatment of learners and physicians may also be a contributing factor to systematic underrepresentation of women and URiM physicians in certain specialties and high-level decisions.



Underrepresentation impacts patient care. Female patients are more likely to survive heart attacks in emergency departments with a greater percentage of female physicians, and patient-doctor race concordance improves physician communication and patient satisfaction.



The solution

When anyone who witnesses derogatory behavior stays silent, they reinforce a structure and culture of discrimination. To change the culture of medicine, individuals must assume responsibility and speak out against derogatory behavior by becoming active bystanders. Active bystanders are persons not directly in the incident who speak out about and/or engage others in responding against derogatory behaviors.



How to be an active bystander

How you respond as a bystander will depend on many factors including who is involved, the severity of the behavior, and the setting in which the incident occurred. If you witness derogatory behavior directed towards a colleague, learner, or patient, the first step is to try to understand the perspective of the recipient of the derogatory behavior. Then, you can utilize the following techniques to intervene as a bystander:



1. Support the recipient

Privately tell the recipient of derogatory behavior that you felt they were treated wrongly and ask how you can best support them.



2. Question the actor

Ask the actor what they meant or why they behaved in a certain way. This method encourages the actor to pause and reflect upon their behavior.



3. Confront the actor

Privately tell the actor their behavior was unacceptable.



4. Debrief with the team

Debrief the incident with other members of the team who witnessed the incident. Express your disapproval of the behavior and discuss how the team can work together to support the recipient and create a better work environment.



5. Speak with a supervisor

Reach out to a supervisor to discuss the behavior.



6. Report the incident

If you think the incident may violate your institution’s discrimination and harassment policy, file a report.