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Doctors dissect medicine’s bullying problem

Lauren Vogel | CMAJ | August 21, 2017

Tolerating abuse is part of the “hidden curriculum” of medicine, said Dr. Franco Rizzuti, president of the Canadian Federation of Medical Students.

Doctors need a new definition of what it means to be professional after a year of increasingly ugly conflict and mounting reports of bullying and intimidation within their ranks.

The problem goes to the very heart of medical culture, said panelists at an Aug. 21 session on professionalism at the Canadian Medical Association’s annual meeting in Quebec City.

“I would liken our issues with intra-professionalism to a chronic disease,” says Dr. Ali Damji, a Toronto family medicine resident and former chair of the Ontario Medical Students Association. “It’s something that’s existed in medicine for a very long time,” he said, describing his own experiences of bullying as an “exacerbation” of that preexisting condition.

Damji shared stories of how he and other trainees faced derogatory remarks and threats for endorsing the Ontario Medical Association’s controversial 2016 physician services agreement. “Some were completely profane and completely inappropriate,” he said. In one instance, “an individual representing a group of physicians went so far as to actually threaten my residency position weeks before the match was supposed to occur.”

The message eventually became public and “that brought things to a head and into the public space,” he said. However, “these experiences really shook me in how I perceived the medical profession and how we treat one another.”

Trainees are particularly vulnerable to abuse, simply because “there is so much power physicians can hold over them,” Damji added. “I was lucky because I was involved in medical politics – I knew the registrar and all the deans so I could advocate for myself and protect myself – but that’s not the case for all trainees or every physician.”

Dr. Franco Rizzuti, president of the Canadian Federation of Medical Students, noted that tolerating abuse is too often part of the “hidden curriculum” of medical training. “We know that vulnerable demographics, whether that be marginalized populations, junior trainees, female colleagues taking maternity leave, or any of those who are not the majority are always at the lower end of the power disequilibrium,” he said. “We know there’s a double standard that it’s ok for those in power to speak their minds and be vocal,” but not someone with less clout.

“This is a bigger systemic issue,” Rizzuti said. “It’s not about the one-on-one encounters or Twitterverse conversations; this is actually part of our culture as a profession.”

And it’s a part of medical culture that’s gotten uglier in recent decades, said Dr. Dennis Kendel, board vice-chair for the Health Quality Council in Saskatchewan and former president of the Saskatchewan Medical Association.

He attributed the erosion of collegiality to an increasing silo mentality in medicine. “We’ve lost the capacity to some extent to forge a shared identity. We’ve gone infinitely more toward allegiance with our particular specialty discipline.”

In the past, “colleagues across a diverse range of disciplines” might socialize in a shared hospital lounge, explained Kendel. Today, “there are probably 900 physicians in the Saskatoon Health Region and we’re lucky if 20 to 30 show up for regional medical association meetings, and frankly most of them have graying hair like me.”

As physicians turn to more impersonal platforms like Twitter to connect, “what troubles me … is the increasing inclination of people to attack one another personally when they disagree.”

“When we see this behaviour, we need to call it out and let our colleagues know it’s just not acceptable,” he said. “What you permit you condone.”

Panelists agreed there should be zero tolerance for bullying in medical schools and organizations. But they also called on the profession to enshrine civility as a fundamental aspect of what it means to be a physician.

This goes “beyond courtesy and politeness,” said Dr. Michael Kauffman, the founding medical director of the Physician Health Program of the Ontario Medical Association. It includes respect, mindfulness, communication, self-care and personal responsibility. Medical trainees and their instructors should be taught and evaluated on these competencies “right from the very, very start,” Kauffman said.

Medical organizations also need to start fixing their “broken windows,” he said, alluding to the theory that links disorder within a community to higher rates of crime. In this case, it means creating clear codes of conduct and promptly addressing instances of incivility.

Delegates at general council expressed dismay at the inaction of medical schools, institutions and leaders in response to repeated reports of bullying and intimidation.

“When trainees were attacked online or in person there wasn’t a large number of staff physicians, preceptors, supervisors, faculties of medicine, or national institutions that came to their defense in any meaningful way,” said an Ontario emergency physician.

General council will discuss developing a charter of shared values in an Aug. 22 session.

Photo credit: CMA

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