Reply: You are a leader as well.

Reply to the Editor:

The authors reported no conflicts of interest.

The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

We read with enthusiasm the article by Tam and Rocha about available mechanisms to report abuse of trainees. They describe the resolution of a particular episode of abuse of a trainee at their institution. Ultimately, the problem was addressed appropriately and the offender was educated about harmful behavior in the operating room. We agree that dealing with inappropriate behavior requires tact and leadership. We would like to raise 2 important points in response to dealing with such situations. Firstly, what is the responsibility of bystanders who witnesses abuse in the hospital? Secondly, how can surgeons learn to be active leaders and role models for their trainees?

The first of these action plans is learning to be an active bystander. Disregarding abuse of others can have very negative consequences. The standard you walk past is the standard you accept, after all. Safe intervention can be accomplished by bystanders in 1 of 4 ways called the 4 D's: Direct action, Distraction, Delegation, or Delayed response. Direct action is using body language and words to indicate disapproval and change the mood of the room. Distraction is creating a diversion such as calling the victim away to another location or another task. Delegation is reporting the abuse to an appropriate authority utilizing an official process. Delayed response is approaching the victim after the episode and determining a response at that time. We must build reporting systems that allow delegation and delayed response to work effectively. Most institutions have official mechanisms, but these mechanisms are often unknown to trainees. It is just as important to recognize that we can intervene in the moment effectively. Derogatory behavior is frequently directed toward those perceived to be lower in the hierarchy of medicine, such as students, resident physicians, or those from underrepresented communities. We challenge the surgical community to accept responsibility for intervention. As Tam and Rocha describe, senior residents should advocate for junior trainees. We extend this to say that we can all learn to accept responsibility and effectively intervene on behalf of others even if that work is hard and uncomfortable. As Dr Martin Luther King Jr said, “In the end we will remember not the words of our enemies, but the silence of our friends.”

The second action plan is learning to be a leader. At every level, surgeons must be committed to developing tangible leadership skills to be an effective care provider. Leadership has been described by experts as one's ability to create conditions that enable agency in others to achieve shared purpose in the face of uncertainty. Leaders can help our culture move from apathy and indifference in the face of hostility toward the need and urgency to act. Effective leaders allow other members of the group to move from: Does what I say even matter? to, How I respond makes a difference. We urge all trainees to read Dr Pasque's article and do the hard work of looking out for each other.