Bullying in the medical profession is common, particularly of student or trainee physicians. It is thought that this is at least in part an outcome of conservative traditional hierarchical structures and teaching methods in the medical profession which may result in a bullying cycle. The rampant problem of medical student mistreatment and bullying was systematically studied and reported in a 1990 JAMA study by pediatrician Henry K. Silver which found that 46.4 percent of students at one medical school had been abused at some point during medical school; by the time they were seniors, that number was 80.6 percent.
According to Field, bullies are attracted to the caring professions, such as medicine, by the opportunities to exercise power over vulnerable clients, and over vulnerable employees and students.
While the stereotype of a “victim” as a weak inadequate person who somehow deserves to be bullied is salient, there is growing evidence that bullies, who are often driven by jealousy and envy, pick on the highest performing and most skilled staff or students, whose mere presence is sufficient to make the bully feel insecure. Threats (of exposure of inadequacy) must be ruthlessly controlled and subjugated. Psychological models such as transference and projection have been proposed to explain such behaviors, wherein the bully’s sense of personal inadequacy is projected or transferred to a victim; through making others feel inadequate and subordinate, the bully thus vindicates their own sense of inferiority.
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 general council 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 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.”
Displacement is another defense mechanism that can explain the propensity of many medical educators to bully students, and may operate subconsciously. Displacement entails the redirection of an impulse (usually aggression) onto a powerless substitute target. The target can be a person or an object that can serve as a symbolic substitute. Displacement can operate in chain-reactions, wherein people unwittingly become at once victims and perpetrators of displacement. For example, a resident physician may be undergoing stress with her patients or at home, but cannot express these feelings toward patients or toward her family members, so she channels these negative emotions toward vulnerable students in the form of intimidation, control or subjugation. The student then acts brashly toward a patient, channeling reactive emotions which cannot be directed back to the resident physician onto more vulnerable subjects.
Beyond its ramifications for victims, disrespect and bullying in medicine is a threat to patient safety because it inhibits collegiality and cooperation essential to teamwork, cuts off communication, undermines morale, and inhibits compliance with and implementation of new practices.