Bully for Us: Confronting Medicine's Bullying Problem

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One estimate suggests that close to 60% of medical trainees report being subjected to bullying in one form or another.
One estimate suggests that close to 60% of medical trainees report being subjected to bullying in one form or another.

In 2017, the Ontario Medical Association — which represents the interests of the 34,000 or so physicians and medical students in Canada's largest province — found itself locked in a heated negotiation with the government over their physician services agreement.1 Physicians in Ontario had been working without a contract for nearly 3 years and patience was wearing thin. After seemingly endless discussion, the government presented an offer that had the support of the Ontario Medical Association executive council but that deeply divided the rank and file.

The organization immediately descended into internecine warfare. What ensued would not have been out of place in Julius Caesar's Roman court: recriminations, innuendo, and threats of mutiny flew back and forth between physicians on either side. As the saga spiraled towards its nadir, a local newspaper, The Toronto Star, got hold of a Facebook message that Tim Bates, a physician who opposed the deal, sent to a medical student who supported it: “I think everyone needs to know your role, and the role of the [Ontario Medical Students' Association] in this matter…. This is why we will be sending all of the dean's letters as soon as possible because quite frankly there are many who feel you should not be a family medicine resident at [University of Toronto] or anywhere else for that matter.”2

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Bullying — defined as harassment or discrimination that the recipient perceives as humiliating, hostile, or abusive — is a big part of medical practice south of the 49th parallel, too.

By one estimate, close to 60% of medical trainees report being subjected to bullying in one form or another3 — and that's just the trainees who are willing to openly confess their darkest professional moments. Who knows how many more repress, downplay, or simply ignore similar experiences.

An argument can be made for letting young physicians weather the tsunami of abuse regularly generated by nurses, patients, staff, and most of all, other physicians. Survival can be seen (in retrospect, anyway) as a badge of honor and proof positive that a physician can be trusted to perform under pressure. It's also at least somewhat reassuring that other demanding industries — law firms and the military come to mind — also pride themselves on making new recruits miserable. Nobody ever said that training would be easy.

The problem with all that — besides the dubious didactic value of being made to feel insignificant and incompetent — is that the culture of bullying is terrible for patient outcomes.4 Bullied physicians are more likely to be forced to manage clinical scenarios beyond their expertise, to work beyond duty hour limits, and to consider leaving medicine altogether5 — all of which helps account for the higher rate of medical errors attributable to bullied physicians.

The optimistic read of that evidence suggests that bullying might have value in identifying rising physicians who are some combination of unfit for, and insufficiently committed to, the profession. That's technically possible — bullies certainly believe that they can somehow sense weakness — but whatever theoretic worth it may have as an early professional Sorting Hat is dwarfed by what we know about workplace bullying's long-term stain.6,7 And really, the causation could just as easily work in the other direction: maybe it's the bullying that causes young physicians' performance to wane and their commitment to waver. Either way, it's clear that bullying is more commonly directed toward female, minority, and disabled physicians,5 which means that, on top of everything else, medicine's permissive culture systematically pushes underrepresented groups to the margins of the profession. Bullying: so not woke.

Yet, it persists. Part of the reason might be that we just don't know any better. A 2008 study published in The Joint Commission Journal of Quality and Patient Safety tried to get a handle on the extent of disruptive behavior — which certainly includes bullying — in hospitals. The results were more or less expected: 51% of physicians reported that they had witnessed other physicians behaving badly at work, and the majority believed that these disruptions led to adverse events, medical errors, and compromised patient safety.4

Although that's not especially surprising, it's interesting to note that that even though only about half of doctors reported witnessing disruptive behavior by other physicians, 88% of nurses said they had observed physicians acting out. That's an enormous gap. Nearly every nurse said that physicians are sometimes bullies; only half of physicians agreed. It wasn't even that physicians were treating their own with kid gloves: when asked about disruptive behavior by nurses, 73% of nurses said they'd witnessed it, compared with only 48% of physicians. Physicians aren't physically isolated from bad behavior; they see the exact same misdeeds that nurses see. They just don't register those misdeeds as problematic. The obvious explanation is that doctors simply have a much narrower — really, too narrow — concept of what constitutes disruptive or bullying behavior. We don't know what bullying is, even when it's right in front of our face.

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As for Tim Bates and his Facebook message promising to blackball a medical student, it seems that he too had a limited idea of what constituted bullying.

When The Toronto Star first asked about the threat, Dr Bates denied any wrongdoing and justified his behavior, claiming that he “may have been a little upset.” This time, however, even other physicians could tell that Dr Bates was in the wrong. Physicians throughout Ontario rallied at the student's defense and told Dr Bates in no uncertain terms that he had gone too far. At long last, Dr Bates saw the error of his ways, and issued a mea culpa, finally admitting, “It was something I shouldn't have said.”

References

  1. Boyle T. Ontario Medical Association executive resigns en masse. The Star. https://www.thestar.com/news/gta/2017/02/06/ontario-medical-association-executive-resigns-en-masse.html. Published February 6, 2017. Accessed April 11, 2018.
  2. Boyle T. Ontario doctors ‘distressed' over wave of bullying, infighting. The Star. https://www.thestar.com/life/health_wellness/2017/02/27/ontario-doctors-distressed-over-wave-of-bullying-infighting.html. Published February 27, 2017. Accessed April 11, 2018.
  3. Fnais N, Soobiah C, Chen MH, et al. Harassment and discrimination in medical training: a systematic review and meta-analysis. Acad Med. 2014;89(5):817-827.
  4. Rosenstein AH, O'Daniel M. A survey of the impact of disruptive behaviors and communication defects on patient safety. Jt Comm J Qual Patient Saf. 2008;34(8):464-471.
  5. Paice E, Smith D. Bullying of trainee doctors is a patient safety issue. Clinical Teacher. 2009;6(1):13-17.
  6. Nielsen MB, Einarsen S. Outcomes of exposure to workplace bullying: a meta-analytic review. Work & Stress. 2012;26(4):309-322.
  7. Vartia MA-L. Consequences of workplace bullying with respect to the well-being of its targets and the observers of bullying. Scand J Work Environ Health. 2001;27(1):63-69.

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