témoignage / perspective

Ending Toxicity: A Call to Reintroduce Constructive Discourse About Contentious Health-Related Issues in Medicine

Jocelyn Downiea

Résumé

Abstract

Il existe un phénomène inquiétant de médecins qui attaquent violemment d’autres médecins lorsqu’ils ne sont pas d’accord avec eux sur des questions litigieuses liées à la santé. Ces attaques peuvent avoir des conséquences négatives importantes sur les soins aux patients, le bien-être des médecins et les politiques publiques. Une réflexion et des réponses à ce phénomène sont nécessaires.

There is a disturbing phenomenon of physicians viciously attacking other physicians when they disagree with them on contentious health-related issues. Such attacks have significant potential negative impacts on patient care, physician well-being, and public policy. Reflection on and responses to this phenomenon are needed.

Mots-clés

Keywords

éthique professionnelle, abus de pouvoir, professionnalisme, enjeux professionnelles et éthiques

professional ethics, abuse of power, professionalism, professional and ethical issues

Affiliations

a Faculties of Law and Medicine, Dalhousie University, Halifax, Nova Scotia, Canada

Correspondance / Correspondence: Jocelyn Downie, jocelyn.downie@dal.ca

There is a disturbing phenomenon of physicians viciously attacking other physicians when they disagree with them on contentious health-related issues. Such attacks have significant potential negative impacts on patient care, physician well-being, and public policy. This issue got a fair amount of attention during an ugly fight over the issue of negotiations between the Ontario Medical Association and the provincial government in 2017 (1). Offensive and threatening emails and social media were sent/posted by physicians targeting other physicians. The attacks were condemned, and some physicians were disciplined (2). However, attacks are still being made.

Noting the toxicity of the debate about gender identity services for children and youth, the 2024 Cass Report stated “There are few other areas of health care where professionals are so afraid to openly disclose their views, where people are vilified on social media and where name calling echoes the worst bullying behaviour. This must stop.” (3) “Five things to know about… Physician incivility in the health care workplace” published in 2024 in the Canadian Medical Association Journal reported that “Prevalence varies and is likely underreported owing to nonstandardized definitions and heterogeneous behaviours. More than 75% of health care employees [nurses, physicians, administrative executives, and “other”] have witnessed uncivil behaviour from physicians, and 31% of physicians report receiving weekly or daily rude, dismissive or aggressive communication from other doctors.” (4)

While happening beyond psychiatry, an illuminating case in point is psychiatrists and the issue of medical assistance in dying (MAiD) for persons with mental illness. The debate concerning access to MAiD by persons with mental illness has been a contentious one, politically, publicly, and professionally. Sometimes, the attacks occur in private. In an email, one psychiatrist opposed to MAiD for persons with mental illness compared another to Himmler – complete with the label “architect” invoking Himmler’s role as architect of the “Final Solution” (the genocide of six million Jews during the Holocaust) (5).

Unfortunately, this is increasingly occurring in public. One psychiatrist, because of what she had written about MAiD where mental illness is the sole underlying medical condition, was explicitly and by name analogized to the self-styled “QAnon Shaman” – complete with a photo of her, the QAnon Shaman, and the noose erected at the US Capital. She had said “[o]ne of my concerns is that too many psychiatrists are using all their energy to try and re-legislate Bill C-7, rather than contribute to the development of guidance, protocols and safeguards during the two-year period before individuals who meet the request for MAID solely on the basis of mental illness.” (6) For this she was linked to QAnon generally – a “decentralized, far-right political movement rooted in a baseless conspiracy theory that the world is controlled by the ‘Deep State’, a cabal of Satan-worshipping pedophiles, and that [then] former President Donald Trump is the only person who can defeat it.” And she was analogized to the QAnon Shaman specifically — an individual who described himself as a shaman, dressed in what he took to be shaman-like garb, and was sentenced to 41 months in jail for his part in the January 6 insurrection (7). Her work was linked to an attack on the US Capitol and an indirect threat against the life of the Vice President of the United States:

I want to point out that I don’t know her. I have heard her speak, she seems like a lovely person, I bet that she is a really nice clinician but I think that she is really wrong in terms of her understanding of this scenario and, it’s a bit terrifying for me because she doesn’t look like a QAnon Shaman even though I experience her somewhat in that way. … So the way that I understand this is essentially as someone who has bypassed science, who has taken a baseball bat and broken into the Capitol Building and is reaching out their hand and saying, “Come on, we are in already, help us do this the right way.” (8)

This statement was made by a psychiatrist giving Grand Rounds at a major teaching hospital (Grand Rounds is a regular academic presentation for all members of a department and for which attendance and participation is expected). The video of that Grand Rounds was subsequently shared (with encouragement to view it) by another psychiatrist to approximately 250 mental health professionals attending online Grand Rounds at a teaching hospital in another city.1

Most recently, a psychiatrist said that another psychiatrist was, in presenting their views on MAiD, “selling a bit of snake oil.” (9) This happened at a Parliamentary Committee hearing, broadcast nationally, and preserved for posterity in the (publicly accessible) videorecording and transcript of the hearing. The psychiatrist also posted a link to his testimony on his X account on February 14, 2024. Within the provision of medical care, “selling a bit of snake oil” has a long history as a demeaning slur. “Snake oil salesmen” were unqualified hucksters, fraudulently peddling worthless pseudo-medical remedies, motivated by profit rather than a desire to help others (10). The psychiatrist’s very public statement insults and demeans the other psychiatrist by using a well-known slur that maligns their qualifications and insinuates that they are not motivated by the desire to help others but rather by personal gain.

But why does any of this matter? Shouldn’t these physicians just ignore the name-calling? Get a thick skin? Accept it as the price of engagement in public debate about contentious issues? I don’t think so, for two main reasons.

First, this behaviour harms patients when physicians say these things publicly and their self-regulatory bodies do not make public statements telling them and others in the profession that such behaviour is wrong. As noted by the Ontario College of Physicians and Surgeons in its Policy on Professional Behaviour: “Unprofessional behaviour impacts patient care and outcomes through the negative effects it can have on the physician-patient relationship, teamwork, a safe working environment, communication, public trust, and morale.” (11) Just imagine being a patient of one of the attacking psychiatrists and wanting to get information about MAiD for mental illness. Would you feel safe to ask? Just imagine being a patient being referred to the psychiatrists analogized to the QAnon Shaman or a snake oil salesman. Would you be comfortable seeking care from them?

The profession and its ability to care for patients are diminished by physicians launching toxic public attacks on other physicians.

Second, this behaviour leads to the loss of key voices in important public debates. Most directly, other physicians, especially but not only those at the beginning of their careers and not yet secure, will stay silent rather than risk public attacks of this sort, especially when launched by senior powerful physicians. Furthermore, people with mental illness as their sole underlying medical condition who want the option of requesting MAiD now or in the future may also stay silent after witnessing such attacks, understandably thinking, “if respected psychiatrists can be publicly attacked this way, what will happen to me if I speak out?”

Public policy is harmed if people cannot participate in public dialogue without facing toxic attacks by physicians.

Physicians should care about the impact of these attacks on the reputation of their profession and the harms to patient care that follow an eroding of this reputation. Physicians should care about their country being able to have constructive conversations about complex health-related issues and the ability of the medical profession to contribute to policy-making by ensuring it is informed by the full range of opinions and perspectives. Attacks like those described above can interfere with patient care and sound public policy. It’s past time for respected leaders in the profession as well as the physician regulatory bodies in all countries to enforce standards of professional behaviour and issue statements condemning these attacks and explaining why they need to stop.

Reçu/Received: 08/11/2024

Publié/Published: 28/04/2025

Conflits d’intérêts

Conflicts of Interest

Aucun à déclarer

None to declare

Édition/Editors: Hazar Haidar & Aliya Affdal

Les éditeurs suivent les recommandations et les procédures décrites dans le Core Practices de COPE. Plus précisément, ils travaillent pour s’assurer des plus hautes normes éthiques de la publication, y compris l’identification et la gestion des conflits d’intérêts (pour les éditeurs et pour les auteurs), la juste évaluation des manuscrits et la publication de manuscrits qui répondent aux normes d’excellence de la revue.

The editors follow the recommendations and procedures outlined in the COPE Core Practices. Specifically, the editors will work to ensure the highest ethical standards of publication, including: the identification and management of conflicts of interest (for editors and for authors), the fair evaluation of manuscripts, and the publication of manuscripts that meet the journal’s standards of excellence.

references

1. Boyle T. Ontario doctors ‘distressed’ over wave of bullying, infighting. Toronto Star. 27 Feb 2017.
   2. Dunham J. Ontario doctors disciplined for sending profane e-mails to medical association head. CTV News. 28 Jun 2018.
   3. Cass Review. Independent Review of Gender Identity Services for Children and Young People: Final Report. NHS England; Apr 2024
   4. Murray H, Gillies C, Aalamian A. Physician incivility in the health care workplace. CMAJ. 2024;196(9):E295
   5. E-mail, January 27, 2023. [on file with the author]
   6. Stewart D. Discussing medical assistance in dying and mental illness in Canada. Department of Psychiatry, University of Toronto. 21 Sept 2021.
   7. ADL. Backgrounder: QAnon. Anti-Defamation League; 28 Oct 2022.
   8. Sinyor M. Fiasco: The anti-scientific origins of canada’s new physician assisted death law and implications for psychiatric (mal)practice. Sunnybrook Health Science Centre Department of Psychiatry Grand Rounds. 19 Nov 2021. [Recording on file with author]
   9. House of Commons, Canada. Standing Committee on Health. Testimony of Dr. Sonu Gaind. Number 102, 1st Session, 44th Parliament; 14 Feb 2024.
  10. Collins Online Dictionary. Snake oil.
  11. CPSO. Professional behaviour. College of Physicians and Surgeons of Ontario; Nov 2007/Sept 2024.

1. Comments made and link posted by Sonu Gaind in the online chat during presentation by Grainee Neilson, McMaster University Department of Psychiatry and Behavioural Neurosciences Grand Rounds, November 24, 2023. “Dr. Sonu Gaind: wrt evidence, I encourage you to watch Dr. Mark Sinyor’s grand rounds on scientific evidence and MAID [link].” [Transcript on file with author]

## Références

1Boyle T. Ontario doctors ‘distressed’ over wave of bullying, infighting. Toronto Star. 27 Feb 2017.

2Dunham J. Ontario doctors disciplined for sending profane e-mails to medical association head. CTV News. 28 Jun 2018.

3Cass Review. Independent Review of Gender Identity Services for Children and Young People: Final Report. NHS England; Apr 2024

H, Gillies C, Aalamian A. Physician incivility in the health care workplace. CMAJ. 2024;196(9):E295

5E-mail, January 27, 2023. [on file with the author]

6Stewart D. Discussing medical assistance in dying and mental illness in Canada. Department of Psychiatry, University of Toronto. 21 Sept 2021.

7ADL. Backgrounder: QAnon. Anti-Defamation League; 28 Oct 2022.

8Sinyor M. Fiasco: The anti-scientific origins of canada’s new physician assisted death law and implications for psychiatric (mal)practice. Sunnybrook Health Science Centre Department of Psychiatry Grand Rounds. 19 Nov 2021. [Recording on file with author]

9House of Commons, Canada. Standing Committee on Health. Testimony of Dr. Sonu Gaind. Number 102, 1<sup>st</sup> Session, 44<sup>th</sup> Parliament; 14 Feb 2024.

10Collins Online Dictionary. Snake oil.

11CPSO. Professional behaviour. College of Physicians and Surgeons of Ontario; Nov 2007/Sept 2024.