Surgeons who resent moves to address endemic bullying and harassment and deny the profession has a problem are among more than 1000 specialists yet to complete compulsory training designed to quash the toxic culture.
The Operating With Respect training module is a core component of the Royal Australian College of Surgeons' (RACS) action plan launched in 2015 after heavy criticism over its "Anglo-Saxon boys club" where senior surgeons "eat their young" and women are frequently discriminated against and sexually harassed.
But 40 per cent of surgeons in Australia and New Zealand have not completed the mandatory 45-minute online course three months before the December 31 deadline, according to an alert sent to fellows in September.
NSW had the lowest completion rate of 56 per cent, followed by Victoria at 59 per cent.
Senior surgeon Gabrielle McMullin said many surgeons resented the directive, and refused to believe the profession had a bullying and harassment issue.
"A lot of people are extremely annoyed about the module and completely dismiss the idea that it's necessary at all," said Dr McMullin, who helped to galvanise public outcry over the issues.
"These are the surgeons who most need to do it," she said, praising the content of the module.
Surgeons who failed to comply with RACS' continuing professional development (CPD) requirements would be unable to legally practice their speciality.
Dr McMullin said she frequently received messages from surgeons asking for help to deal with bullying colleagues because the formal process still failed to protect complainants, and instead investigated the victims.
Senior female surgeons warned female trainees not to make formal complaints for fear it would jeopardise their careers, and instead to find a sympathetic senior surgeon to speak with, she said.
Sydney urological surgeon Henry Woo said several colleagues had called the focus on bullying and harassment a "beat up".
"There are still many surgeons who simply do not believe that bullying, discrimination and sexual harassment exists within the profession," Dr Woo said.
RACS "could not have done more in their attempts to motivate surgeons to complete the module", Dr Woo said.
But the primary motivator for many would be to "tick the boxes" to meet their CPD requirements, Dr Woo said.
"It is hugely disappointing that so many surgeons have to literally be taken kicking and screaming to complete the module," he said.
RACS vice president Cathy Ferguson said on Sunday the module completion rate had risen to 65 per cent.
"We're happy with that and we're confident we'll get everybody across the line by the end of the year," Dr Ferguson said.
She said "there are always going to be people who are deniers and think we have gone too far ??? but it's a shrinking number".
"We are working really hard to get those people to open the module ??? they might go into it with that mindset, but most people have been pleasantly surprised by it."
She said bullying and harassment were still pervasive among the profession and the college was committed to creating long-term change through a multi-pronged action plan that also focused on overhauling the teaching-by-humiliation training techniques.
She acknowledged the complaints process was a major challenge for the college.
"We are very much committed to creating a culture where people are not scared to come forward because of potential harm to their training ... We know this has to be a long-term focus of ours," Dr Ferguson said.
RACS had received 126 complaint inquiries. About 70 per cent were related to unacceptable behaviour, mostly bullying. Only 25 per cent of inquiries became formal complaints, Dr Ferguson said.
But she rejected the criticism that RACS was paying lip service to quashing bad behaviour.
"Years ago people could have said we did pay lip service ??? but we've now put a huge amount of resources into this," she said.
In addition to the action plan, RACS had signed 25 memoranda of understanding with other organisations, including public health organisations, hospital operators and universities, to share strategies and address the issues.
"A lot of this is dependent on what happens in the workplace," Dr Ferguson said. "We can't do this on our own."
Dr McMullin, a Sydney vascular surgeon, said she did not expect surgeons would change their behaviour unless "black boxes" were installed in theatres to record interactions.
The college had considered the "black-box" strategy, Dr Ferguson said, but had not pursued it in light of the cost and privacy barriers, and an expected strong resistance from hospitals and health services.
On November 14, an independent advisory group will meet to review RACS' progress since launching its action plan. The college is also in the process of appointing an external reviewer for its complaints process.