A damaging wave of cyberbullying and intimidation is sweeping through the ranks of Ontario doctors, complete with obscene emails, threats against each other’s medical careers and refusals to take patient referrals from adversaries.

Although experts say bullying has always been a problem in medicine, in Ontario it has escalated since last summer’s failed ratification vote over a proposed deal between the government and Ontario Medical Association, which represents the province’s 34,000 doctors and medical students.

The problem has grown even harsher since the sudden decision by the OMA executive to resign en masse following a vote of non-confidence by the group’s 260-member elected council last month.

“I have not heard anything like this before to this degree,” said Dr. Sharon Straus, vice-chair of the department of medicine at the University of Toronto and a researcher in the area of bullying within the profession. “It makes me sad, ashamed and distressed.”

She said the perpetrators of unprofessional behaviour are a minority among physicians.

The targets are mainly doctors who opposed the move last month to oust the OMA executive team and who voiced support for last summer’s tentative deal between the province and OMA. They range from the youngest in the profession — students seeking training positions in hospitals and universities — to those at the top, including past OMA president Dr. Virginia Walley.

Walley served at the helm of the organization during one of the most tumultuous periods in its 136-year history until her resignation this month. She and the rest of the six-member executive resigned a week after the OMA’s council passed a non-confidence motion against them. (Votes on motions to force each member of the executive to step down failed.)

The Star has learned that dozens of disturbing emails were sent to Walley via the OMA. They include this misogynistic one from a southwestern Ontario anesthesiologist sent shortly before last August’s ratification vote:

“You are a c---. Crash and burn as you deserve to do!! This will be a NO vote and the end of the OMA. Sincerely, F--- YOU and the OMA!!!”

Walley has registered concerns about a handful of the emails with the College of Physicians and Surgeons of Ontario, the regulatory body.

Another physician involved with the OMA, someone who has participated on a negotiations committee for the association, has been a target through abusive phone calls, the Star has learned.

“I hope none of your patients need to come here to have any kind of investigative radiology done,” a radiologist yelled at this doctor.

This doctor also received a threat over the phone from a Toronto family physician: “You don’t know what you are doing and you are going to pay for this. You hate doctors and must have it out for doctors. You will never work in leadership again.”

(Many of the doctors targeted for the abuse and cyberbullying provided evidence and talked with the Star only on the condition they not be identified publicly for fear of further abuse.)

Straus says the body of literature about unprofessionalism in medicine is substantial. A 2014 analysis of 60 international studies led by a medical student working with her research team found more than half of physicians have experienced bullying, mostly through verbal harassment and mostly directed at junior doctors or medical students by senior doctors.

Social media exacerbates the problem, Straus says.

Patients can be affected if doctors are bullied to the extent they become stressed, suffer PTSD, quit their jobs or even abandon the profession, she warns.

Patients pay the price if doctors cannot work together, Straus says, explaining that health care is increasingly provided by teams of professionals working collaboratively.

Unprofessional behaviour also jeopardizes patients’ trust in their doctors, Straus says, noting that medicine is one of the most trusted professions with patients confiding the most intimate details about their bodies and lives.

Unless addressed, the problem perpetuates itself, affecting the next generation of doctors, she warns.

Some of the ugliest attacks have been directed at St. Michael’s Hospital family physician Dr. Philip Berger over the past month on the members-only Facebook group, Ontario Doctors Discussion Forum.

In response to an opinion piece and letter to the editor that Berger wrote for the Star in which he offered his take of what’s behind all the feuding, other physicians have diagnosed him with mental health problems and suggested drug treatments.

Toronto family doctor Geoffrey Forbes wrote that Berger needed a sedative: “Whew. lorazepam 0.5 s/l stat over here please.”

Forbes did not respond to interview requests left with his practice or at Humber River Hospital, where he also works.

Dr. Ira Bernstein, also in Toronto family medicine, wrote Berger needed a stronger drug, an antipsychotic: “Ativan won’t be enough. Clopixol needed. This is clearly Psychosis.”

Bernstein did not respond to interview requests left with his practice or with Humber River Hospital and the University Health Network, where he also works.

Alliston family physician Dr. Oswaldo Ramirez piled on in Spanish: “Coño hijo de puta anda a chupar Berger. (Translation: F--- you son of a whore. Why don’t you go and suck Berger.) Sorry. Couldn’t hold that rant back. I revert to my native tongue when mad.”

Forbes also wrote this about Berger on the Facebook page: “RT = gathering the wolf pack to go hunting. Berger is the target here.” (“RT” refers to “retweet,” which is how messages spread on Twitter.)

A reporter tried to reach Ramirez through the media relations department at Stevenson Memorial Hospital where he is a staff physician, but heard back instead from his boss.

“Stevenson Memorial does have a policy that prohibits this very kind of activity on social media,” said the chief of staff, Dr. Barry Nathanson, adding that a senior team would be taking up the issue with Ramirez.

“Dr. Berger is entitled to express his views, as we all are, without vulgar responses, public or private, from anyone. As a physician myself, I am embarrassed that any colleague would conduct themselves in a manner which lacks the dignity and professionalism that medicine is based upon,” Nathanson added.

Berger said he is astounded such conversations are allowed to happen on the Facebook forum and charged that a vocal minority is trying to silence anyone who opposes them:

“The doctors’ language is far worse than the profanities I heard when I worked as third cook for the Canadian Pacific Railway in 1969. That was a rough place to work and the workers never swore at each other or name-called.”

Former deputy health minister Michael Decter says medical politics aren’t for the faint of heart. He took his share of slings and arrows after the 1991 agreement was reached between the province and OMA.

“Medical politics doesn’t bring out the best in people,” said Decter, currently chair of Patients Canada.

“There are huge, internal battles within the association among the various sections and some of those involved feel very entitled and are willing to make extreme threats and use unpleasant and foul language,” he explained.

Medical politics in Ontario have become so dirty that a police report was filed about false email accounts being set up last summer in the name of an OMA board member who was in favour of the proposed agreement with the province, Toronto police confirmed. Emails were sent out from the accounts to physicians around the province, saying the board member was opposed to the deal and urging them to vote against it.

Dr. Cathy Faulds, a former president of the Ontario College of Family Physicians and a professor at Western’s medical school, said bullying deters many doctors from getting involved in the OMA and medical politics.

“The intimidation and bullying discourages people from becoming leaders in the province,” she said.

There are currently elections underway within Ontario’s medical profession to fill vacant seats of the OMA’s governing council and board of directors.

Faulds says that most family physicians choose to “ignore the ugliness” and focus instead on patients:

“There is a group of physicians who are silently disengaging from the politics. There is some less-than-professional behaviour going on by a segment of physicians, but the vast majority are trying to deliver high quality care despite the health system issues.”

The intent of some bullies is to stymie much-needed reforms to Ontario’s health system and in that respect they are succeeding, Faulds charges.

“It (bullying) truly is at the root of those problems. I have been watching this for 30 years and now it is blowing up,” she says, noting that the OMA has been thwarted in efforts to modernize the OHIP fee schedule and tackle the problem of relativity — the large variations in what different classes of physicians earn.

The infighting within the profession has become so intense recently that OMA dissenters are forming factions and battling among themselves.

This was evident last month when a whistleblower involved with a group of doctors that forced the non-confidence vote leaked screen-captured images of a conversation from their “secret Facebook group.”

The Facebook conversation was widely circulated in an email with the subject line “When Transparency Isn’t Transparent.” It’s unclear who wrote the email, which came from an address dubbed “Engaged OMA Members.”

It states that some of these physicians had been plotting for months to overthrow the OMA executive and replace it with some of their own. The whistleblower wrote that Dr. Lisa Salamon-Switzman and Dr. Audrey Karlinsky “had spoken for” the positions of treasurer and president-elect.

Salamon-Switzman did not respond to interview requests left with her family practice in Maple or with the Scarborough and Rouge Hospital where she also works. Karlinsky did not respond to requests left at her Toronto family practice or at Mount Sinai and Women’s College hospitals where she has privileges.

The whistleblower expressed concern that Salamon-Switzman and Karlinsky do not have the “many years of experience” that those who usually take on these roles have. “The apparent disregard for a democratic process speaks to the lack of transparency and ill-intent of this group.”

The screen-captured images from what the whistleblower referred to as this faction’s “secret Facebook page” showed these doctors speaking ill of other breakaway factions, the Coalition of Ontario Doctors and Concerned Ontario Doctors.

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A statement attributed to Salamon-Switzman says: “I purposely didn’t put COD or COODers on the petition. Yes it was f-----‘ deliberate! No one respects them.”

A statement attributed to Karlinsky refers to leaders of the COOD and COD, Drs. David Jacobs and Kulvinder Gill.

“Eventually, all reasonable members leave the cuckoo’s nest of DJ and KG. It’s just a matter of time for most, if not all.”

Jacobs and Gill did not respond to multiple interview requests.

The whistleblower went on to allege that the group had been aided in the “planning of this coup” by Kingston consultant Tim Bates who had been promised a job at the OMA as a reward for his work.

Reached by phone, Bates acknowledged that he “helped out with some advocacy” but has “no interest in working for the OMA.”

After the Star wrote about the whistleblower email, Ali Damji, chair of the Ontario Medical Students Association, was wrongly accused of leaking it to this reporter, according to sources.

Salamon-Switzman and Nikolina Mizdrak, another Toronto family doctor involved in attempting to oust the executive and named by the whistleblower, made the accusation to Damji at the OMA meeting where the non-confidence vote was held, sources say.

Mizdrak did not respond to interview requests left with her family practice at the University Health Network.

Damji’s denials were apparently not believed and two days later he received a threatening Facebook message from Bates, a copy of which was obtained by the Star:

“I’m just speaking with some of the physicians involved and they tell me you have not apologized. This is why we will be sending all the deans letters as soon as possible because quite frankly there are many who feel you should not be a family medicine resident at UofT or anywhere else for that matter.”

Damji declined to be interviewed for this story, but was rattled by the threat, fearing it could derail his career, according to friend Dr. Dan Raza, a family physician at St. Michael’s.

“He is quite distraught and shaken by this,” Raza said.

When first asked about the threat, Bates denied making it. When pressed, he admitted to it:

“I may have been a little bit upset with Ali because I was shown an email that said that he had sent a piece of cyberbullying to you,” he said. “I was upset with him because I had mistakenly believed that he had done that . . . It was something that I shouldn’t have said.”

The incident has attracted a lot of attention — and anger — in Ontario medical circles, with many physician leaders rallying around Damji.

“I am aware that it has been reported that one of our student leaders has been threatened inappropriately. Collectively, the Ontario deans are very concerned about this situation and are investigating appropriate actions,” said Dr. Richard Reznick, co-chair of the Council of Ontario Faculties of Medicine.

“We very much want our students to be involved in leadership activities, and understand that on occasion this may include involvement with politically charged issues. I am confident that any outsider’s comments about one of our student’s activities would in no way jeopardize that student’s career aspirations. That said, we very much are outraged if the purported allegations of a threat to a resident’s career are validated,” continued Reznick, dean of the faculty of health sciences at Queen’s.

Medical students have also been attacked on the Facebook forum. A quote attributed to Dr. Daniele Wiseman, a radiologist at the London Health Sciences Centre, says this about University of Ottawa student Jonathan Gravel, who last summer voiced his support of the tentative agreement:

“That kid should be shot with a ball of his own s---.”

Reached at her office over the phone by this reporter who identified herself and inquired about the remark, Wiseman responded: “I don’t really recall this . . . I don’t know who you are or what you are talking about . . . I am going to hang up now.”

Gravel declined to comment.

Georgetown family physician Dr. Nadia Alam, another doctor behind the non-confidence vote, alerted physicians on the Facebook forum a week ago that the Star was working on this story and advised them to watch their words:

“Have care in what you say, what you write, what you tweet.”

Dr. Rocco Gerace, registrar for the College of Physicians and Surgeons, says he is dismayed to hear of allegations of bullying:

“I am particularly disturbed to hear allegations that medical trainees have been subjected to threats and intimidation. Physicians are expected to model appropriate behaviour for trainees and foster a culture of respect within the professional environment, and abusive conduct will not be tolerated.”

The college has a policy, titled Physician Behaviour in the Professional Environment, which sets out expectations. It offers examples of unacceptable conduct, such as using “rude, profane, disrespectful, insulting, demeaning, threatening, bullying, or abusive language, tone, innuendos, and behaviour.”

In addition, the provincial government has issued a regulation that stipulates that engaging in “conduct unbecoming a physician” may be considered an act of professional misconduct and subject to discipline. Under the Professional Misconduct Regulation, “conduct unbecoming” is intended to capture conduct outside the practice of the profession that is inappropriate and reflects poorly on the physician or profession.

After three years without a contract and seven months of no negotiations, the OMA and province are about to go back to the bargaining table. In the last week, both sides have announced their respective negotiating teams.

The stakes are high. So are emotions and tensions.

Even so, doctors are expected to take the high road, Gerace said.

“At all times, the college expects that physicians will act respectfully toward their patients, colleagues and other members of the health-care team.”

If they don’t, there will be consequences, he warned.

“Physicians who engage in threatening or bullying behaviour, or use profane or abusive language are advised that the college can and will investigate their conduct. Allegations of abusive conduct are taken very seriously, and investigations will be decided in accordance with our public interest mandate, and may include disciplinary action.”

Reach Theresa Boyle at tboyle@thestar.ca or (416) 869-4915