#MeToo movement in medicine: ‘Community of allies’ required to end culture of sexual harassment

The statistics are staggering.

Up to 50% of female medical students report experiencing sexual harassment from faculty or staff, according to a consensus study report issued in June by The National Academies of Sciences, Engineering, and Medicine (NASEM).

In addition, 12% of female physicians, nurses, nurse practitioners and physician assistants report personally experiencing sexual harassment, abuse or misconduct while on the job in the past 3 years, according to two other surveys released this year.

The problem is so pervasive, Esther K. Choo, MD, MPH — the author of one of two perspectives on the topic published this fall in The New England Journal of Medicine — referred to sexual harassment as a “chronic debilitating disease” in the field.

Most individuals are well-intentioned, Choo said. The problem arises, she said, when organizations or institutions are not explicit about their values and expectations, and they fail to clearly state how they will respond to inappropriate actions.

“When we are thoughtless about sexual harassment, we inadvertently create an environment where it simply flourishes like bacteria on a Petri dish,” Choo, associate professor at Oregon Health & Science University’s School of Medicine, told HemOnc Today. “When we make a ‘primordial soup’ for things, these things tend to grow.”

A sobering reality

Evidence cited in the NASEM report suggests sexual harassment in medicine is pervasive even in training settings.

A 2014 forum on campus sexual assault and harassment at Georgia State University prompted the creation of the Administrator-Researcher Campus Climate Collaborative (ARC3), which developed a comprehensive survey with input from sexual violence researchers, campus law enforcement, victim advocates, counselors and other stakeholders.

The ARC3 Campus Climate survey incorporates components of the Sexual Experiences Questionnaire to measure all subtypes of sexual harassment, including unwanted sexual attention and sexual coercion.

More than 150 higher education institutions have used the ARC3 survey to measure campus climates.

The NASEM report summarized results from two such surveys.

One conducted at The Pennsylvania State University System showed 33% of undergraduate students, 43% of graduate students and 50% of medical students reported experiencing sexual harassment from faculty or staff. A similar survey conducted at The University of Texas system showed more than 40% of medical students reported experiencing sexual harassment from faculty or staff.

The prevalence is similar among those who are established in their fields.

A cross-sectional survey of U.S. academic medical faculty in 1995 showed 52% of women and 5% of men reported experiencing sexual harassment during their careers. Participants in that survey began their careers at a time when men comprised a much greater percentage of medical school students than women.

Two decades later, Reshma Jagsi, MD, DPhil, professor and deputy chair of radiation oncology at University of Michigan, and colleagues assessed the prevalence of sexual harassment among faculty who started their careers at a time when women accounted for more than 40% of medical students.

Jagsi and colleagues surveyed individuals who received K08 and K23 career development awards from NIH between 2006 and 2009. A questionnaire evaluated respondents’ career and personal experiences related to gender bias, gender advantage and sexual harassment.

Those who reported experiencing sexual harassment in their professional careers were asked to share the perceived effects on confidence and career advancement, as well as to specify the severity of the experience.

The analysis included 1,066 survey respondents (mean age, 43 years; 54% men; 71% white).

Source: Michigan Medicine.

 

“I quite honestly was looking for good news,” Jagsi, who also directs her institution’s Center for Bioethics and Social Sciences, told HemOnc Today. “I thought we were going to find that overt discrimination and harassment would be much less common [given] that women were so much better represented among medical students and were starting to be better represented among faculty cohorts.”

The results — published in 2016 in JAMA — painted a different picture.

Thirty percent of women reported experiencing sexual harassment. Nearly all (92%) of those women indicated they experienced sexist remarks or behavior; 41.3% indicated they were subjected to unwanted sexual advances; 9.3% reported coercive advances; 6% reported subtle bribery to engage in sexual behavior; and 1.3% indicated they received threats to engage in sexual behavior.

More than half (59%) of those who reported harassment perceived a negative effect on their professional confidence, and 47% indicated the experiences negatively affected their career advancement.

“I was sobered by the reality that has now become clearly apparent to everyone after the disclosures that have taken place in the #MeToo movement and the attention it has generated,” Jagsi told HemOnc Today.

Four percent of men who responded to the survey by Jagsi and colleagues reported experiencing sexual harassment.

Results of two surveys released this year by Medscape yielded similar results. In those reports, 6% of male nurses, nurse practitioners and physician assistants reported experiencing sexual harassment within the past 3 years, as did 4% of male physicians.

“The problem is more widespread than women being sexually harassed,” Jubilee Brown, MD, professor in and associate director of the division of gynecologic oncology at Levine Cancer Institute at Atrium Health, told HemOnc Today. “Men in the gynecology specialty can feel discriminated against, as can anyone throughout the field of oncology. ... Vulnerable populations — whether related to gender or not — are subject to harassment and discrimination, and it will take a culture change to fix this.”

Contributing factors

The experts with whom HemOnc Today spoke identified several key factors — including abuse of power, lack of accountability at the leadership level, poor institutional culture and scarcity of clear established policies — that contribute to the sexual harassment epidemic in medicine.

Women hold only 38% of faculty member positions, and they account for just 16% of medical school deans and 15% of department chairs, according to an Association of American Medical Colleges report.

“Sexual harassment appears more common in organizations where women are in the minority and do not share equally in the power of the organization,” Jagsi told HemOnc Today. “There is a hierarchical structure in medicine, and it has been suggested that hierarchical environments foster harassment. We might expect to see this in any hierarchical field that traditionally and historically has been dominated by men.”

Shifting demographics in the medical field, however, may create an ideal scenario for change.

Between 2015 and 2017, the number of female new enrollees in medical schools increased by 9.6% while the number of male enrollees declined by 2.3%. In 2017 — for the first time ever — more women than men enrolled in U.S. medical schools.

“Medicine has long been comprised of a fairly homogenous leadership, and it is wonderful to begin to see more diversity at the top. I have seen it become more possible to stand up for a healthy work climate in recent years,” Ann Brown, MD, MHS, vice dean for faculty and professor of medicine at Duke University School of Medicine, told HemOnc Today.

“There can be a group mentality that can silence discussions about something as charged as gender harassment. But, with more women in leadership, I see more open discussions, and both men and women standing up for those who are vulnerable,” she said. “Building in diversity can bring new perspectives, allowing for the potential to create a more aware environment in which people understand how their behavior affects others.”

Even if that happens, accountability is essential, according to Barbara Burtness, MD, professor of medical oncology, leader of the head and neck cancers program, and co-director of the developmental therapeutics research program at Yale Cancer Center.

In the past, it was fairly uncommon for a meaningful penalty to be instituted that sent a clear message to others that sexual harassment would not be tolerated.

“Even when things escalated and were dealt with at an institutional level, there was still a great concern for protecting the privacy of the aggressor, because of the belief that women were making these stories up,” Burtness, a HemOnc Today Editorial Board Member, said in an interview. “As we learn more about how difficult it is for people to come forward, what’s become apparent is that [sexual harassment] happens many more times than it is reported.

“For many people in my generation, the risk of being called a liar, [being labeled as] ‘difficult’ or receiving a bad evaluation meant it was not worth it to them to speak up. We kept our mouths shut,” she added. “I admire today’s young people in other industries who are taking risks to come forward, and my hope is this culture change will help us in medicine, too.”

‘Death by a thousand cuts’

The consequences of sexual harassment extend far beyond the individual to whom it is directed.

It has the potential to disrupt the mission of academic health care centers or medical institutions, often creating hostile work environments and low levels of career satisfaction.

“‘Death by a thousand cuts’ comes to mind,” Ann Brown said. “Seeing that bad behavior is permitted and that no one does anything about it — especially when it comes to those who have power and privilege — leads to a lack of trust in an institution and, ultimately, the inability and unwillingness to communicate about challenging issues. This clearly threatens the very things that we hold sacred — patient care and scientific integrity.”

The reactions and responses of those in the field to this problem can take different forms.

“As a teacher, I feel a responsibility to correct the issues presented in the NASEM report that showed medical students are subject to sexual harassment even more so than trainees in other science-related career fields,” Jubilee Brown said. “We cannot tolerate harassment and discrimination in medicine. ... We need diversity in mentorship and a radical culture change.”

However, research suggests women who experience sexual harassment are more likely to report symptoms of depression, stress and anxiety. They also are more likely to forgo career opportunities, leave their institutions or even pursue a different career.

“The shocking part of the NASEM report is the finding that there has not been any headway made,” Choo said.

“A lot of women in the medical field wonder why we should even bother to advance or take on leadership roles when, despite our best ability, we are faced with the choice to either stay in a workforce that is demoralizing or to ‘check out’ as a natural self-preserving response,” she added. “This is a tragedy. It represents significant loss of talent, potential, energy and, ultimately, good patient care.”

Burnout also is a potential consequence, Victor J. Dzau, MD, president of the U.S. National Academy of Medicine, and Paula A. Johnson, MD, MPH, co-chair of the NASEM committee that issued this year’s report on sexual harassment, wrote in a perspective published in September in The New England Journal of Medicine.

“We cannot ignore the possibility that there are overlaps between the professional and health effects of sexual harassment in academic medicine and the epidemic of burnout among U.S. physicians,” Dzau and Johnson wrote.

“Burnout is one of the most significant threats to the functioning of our health system, and many of the factors that drive it are also those that allow sexual harassment to thrive,” they added. “Addressing the systemic and cultural issues that contribute to burnout may also mitigate the damage caused by sexual harassment, or even prevent it from occurring.”

Proposed solutions

The NASEM report outlines 15 evidence-based recommendations for academic institutions to consider and adapt to their particular circumstances.

The suggestions include creating diverse, inclusive and respectful environments; moving beyond legal compliance to address culture and climate; improving transparency and accountability; diffusing the hierarchical and dependent relationship between trainees and faculty; providing support for the target; striving for strong and diverse leadership; measuring progress; incentivizing change; and encouraging involvement of professional societies and other organizations.

Frank C. Morris Jr., Jonathan K. Hoerner and Katherine “Katie” Smith — all of Epstein Becker and Green, one of the nation’s largest health care law firms — also offered several suggestions for health care practices to protect themselves and their providers.

• Act vigilantly.

“Health care employers should implement training, policies and procedures to define and prohibit sexual harassment, as well as prohibit retaliation against anyone making a complaint,” Morris, Hoerner and Smith wrote for a Healio Legal Perspectives column on HemOnc Today’s online platform, Healio.com. “The policies and procedures should be written in a way that employees can understand what constitutes sexual harassment and what conduct is prohibited.”

Practices also should regularly reach out to employees who work in isolated or remote environments to ensure a lack of daily oversight or communication does not foster an environment of inappropriate behavior.

• Quickly address complaints.

“It is not enough to simply maintain policies prohibiting sexual harassment; health care entities must also take reasonable care to enforce their policies,” Morris, Hoerner and Smith wrote. “This means demonstrating that every claim is taken seriously and reasonably investigated. In doing so, employers must hold all employees to the same standard, without making exceptions for ‘high-performing’ or revenue-generating employees, or well-known and popular physicians.”

• Document all sexual harassment complaints, as well as the results of all investigations and disciplinary actions.

“This critically important history serves as a guidepost for interpreting any future allegations,” Morris, Hoerner and Smith wrote. “For example, a single instance of an individual reporting feeling uncomfortable from an employee’s behavior becomes more serious when the harasser continues to engage in the inappropriate behavior despite being counseled about such behavior. Additionally, this helps ensure that this critical information and institutional knowledge survives changes in supervisory and management personnel over time.”

• Comply with health care-specific obligations.

“In addition to responsibilities incumbent upon all employers to guard against sexual harassment, health care employers must ensure that they are aware of and compliant with privacy-related and reporting obligations that are unique to the health care industry, including under HIPAA,” they added.

The physician experts with whom HemOnc Today spoke offered additional suggestions.

“More women are needed in leadership roles, and the younger generation needs to feel that they have someone to confide in and turn to,” Burtness said. “When an institution believes that there is a credible allegation, there needs to be a university-wide committee that addresses it. How much effort an institution puts behind investigating and addressing a complaint is important.”

Institutions also should clarify their policies and delineate grievance procedures to clearly explain disciplinary actions and prohibit retaliation, Jagsi said.

“We need to promote respect, because a respectful environment will inherently be an environment that will not be conducive to harassment,” Jagsi told HemOnc Today. “We need to create a community of allies by empowering and equipping bystanders to act.”

‘Unique time in medicine’

The #MeToo movement has shined a spotlight on sexual harassment throughout American society.

The health care community is no exception, but positive trends have emerged.

“A lot of [the proposed interventions] require commitment from senior leadership,” Jagsi said. “This is one of the great things that has come out of the awareness of this issue. I am seeing true and genuine commitment from our most senior leaders.”

The AMA House of Delegates adopted an antidiscrimination policy at its 2017 annual meeting. Earlier this year, the house adopted additional reporting, investigational and enforcement mechanisms, including a website and hotline that allows employees and meeting attendees who experience or witness harassment to report it confidentially.

When the AMA House of Delegates met in November, it unanimously adopted a resolution that directs the association to engage outside consults to evaluate and improve the process for addressing harassment claims.

“In medicine — as with all professions — harassment sometimes exploits inequalities in status and power, such as the relationships between faculty and trainees, or administrators and staff members. This behavior is unacceptable,” AMA President Barbara L. McAneny, MD, an oncologist from Albuquerque, N.M., and Jack Resneck Jr., MD, chair of the AMA, wrote in the AMA Wire.

“Harassment simply has no place within the AMA, within our medical community, or anywhere in society. And as a community of healers, we are better than this,” McAneny and Resneck wrote. “Physicians enter this sacred profession because we are driven to help people, and to improve the lives of all in our care. We must similarly safeguard the dignity and safety of those with whom we work and interact.”

Other professional societies have taken action, too.

For instance, in September the NIH announced it would strengthen its sexual harassment policy and introduced a centralized system for reporting harassment.

Further, the National Science Foundation (NSF) announced that starting Oct. 21, all institutions must report findings of any harassment investigations of scientists who received research grants from the foundation. Consequences may include removing principal or co-principal investigators, reducing award funding, or suspending or terminating awards.

“We are committed to a nurturing research environment. One that is encouraging and supportive of all researchers,” France A. Córdova, PhD, director of the NSF, said in a statement. “We have heard the voices of the wider community and have responded. We will continue to listen and to take action as a federal granting agency. NSF has no tolerance for harassment.”

The American Association of Gynecologic Laparoscopists board of directors received a letter from a group of members expressing concern about gender equality within the organization, Jubilee Brown said.

In response, the group announced it would re-examine its policies and expectations regarding harassment, diversity, inclusion and incident reporting. The board also created a task force to evaluate and update the association’s policies to ensure a safe, productive and inspiring environment for members, Jubilee Brown said.

The American College of Surgeons also addressed the issue in its most recent Statements on Principles.

“A policy regarding sexual harassment that is consistent with the policies of the institution and the law should be in place in each department and should be strictly enforced,” the statements read. “Educational programs for all attending and resident staff relative to sexual harassment and gender bias should take place on a regular basis.”

These efforts are essential but also long overdue, Choo said.

“The issue of sexual harassment feels so old to me, so delayed,” she said. “I do not even feel like an innovator speaking up about these things. I feel like I should apologize for waiting until my 40s to start advocating openly about the issue. ...

“Speaking up can mean a difference between moving forward in a career and not being able to move forward in a career,” Choo added. “It is my generation of women and those above me who need to talk about these things so that we can make it better for the younger generation.” – by Jennifer Southall

References:

American College of Surgeons. Statements on Principles. Available at: www.facs.org/about-acs/statements/stonprin. Accessed on Nov. 20, 2018.

Association of American Medical Colleges. The State of Women in Academic Medicine: The Pipeline and Pathways to Leadership, 2015-2016. Available at: www.aamc.org/members/gwims/statistics/489870/stats16.html. Accessed on Nov. 19, 2018.

Brown J. J Minim Invasive Gynecol. 2018;doi:10.1016/j.jmig.2018.02.008.

Choo EK, et al. N Engl J Med. 2018;doi:10.1056/NEJMp1809351.

Dzau VJ and Johnson PA. N Engl J Med. 2018;doi:10.1056/NEJMp1809846.

Jagsi R, et al. JAMA. 2016;doi:10.1001/jama.2016.2188.

Jagsi R. N Engl J Med. 2018;doi:10.1056/NEJMp1715962.

Kane L. Sexual Harassment of Physicians: Report 2018. Available at: www.medscape.com/slideshow/sexual-harassment-of-physicians-6010304. Accessed on Nov. 19, 2018.

Kane L and Levy S. Sexual Harassment of Nurses, NPs, and PAs: Report 2018. Available at: www.medscape.com/viewarticle/898152_2. Accessed on Nov. 20, 2018.

McAneny BL and Resneck J Jr. Confronting harassment within medicine head on. Available at: wire.ama-assn.org/ama-news/confronting-harassment-within-medicine-head. Accessed on Nov. 20, 2018.

The National Academies of Sciences, Engineering, and Medicine. Sexual Harassment of Women: Climate, Culture, and Consequences in Academic Sciences, Engineering, and Medicine. Available at: www.nap.edu/catalog/24994/sexual-harassment-of-women-climate-culture-and-consequences-in-academic. Accessed on Nov. 19, 2018.

For more information:

Ann Brown, MD, MHS, can be reached at Duke University School of Medicine, 200 Trent Drive, Durham, NC 27710; email: ann.brown@duke.edu.

Jubilee Brown, MD, can be reached at Levine Cancer Institute at Atrium Health, 1021 Morehead Medical Drive, Charlotte, NC 28204; email: jubilee.brown@atriumhealth.org.

Barbara Burtness, MD, can be reached at Yale Cancer Center, P.O. Box 208028, New Haven CT 06520; email: barbara.burtness@yale.edu.

Esther K. Choo, MD, MPH, can be reached at Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239; email: chooe@ohsu.edu.

Reshma Jagsi, MD, DPhil, can be reached at University of Michigan, 1500 E. Medical Center Drive, UHB2C490/SPC 5010, Ann Arbor, MI 4810; email: rjagsi@med.umich.edu.

Disclosures: A. Brown, J. Brown, Burtness, Choo and Jagsi report no relevant financial disclosures.