Matrix of Clinician Distress - Part 6 – Discrimination, Harassment, and Medicine's Bully Culture
Three prominent but seldom explored dimensions of clinicians' matrix of distress.
We continue our exploration of the matrix of clinician distress here in Part 6 with an examination of the seldom explored undercurrent of discrimination and harassment and the cultures of healthcare institutions and of medicine as a whole.
Organizational & Sociocultural Stress – Discrimination, Harassment, and the Bully Culture of Medicine
The essence of discrimination is "you're defective, you're different, you're inferior, you don't belong here.” It doesn't take advanced training in mental health to comprehend the powerfully detrimental impact on the individual who is subjected to such a mindset.
The discriminatory focus can be one of several; often multiple discriminatory components are present at the same time as detailed below.
The Long History of Racism in Our WASP Culture
White v. Non-white (i.e. everybody else)
This demarcation with its arbitrary boundaries has been in existence since the earliest days of our country when European explorers began colonizing North America and wresting away lands from our indigenous peoples, Native Americans. The history of the transcontinental slave trade is parallel to that colonization. And as has been eloquently explained in contemporary writings that have become more prominent in the context of the Black Lives Matter movement, we are only beginning to appreciate the insidious and pervasive effect of hostile discrimination against those determined to be "non-whites."
This hostile racial discrimination has permeated our thinking as a society and affected all of our educational and healthcare institutions.
Despite the noble cause of ending slavery and granting freedom to all, independent of their color or national origin, the hideous legacy of that overt racism persisted up until the seminal US Supreme Court case Brown vs Board of Education in the ‘50’s and President Johnson's administration a decade later.
And even though that was nearly 70 years ago, the pervasive effects of racism have persisted. It really wasn't until the recent George Floyd police brutality case and the emergent Black Lives Matter movement that people’s attention was garnered toward the inequitable punishment that those who are non-white suffer at the hands of various governmental agencies – in Floyd’s case police departments.
Nevertheless, racial prejudice persists not only in medical education but in postgraduate training and in practice opportunities. Black (African-American) physicians have suffered this hideous discrimination throughout their training. Stories abound of the second-class treatment and lack of respect these physicians are subjected to in their clinical rotations and as PGYs.
It would represent willful negligence if we continue to ignore the immense effect of that omnipresent stress on one who is subjected to racial discrimination.
Like racial discrimination, we also harbor a variety of ethnic and cultural prejudices. Of course, this article is not intended to be a comprehensive overview of racial and ethnic discrimination. It is simply to name the reality that those of a non-native national origin and those who may come from a nation or culture whose traditions are foreign to us may experience immense stress from being discriminated against solely on these grounds. Given that we as a nation seem to have committed to an endless war, those nations and ethnicities that we have been at war with are considered our enemies. And therefore the carryover prejudicial effect toward all who come from such nations and cultures is that they are treated with suspicion and disdain. This discriminatory mindset is seldom based on clinical competency but stems from prejudices toward their religious/cultural beliefs and practices.
Amongst the prominent biases manifested are those against people coming from certain cultures, e.g. Middle-eastern, Asian, Indian, Latino, African and Native American.
The Boys Club of US Medicine
“It’s Our Treehouse – ‘No Gurlz’”
It's been well-established that American medicine has from time immemorial been a boys’ club. Of course, that gender prejudice has not been limited to medicine but pervades all of science and, for that matter, all of civilized life in the United States. While we are not here trying to examine the complex social history that has led to this prevailing prejudice, suffice it to say that it has been a dominant strain in our medical cultural thinking. The good news is that a variety of forces have coalesced to change that dynamic.
The Anti-female Strain
Operating an exclusionary boys club is one thing. Being hostile to women in diverse ways is another. To use the race metaphor, it's one thing not to be able to join an all-white country club because you are not white. It's another thing to be stalked and abused because you are non-white. So too with gender. There are a range of misogynistic attitudes and behaviors from the more ”benign” mentality holding (with no basis) women as inferior and not belonging in medicine to active misogyny in which women are treated inferiorly, passed over for promotion, or actively diminished in some concrete way.
Manifestations of both of these dynamics - attitudinal misogyny and active misogynistic behavior - vary significantly across the country. And there are certain areas where both are powerfully present.
Similarly, heterosexual orientation and marriage have been the prevailing norm both in medicine and in US culture generally. More recently, progress has been made in understanding and accepting the diversity of sexual preference orientation. Medicine as a profession has been slow to incorporate these changed attitudes. Anti-gay bias persists.
While not per se a form of discrimination, like elsewhere in society and especially in closed societies such as the military, police, and medicine, sexual harassment and sexual assault are a prominent problem, its primary manifestation being the male to female variety.
And in the environment of a bully culture, also predominantly male, the pressure to remain silent, to “normalize” the behavior, and to even fail to report overt sexual assault for fear of not being taken seriously or fear of adverse career consequences, is pervasive.
While we’ve witnessed the powerful effect of the #MeToo movement, even it is still suffering from pushback. And while the general civilian and governmental workforce may - may - afford more protections for those who may be harassed, I suspect the same protections don’t carry over to closed groups (e.g. medicine) and thus there are less disincentives to prevent the harassment behavior. Thus, it flourishes.
As mentioned previously, these articles in this clinician distress matrix series are not intended to give definitive treatment to each of these distress contributors.
Suffice it to say, if you are in the unfortunate if not dangerous position of being one subject to such harassment, this degree of omnipresent baseline stress can create an awesome burden that is almost invariable borne silently. Combine this with any other stress syndrome and clearly the adverse effect is beyond simply additive.
Elitism - Discrimination Based on Where You Trained or Your Socio-economic Status
While there is diversity in the quality of education received across the US, there tends to be a significant prejudice toward those who have attended non-US-based medical education facilities. Thus, despite passing all requisite qualifying examinations, generalizations are often made about the competency of undergraduate training of certain groups of people based upon where they trained and not on the basis of their actual academic and skills achievement. Likewise, those entering professions from a less-privileged background made be subjected to implicit biases that add to their stress load.
Suspicion abounds about those who have non-Christian belief systems.
Mirroring society, medicine has been predominately WASPy. The acronym stands for White, Anglo-Saxon, and Protestant (a Christian sect). As you can see on closer examination, this is quite a package. It contains racial, ethnic, and religious components.
Those of a non-Christian religious orientation have been greeted with suspicion if not overt disdain. This prejudice, often handed down within one’s family or community of origin and rooted in ignorance about the core beliefs of other religions, persists. The prevalence of anti-Jewish and anti-Islamic sentiment has seeped into the culture even where members of that majority culture don't actually practice Christianity or for that matter any sort of organized religion.
It is truly ironic that little such suspicion is directed toward those who are non-practicing, or toward agnostics or atheists.
Our society has become infected with political polarization which is often accompanied by the breakdown in respectful rational dialogue. So too, to some extent, these influences permeate US medicine. And just as in the larger society, we don’t seem to know how to bridge this gap.
Here as in so many other of these challenges, the healthcare institutions and medical societies themselves must play a significant role in confronting these prejudices.
The Bully Culture of Medicine
It is no great revelation that a “survival of the fittest” mindset has permeated US medicine. In an earlier era when medicine was an esteemed profession and its career opportunities promised a well-rewarded lifetime job accompanied by both social prestige and coveted income, the rigors to get into med school and then a desirable residency were significant. So too the striving to position oneself to get into a desirable practice setting. To accomplish these, you had to prove your mettle. In the process, institutions set rigorous standards, accompanied by an almost boot camp survival mentality enforced by drill sergeants in white coats – your professors and attendings – who held control over your advancement.
Despite the changed status of physicianhood, being significantly less esteemed by the general population and offering fewer rewards (but considerably more demands), the bully culture still operates. Hospital and corporate group practice politics still attract those who know how to play the game and achieve their business objectives at all costs. And unfortunately, as is seen elsewhere in the competitive corporate world, such a role may attract some whose narcissistic style fosters a toxic leadership mindset. Toxic leadership enables a toxic culture, one where bullying and a spirit of meanness predominates.
You see this in numerous settings: the interaction between the non-MD MBA-style healthcare leaders and the medical staff; the medical leadership of a high-powered practice group and its members; the physician-midlevel and physician-nurse tension, to name but a few.
Of course, the effect of such a cultural mindset seldom contributes to people’s wellbeing … that is, except for the bullies and their cronies who are running the show.
Two notable areas where this bully culture is on full display are to be found in the medical regulatory arena.
Sham Peer Review and Sham Performance Appraisal
In the prior article on the MRTC, we referenced the stress of dealing with state medical boards, physician health programs, and privilege-credentialing entities.1
There are pockets of unethical players in medicine who may resort to a bullying tactic to rid themselves of a colleague whom they do not wish to have on their staff. One vicious tactic that is used is that of a sham peer review alleging that the physician’s care is deficient in some way.2 A similar tactic is used in training institutions where the process is referred to as an annual performance evaluation. Such performance reviews are not only conducted on PGYs but faculty as well, and can be used in a hostile manner to thwart advancement and to disparage one’s reputation. Outside of the medical profession, in both, the ethics and integrity of the evaluating entity are presumed to be upstanding and they are given great deference, including in the administrative and civil courts. However, as is well documented, there is little to no oversight of these processes, and individual clinician appeals, even with counsel, are generally futile. Thus, the wisdom of reliance on fairness and integrity in these settings is increasingly questionable. Needless to say, the stress one experiences when subjected to a sham peer review process is extraordinary, compounded further by the cost of retaining sufficiently knowledgeable counsel to try to protect one’s rights.
Sham Fitness-for-Duty Evaluation
With the rise of the so-called “physician health program” movement (one which seems to have had a genuinely benevolent origin) and its close ties with licensing and credentialing authorities, a deeply disturbing trend is emerging. Sham mental health evaluations performed by these exclusively contracted PHPs under the false designation of fitness for duty or psychiatric assessment are subjecting untold hundreds if not thousands of physicians yearly to such invasive evaluations which deprive them of their civil rights and also mark them as “damaged goods” for the remainder of their careers. This movement, organized as a non-profit federation that has no ethical charter holding its members responsible for compliance with ethics or law, operates with utterly no oversight or legal accountability. This is especially worrisome as, due to their often secretive contracting, member PHP organizations operate as an exclusive “fitness for duty” evaluator for nearly all state medical boards which themselves operate virtually untethered from governmental oversight and enjoy near-total immunity. The combined absence of oversight and accountability and invariably deferential treatment by civil courts are a rich medium for insider dealing and unfairness, if not overt corruption.
Having interviewed at length well over 500 physicians, I can attest to the profound abuses of due process that have occurred and, in many cases, the falsity of the pseudo-legitimate mental health evaluation findings which are presented as definitive to the MLB. These legitimate-sounding findings are then used to justify mandatory MLB referral to a “preferred” evaluation center whose four-day multi-person evaluation process, often assisted by polygraph interrogation, costs upwards of $10,000. The findings from that non-neutral and non-peer-reviewed process may then be used to enable the state MLB to order that physician into an unusually prolonged “treatment,” again at yet another “preferred” program. The term is a bit of a crafty euphemism as one is forbidden from going to any other than one of the “preferred,” i.e. in-network, privately-owned proprietary, programs that the PHP and MLB have designated. That this quasi-state agency is allowed to operate in such a non-overseen unlawful manner and to harm so many physicians while infallibly diagnosing them with any variety of mental or substance-abuse related conditions while depriving them of their rights to contest such a bogus process continues to boggle the mind.
I guess it should come as little surprise that anyone subjected to such a heinous human rights violation which also threatens to end their careers and their livelihoods causes not only extreme stress but embeds the virtually irreversible bitterness of moral injury.
And lastly, but certainly not least important, it's essential to note that there is a pervasive underlying dynamic in medicine that has been hostile toward those with any sort of perceived imperfection or “disability.” Sometimes it seems as though American medicine has not yet become aware that discrimination in employment on the basis of disability is explicitly prohibited. But evidence exists that MLBs are well aware of the Americans With Disabilities Act (ADA) and its prohibitions against discrimination on the basis of preconceived job incapacity due to stereotyped notions about impediment or “alter-ability”, be it physical or mental.3
Significant barriers to full engagement prevail throughout much of US medicine. While one generally imagines disability as a physical limitation, there is also a powerful discriminatory animus towards those who have experienced emotional illnesses and addiction. Stereotypical beliefs are often applied to those who have had a history of depression or substance abuse and who are in recovery.
Disturbingly, almost 50% of state medical licensing boards still demand answers to invasive questions about physician licensees’ mental health and substance abuse history on their licensing applications. These questions are clearly impermissible under the ADA as demonstrated by numerous court decisions. Nevertheless, due to nearly complete failure of action by state government and by medical societies which should be demanding comportment with federal and state law, these impermissible questions continue to be asked.
But what many do not understand is that it is not simply the impermissibility of the questions that is problematic, as intrusive as they are and prone toward lack of confidentiality protection. It is what happens to the licensee after they have answered in the affirmative about any of these matters. They are generally referred for non-neutral discriminatory “evaluation,” customarily at the MLB's exclusively contracted PHP which conducts a “screening” assessment and then makes a determination of (or conjectures as hypothesis) an illness or impairment which then, via its “recommendation” to the MLB, itself a virtual board order, subjects the physician to costly if not bankrupting hurdles to prove their non-impairment.
“Res ipsa loquitur” (“the thing speaks for itself”) best sums up the rights violations this comprises. As referenced previously re sham performance appraisal, sham peer review, and sham fitness for duty assessments, the psychological distress resulting from such a process is itself likely magnitudes more harmful than whatever alleged condition might have prompted this witch hunt, if indeed any existed to even warrant initiating such.
One can reasonably predict that anyone subjected to such a combined civil and human rights violation, one which also threatens the viability of their careers and entire livelihoods on the falsely contrived, due process-denied basis of mental or addictive illness impairment will suffer the physical and mental consequences comparable to that of sustained life-threatening stress. And given the multi-component betrayals of fairness and the complicity via silence of organizations that should have advocated, indeed demanded, accountability and fairness, the toxic bitterness and psychological retreat from life that are the hallmarks of moral injury compound the distress even further.
Underlying and fueling much of this diverse discrimination is a prevalent bullying mentality rooted in anger. This bullying dynamic, so often interwoven with narcissistic psychopathy, seldom pertains to legitimate enforcement of the rigorous standards of medicine and public safety. Rather, it seems this permeating undercurrent of hostility is often selfishly motivated, pompously judgmental, and anti-competitive, driven by a craving for the acquisition and exertion of power and the attainment of both economic advantage and prestige. Yet again, this malignant dynamic mirrors that which is going on in society as a whole.
US Medicine Is At A Major Crossroads
As we’ve seen in the articles comprising this series, while “burnout” is a most timely and useful construct to help mobilize all within healthcare around endorsing a healthier culture of medicine, it’s become a catchall term. And though a convenient conceptualization, the connotation that it captures all that’s causing clinician distress is a dangerously flawed one.
Numerous separate stress phenomena are resulting in their own unique stress response syndromes, each with a characteristic array of symptoms. And the various mental, physical, and behavioral manifestations of each often share syndromic manifestations with the burnout stress syndrome. And they also add to already-existent burnout’s symptom array. Just as in complex illness when multiple pathological processes are co-occurring and require their own treatment, so too with clinician distress. Ignoring the concurrence of these does a dual disservice: the burnout remedy is doomed and thus remains disabling; and the concurrent stress syndromes, e.g. moral injury, PTSD, mood disorder et al., remain unaddressed and thus leave the clinician in a state of progressively wearying distress.
And as we in clinical medicine all well know, the deleterious effect of the persistence of untreated illness is not due just to that organ system’s diminished function. The patient suffers a progressive whittling down of compensatory resources which, when depleted, accelerate the decline.
We are at a major crossroads in US medicine, as both an economically via profession responding to a societal need and as a profession of expert and compassionate healers whose training comes at great effort.
The composite distress afflicting our clinicians has to be comprehensively addressed if we hope to maintain a viable healthcare profession. I believe the time is ripe for a radically honest discussion about the current dynamics that define the culture of medicine, both as exist now and as we wish to create.
However, it may take even further distress before the medical community as a whole is courageous enough to lay down on the analyst’s couch and explore these deep-seated dysfunctional currents which thwart its wellbeing.
In part 7, the last of the Clinician Distress Matrix series, we’ll recap some key themes and explore some potential approaches.
Please know that articles in this series are also available as podcasts that generally follow the text of the article. Simply look for the headphones icon in the table of contents.
"Systematic Abuse And Misuse Of Psychiatry In The Medical Regulatory Therapeutic Complex" [http://www.jpands.org/vol23no4/emmons.pdf]
See: THE MEDICAL SOCIETY OF NEW JERSEY, Plaintiff, v. FRED M. JACOBS, M.D., J.D., and the NEW JERSEY STATE BOARD OF MEDICAL EXAMINERS, Defendants. Case No.: 93-3670 (WGB)