How the Medical Culture Contributes to Coworker-Perpetrated Harassment and Abuse of Family Physicians

Baukje Miedema; Leslie MacIntyre; Sue Tatemichi; Anita Lambert-Lanning; Francine Lemire; Donna Manca; Vivian Ramsden

doi:10.1370/afm.1341

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Abuse matters
Hubinette Maria

Published on: 14 April 2012
Author response to Dr. Herbert comments
Baukje (Bo) Miedema

Published on: 22 March 2012
You Needed a study to figure this out?
George J. Atiee

Published on: 19 March 2012
Re:How the Medical Culture Contributes to Coworker-Perpetrated Harassment and Abuse of Family Physicians
Parker J Magin

Published on: 19 March 2012
Overgeneralizing from limited data?
Carol P Herbert

Published on: 13 March 2012

Published on: (14 April 2012)

Abuse matters
Hubinette Maria, Physician
Other Contributors:
Reply to "How the Medical Culture Contributes to Coworker-Perpetrated Harassment and Abuse of Family Physicians" Maria M Hubinette and Erica Frank. This study explores the aspects of medical culture that may contribute to abuse. Medical training has been described as a "process of moral enculturation" and medical schools as "moral communities" (Hafferty, 1998). But which morals? One large (16 medical school) recent study (Frank...
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Reply to "How the Medical Culture Contributes to Coworker-Perpetrated Harassment and Abuse of Family Physicians" Maria M Hubinette and Erica Frank. This study explores the aspects of medical culture that may contribute to abuse. Medical training has been described as a "process of moral enculturation" and medical schools as "moral communities" (Hafferty, 1998). But which morals? One large (16 medical school) recent study (Frank et al, 2006) showed that 85% of U.S. medical students report having been harassed or belittled. Furthermore, harassment and belittlement were associated with regretting going to medical school, suicidality, and binge drinking. If students are routinely being exposed to an underlying culture of abuse, the message is that abuse is acceptable and tolerated. Perhaps this is linked to a shortage of physicians, which has also been purported as a factor contributing to abuse. Perhaps abusing physicians have overly-high expectations. Physicians may feel entitled to be well-respected, well-paid, and intellectually and socially fulfilled by our profession, and may feel that they have permission to treat those with less power than them poorly (Frank 2009). To us, this seems excessively entitled in a profession that gives us a years-longer-than-average life expectancy, and many daily opportunities to significantly improve the world. Frank E et al. Experiences of belittlement and harassment and their correlates among medical students in the United States: longitudinal survey. BMJ 2006; 333 (7570):682. Frank E. Physician, humble thyself. BMJ 2009; 339:b4218. Hafferty FW. Beyond Curriculum Reform: Confronting Medicine's Hidden Curriculum. Academic Medicine 1998; 73(4):403-407.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (22 March 2012)

Author response to Dr. Herbert comments
Baukje (Bo) Miedema, Fredericton, NB, Canada
Other Contributors:
Dear Dr. Herbert: Thank you for your comments regarding our article. You stated that our findings and conclusions are based on a (too) small percentage of the survey participants and we feel the need to respond to your concerns. We have the sense that our qualitative study is being viewed through a quantitative research analysis lens. This paper is entirely based on the 47 qualitative interviews with participants who...
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Dear Dr. Herbert: Thank you for your comments regarding our article. You stated that our findings and conclusions are based on a (too) small percentage of the survey participants and we feel the need to respond to your concerns. We have the sense that our qualitative study is being viewed through a quantitative research analysis lens. This paper is entirely based on the 47 qualitative interviews with participants who have experienced abuse. The interviews represent a diverse group of physicians from across Canada including males and females, and participants whose first language is either English or French. As stated in the article, qualitative data is not generalizable to the population but may be transferable to similar situations.
The quotes in our article are not presented as "proof" of concerns raised by the participants; rather they are representative of the impact of the issues and give the participants a "voice", thereby enriching the quantitative findings. The quotes are illustrative of the themes that emerged from analysis of all of the interview transcripts, we based our findings on the analysis of all of the data, not on only one participant's disclosure.
Qualitative research can be exploratory (leading to hypothesis testing) or explanatory to elucidate, in our case, aspects of the quantitative data. Data that emerged from our previously reported quantitative study has demonstrated that the most frequent perpetrators of abuse are patients and family members of patients, but in this article we report on the qualitative data set which has demonstrated that the most severe impact of abuse is when the perpetrators are teachers, colleagues etc. Further, many of the interviewees recalled abusive incidents that happened during their medical training. Based on this research we do believe that medical educational establishments are no different than other educational institutions (very much in the news these days) and that abuse/harassment/bullying needs to be addressed. The "broken window" theory underscores that an 'ounce of prevention' may be worth more than a pound of cure in the case of work related abusive incidents. We hope that based on our research, at least a discussion about abuse in medical education and professional practice will ensue.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (19 March 2012)

You Needed a study to figure this out?
George J. Atiee, Senior Director
Medical school and residency is not for the feint of heart. The goal of training should be to produce a competent physician that is capable of making life and death decisions, sometimes in a split second. Feelings, emotions, self esteem have nothing to do with it. I am a Family Physician (Board Certified since 1988). I trained at Baylor Medical center. The Family Physicians were always looked down upon as inferior. Res...
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Medical school and residency is not for the feint of heart. The goal of training should be to produce a competent physician that is capable of making life and death decisions, sometimes in a split second. Feelings, emotions, self esteem have nothing to do with it. I am a Family Physician (Board Certified since 1988). I trained at Baylor Medical center. The Family Physicians were always looked down upon as inferior. Respect was earned with hard work and thick skin. If you want pleasant working conditions and lots of pats on the back you are in the wrong field.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (19 March 2012)

Re:How the Medical Culture Contributes to Coworker-Perpetrated Harassment and Abuse of Family Physicians
Parker J Magin, Conjoint Senior Lecturer
These are interesting findings but the central issue of horizontal violence in family practice remains unclear. Most of the quotations refer to non-family practice settings. How the issues raised manifest themselves in the less-hierarchical structure of family practice and how modelling behaviour in other settings impacts upon behaviour in family practice are important issues that aren't fleshed out by the findings in the...
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These are interesting findings but the central issue of horizontal violence in family practice remains unclear. Most of the quotations refer to non-family practice settings. How the issues raised manifest themselves in the less-hierarchical structure of family practice and how modelling behaviour in other settings impacts upon behaviour in family practice are important issues that aren't fleshed out by the findings in the paper.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (13 March 2012)

Overgeneralizing from limited data?
Carol P Herbert, Professor, Department of Family Medicine
The authors are to be commended for investigating the issue of abuse of physicians by co-workers. The application of 'broken windows' theory is interesting. However, I do have some concerns about findings based on a 20% response rate to the original survey and a subsequent small number of interviews, amounting to 0.1% of the total survey sample. While the authors point out the limitation that those who consented to be...
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The authors are to be commended for investigating the issue of abuse of physicians by co-workers. The application of 'broken windows' theory is interesting. However, I do have some concerns about findings based on a 20% response rate to the original survey and a subsequent small number of interviews, amounting to 0.1% of the total survey sample. While the authors point out the limitation that those who consented to be interviewed could be a skewed group, they draw broad conclusions. For example, on the basis of a single quote which claims that specialists are paid to be on call for Surgery while family physicians are not (which may be true in some jurisdictions, but certainly is not the norm) and a second quote regarding the behavior of senior trainees in relation to junior trainees, the issue of professional hierarchy is invoked in the discussion. While I do not doubt that issues relating to professional hierarchy may result in inappropriate behaviors, I do not think the data reported in the article support the claims. Hypotheses can be generated from these limited qualitative findings for testing in subsequent research projects.
Competing interests: None declared
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Competing Interests: None declared.