Cultural structures that perpetuate silence: an East Asian reflection on bullying in the operating theatre.
Journal
Anaesthesia
ISSN
1365-2044
Date Issued
2025-08-15
Author(s)
Abstract
We strongly support the call made by Nelson [1] to recognise bullying not merely as a behavioural issue but as an institutional phenomenon, sustained and normalised by entrenched hierarchies and cultural inertia within the operating theatre. In East Asian medical systems, this observation resonates particularly strongly. We write to further this conversation by highlighting structural conditions that hinder progress and, in some cases, perpetuate harm under the guise of professional co-operation. In many academic hospitals across East Asia, career promotion, research funding and institutional visibility are influenced disproportionately by a small number of senior figures, often concentrated in procedurally dominant specialties. Under such power dynamics, junior clinicians frequently navigate unspoken pressures to comply with decisions that may conflict with patient safety principles. Even in elective cases, clinicians may feel compelled to proceed with anaesthesia despite disproportionate risk, simply to avoid perceived insubordination. Institutional language such as ��internal customer service�� is often invoked to rationalise unsafe compromise, and ��team harmony�� is wielded to delegitimise dissent. In these settings, silence becomes a survival strategy, and deference is misread as professionalism. Many trainees and junior consultants find themselves ethically cornered; fully aware of the risk to patients yet paralysed by the knowledge that resistance may jeopardise their academic progression or future research support. What makes this culture especially insidious is its recursive nature. Those who survive this system and ascend to positions of influence often internalise its logic, perpetuating the same pressures they once endured. As Averbuch et al. noted, academic bullying is rarely an anomaly �V it is more often the outcome of systems that concentrate power without adequate oversight [2]. Villafranca et al. also identified the peri-operative environment as particularly vulnerable to these dynamics [3]. We acknowledge the call for action by Nelson, especially the emphasis on psychological safety, leadership training and reporting mechanisms. However, we wish to extend this by highlighting a foundational challenge: efforts to address bullying may falter if the underlying mechanisms of institutional reward continue to reinforce silence and submission. As the American Medical Association has argued, workplace aggression must be approached as a systemic threat and not merely as an interpersonal failing [4]. Changing this culture requires more than policies �V it requires a restructuring of how we define excellence, distribute opportunity and protect professional autonomy. Without this, even the most well-intentioned reforms may be absorbed into the very systems they seek to change.
Type
letter