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Ontario Medical Review
November 24, 2020
DMM
Dr. Maryna Mammoliti

This article originally appeared in the September/October 2020 issue of the Ontario Medical Review magazine.

Violence against physicians

Uniting the medical community in understanding and acting against violence experienced by physicians in the workplace

By Dr. Maryna Mammoliti, MD, FRCPC Psychiatry 
Chair, OMA Section on Psychiatry  

Violence experienced by physicians at their workplace, community, and within their homes and personal relationships is poorly studied and yet presents such a paramount aspect impacting physician health and well-being, as well as their ability to function as a physician and perform their occupational duties.  

As a psychiatrist who treats patients for trauma-related disorders — many of whom are physicians and other health care providers, and myself having been physically assaulted while pregnant in a clinical situation — I see the lasting impact of workplace violence, as well as violence experienced in patients’ personal relationships across their lifetimes.   

At this point there is no standardized definition of workplace violence, however, the Canadian Nurses Association defined workplace violence as physical, psychological, sexual harassment, and financial violence in their May 2019 submission to the House of Commons Standing Committee on Health.

Experiences of violence can be understood as:

  • physical violence
  • psychological violence (threats, bullying, harassment, intimidation)
  • sexual violence (harassment, assault, intimidation, verbal remarks)

In the online era, experiences of violence can be understood as:

  • online bullying
  • stalking
  • threats
  • targeting of physician’s family
  • derogatory comments on reputation

Experiences of violence may be perpetrated by a patient, a patient’s family, physician peers, physician supervisors or medical co-workers at the workplace — the scope of which we still do not fully understand due to limited data of experiences by Canadian physicians, let alone the violence physicians may experience within their homes and in their personal lives.  

A June 2019 report to the House of Commons Standing Committee on Health highlights that “Health care workers have a four-fold higher rate of workplace violence than any other profession. And yet, most of the violence experienced by health care workers goes unreported due to a culture of acceptance.”

Physicians in particular are in a legal limbo as they are often not employees of an organization, but rather have affiliations, run their own practices, and are considered to be the employer, thus falling outside of local labour laws or duty of providing safe workplace environments when faced with workplace violence. Moreover, after being subjected to workplace violence and in a traumatized state,  physicians often have nowhere to turn for protection, thus perpetuating the impact of the original event of violence in contributing to development of mental health struggles, including post-traumatic stress disorder (PTSD).  

Aside from unclear rights and protection after a workplace violence event, physicians are often subjected to threats or actual disciplinary complaints to their regulatory colleges by the perpetrators of violence, further re-victimizing the physician victim and perpetuating the initial trauma impact.

Unpredictable interactions with law enforcement, due to variable understanding of violence experienced by health care workers, may further invalidate the physician who may want to pursue criminal charges by discouraging of criminal charges or perpetuating the myth that violence is part of our job. Unfortunately, due to lack of education and systemic supports, most of us and other health care workers almost accept that workplace violence, especially from patient interactions, is part of our job, and yet recognition of development of PTSD by physicians from workplace violence is almost non-existent. 

The Diagnostic and Statistical Manual of Mental Disorders (DSM–5) defines PTSD as “exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways: directly experiencing the traumatic event; witnessing, in person, the event(s) as it occurred to others; learning that the traumatic event occurred to a close family member or friend; experiencing repeated or extreme exposure to aversive details of the traumatic events.” Along with:  

  • symptoms of intrusion, symptoms of traumatic events (flashbacks, psychological distress at exposure of cues that resemble traumatic event, physiological reactions, etc.)
  • persistent avoidance of stimuli associated with traumatic event (avoidance of memories, avoidance of external reminders like people, places, conversations, activities, objects)
  • negative alterations in cognitions and mood associated with traumatic event (negative beliefs about self or others or the world, persistent distorted cognitions about cause or consequences of traumatic event that lead the individual to blame himself/herself or others, persistent negative emotional state – fear, horror, anger, guilt, shame, diminished interest in activities, feelings of detachment or estrangement from others, persistent inability to experience positive emotions)
  • marked alterations in arousal and reactivity associated with the traumatic event (irritable behaviour and angry outbursts, reckless or self-destructive behaviour, hypervigilance, exaggerated startle response, problems with concentration, sleep disturbance). 

We know that as physicians we are exposed to all sorts of “badness” through clinical care (for example: horrific injuries, horrific stories of abuse) that can be the “traumatic event” leading to development of PTSD — whether you are a psychiatrist providing care or the ER doctor resuscitating a victim of violence or a surgeon or OB/GYN repairing the injuries, or the family doctor providing ongoing care.  

But what about when we are threatened by patients and their families to be killed, raped, or actually are physically assaulted or stalked in real life or online, get called various obscenities or are verbally threatened, sexually harassed while we are doing a procedure, delivering a baby, or doing an in-clinic assessment? Those are also traumatic events that qualify under the DSM-5 definition of a traumatic event. Yet we have very little literature to show how workplace violence leads to PTSD and trauma-related disorders in physicians, let alone physical injuries that can be sustained in a workplace violence event, such as broken bones, head injuries, concussions or even worse — death.  

These are just some of the cases highlighting physical violence experienced by physicians in the workplace, but we rarely hear about the sexual violence or psychological violence facing Canada’s physicians daily.  

Among various physician online groups there are often panicked anonymous posts about fear of physical violence and harm, usually in the same sentence as fear of college complaints after a violent workplace event has taken place, as well as clear lack of systemic supports either within the physician’s workplace or legal system.  

Over the years, treating physicians who have been assaulted and threatened (I see the impact of workplace violence in every part of their existence) experience mental health and mood changes, including fear, suicidal thoughts, withdrawal, helplessness, shame, and changes within social functioning and family. Physicians may also experience blame by their environment, regulatory colleges, and even law enforcement that responds to an event, or the legal system that they turn to in the wake of an assault or trauma. Yet, since trauma response is not recognized within our profession as such and the development of PTSD from workplace violence, when we see an “irritable” or “angry” or “withdrawn” physician we do not consider that they may be struggling with untreated PTSD from a past workplace violence event or an ongoing violence event that is not recognized or addressed. At times, this is because the physician themselves do not recognize that it is workplace violence that they experience and do not even know how to verbalize where to seek help, or feel unsupported by their work environment in doing so. Being labelled as “difficult,” these traumatized physicians face disciplinary issues within their workplace environment or their regulatory colleges due to an “angry outburst.” 

So much of anger in general is a trauma response where anger is the tip of the iceberg of helplessness and fear. Physicians, having the same brain anatomy as other humans, will develop trauma symptoms due to workplace violence, and anger as a symptom of trauma response. Yet, unfortunately, we as a society do not recognize the impact of trauma and PTSD in physicians. Nor is it recognized in the medical community or within disciplinary committees of hospitals and regulatory colleges.

To this day, every time I look at my child that I was pregnant with when assaulted, I have the lingering memory and guilt of what my job as a physician exposed this child to and I still cannot decide what part of that experience was most traumatizing — the assault, the call from my regulatory college about a complaint resulting from this violent event, the invisibility of something so violent that was accepted as “part of my job,” the number of similar stories I hear from my physician peers daily from various disciplines, or how many physician patients I have supported and treated for similar situations where the workplace violence has been quite real and life changing.

I have considered quitting medicine as I refuse to accept that workplace violence should be a “norm,” but instead I have turned my experience of being assaulted, and then facing a college complaint, into raising awareness of workplace violence physicians face daily, the lack of systemic supports to protect and support physicians, the financial impact and lack of financial supports for victim physicians, and the lack of recognition of how workplace violence impacts physicians’ physical and mental health and their behaviour within the workplace and their personal life, and the punishment suffered by physicians for misunderstood behavioural manifestations of trauma-related symptoms. 

We also have to consider that since most physicians are self-employed — most of us have no access to paid sick leave, extended care benefits to pay for reconstructive surgery, and most private disability plans have a 90-day waiting period. If a physician is assaulted at work — we also have to pay and fund treatment of injuries sustained in the workplace environment while potentially also dealing with a regulatory college complaint by the perpetrator, further adding psychological toll of a workplace violence event.  

Our families are also not immune to workplace violence events, as I personally have been threatened with threats directed toward my family.  From my professional experience treating other physicians, and from discussions with colleagues, I know that they have experienced threats to their children and families; and, our children and families do not have protection against, or even recognition of, what they get subjected to due to our jobs. When I had to speak to the principal of my children’s school after yet another threat of physical violence toward my family being expressed by a patient, the principal was in disbelief that as a physician this is what I am subjected to, since threats to our families continue to be an unspoken and unacknowledged aspect of workplace violence and how it extends into every aspect of our lives.

Confidentiality laws pose another barrier to awareness of workplace violence faced by physicians and health care workers, especially when there is a physician-patient relationship which poses limits on information-sharing or physicians discussing their workplace violence experiences aside from limited comprehensive research on this issue.  

Aside from workplace physical violence resulting from patient interactions, sexual harassment and psychological violence experiences are paramount in how physicians experience their workplace. Sexual violence by patients toward physicians — especially female physicians, with unsolicited comments, threats of sexual violence, assaults and stalking online and in real life — paired again with a possibility of lack of support by the workplace, college complaints, or an unpredictable response of the legal system, is a real but invisible occupational experience for physicians that contributes to trauma-related and PTSD manifestation. Sexual violence by colleagues, managers, or immediate supervisors toward physicians is also another contributor that needs to be studied further. 

As we discuss workplace violence we have to acknowledge the lack of power and helplessness physicians experience when facing workplace violence, especially when physicians and physicians-in-training are in a systemically entrapped and vulnerable position, such as medical students, residents, or foreign-trained doctors employed on conditional and restricted license. Medical students and residents depend on their immediate supervisors for action after a workplace violence event, but supervisors themselves often have little knowledge or practice in addressing workplace violence. Or if workplace violence involves a peer or a supervisor, addressing such an event could cause future career ramifications for these learners since, in medicine, to progress across learning stages and career, depends on subjective evaluations and reference letters.

Physicians who are brought in from abroad on restricted conditional licenses may feel more helpless and fearful. These physicians may not address a workplace violence event for fear of losing their job, conditional medical license, and immigration status in Canada after they relocated their families and have limited social supports as it is, given their relocation from their country of origin.  

Violence experienced by physicians within their homes and personal relationships is also poorly understood, as we often do not picture intimate partner violence (IPV) when we hear the word “doctor.” We accept the myth that it doesn’t happen to “educated people like us.” We fail to recognize violence experienced in childhood that leaves a life-long impact on the physician, or assaults from physicians’ adult children and other family members.

We may be educated on how to screen and support our patients on experiences of IPV, but we often do not see that our colleagues, our students, or we could be abused within personal relationships. There is the intense shame physicians experience to even consider that we are abused, or to admit the abuse, as well as the perceived and real judgment that we may experience if we do admit the abuse, with invalidation and potential professional impact of such a disclosure.

The tragic death of Dr. Elana Fric at the hands of her physician husband in 2016 brought the intimate partner violence experienced by physicians to our awareness. But therapists and psychiatrists who treat physicians have contained that devastating aspect of physicians’ lives in the confidence of our offices for years. This paramount contributor to physician well-being continues to stay hidden, yet influences our mental health, our ability to function at work, suicide rates, and possible disciplinary issues (such as when the abuser threatens or lodges complaints to the hospitals or disciplinary colleges with various unsubstantiated complaints to cause further psychological violence and harm after a relationship ends).

In my practice, when discussing IPV with physicians, I constantly hear “how could I have not seen this?” “I am educated, how could have I fallen for this person?” “This isn’t so bad.” I hear about various physical assaults toward physicians by their fathers, mothers, and children that they do not seek help due to shame. They hide the injuries that, at times, can be life-threatening like broken bones and choking. I have called the Children’s Aid Society more than once while treating my physician patients due to safety concerns and abuse they are living with daily. Those are not the images we conjure when we think of the word “doctor,” yet this is reality for many physicians around us. 

With events in the news about violence against physicians that has led to injury and death, the growing unification of physicians in accepting the need to address violent experiences, and the increased understanding around trauma and PTSD manifestations, we — as a medical community must unite and support each other in acting against violence experienced by physicians. The time to understand and act is now. Please join us. For more information, please send your comments to Dr. Maryna Mammoliti, Chair, OMA Section on Psychiatry, at info@oma.org.

Dr. Maryna Mammoliti is a psychiatrist who splits her time between London and Toronto, practicing comprehensive psychiatry with a focus on psychotherapy, physician health, ADHD, developmental trauma and PTSD. Dr. Mammoliti is Chair of the OMA Section on Psychiatry and provides Teleconsulting and Psychiatry ER shifts at Toronto’s Centre for Addiction and Mental Health (CAMH). She is dedicated to promoting physician wellness by building awareness and systemic changes as well as building a more validating, compassionate, non-judgmental medical community with real supports available to physicians, and challenging the shame-based culture from medical students to practicing physicians. Dr. Mammoliti considers her best teachers to be her four young children, who daily provide opportunities for her to practice her leadership, multi-tasking, organizational, social, and emotional regulation skills.