Medicine's #MeToo movement

Sexual harassment and assault grabbed the spotlight in 2017 when actress Alyssa Milano promoted the hashtag #MeToo on social media as a way for victims to share their experiences (although the “Me Too” movement actually goes back 10 years earlier, to the credit of activist Tarana Burke).

The medical profession and its places of healing may seem shielded from these problems, but the recent focus has led some physicians to share troubling stories.

If the prospect of doctors behaving badly seems hard to believe, consider the evidence. In a survey of 1,066 clinician-researchers, 30% of women reported personally experiencing sexual harassment from a colleague or superior, compared to 4% of men, according to results published in May 2016 by JAMA.

“Unfortunately, what we found was that experiences of sexual harassment continue to be strikingly common, even today,” said lead author Reshma Jagsi, MD, DPhil.

Of the 150 women who said they had experienced harassment, 92% reported sexist remarks or behavior, 41% reported unwanted sexual advances, and 9% reported coercive advances. Regarding gender bias, 66% of women reported being left out of opportunities for professional career advancement based on their gender, compared to 10% of men.

At the same time, the Association of American Medical Colleges (AAMC) announced in December 2017 that, for the first time, the number of women enrolling in U.S. medical schools had eclipsed (albeit slightly) the number of men. Since 2015, the number of female enrollees grew by nearly 10%, while that of men declined by 2.3%, the AAMC reported.

With more women in medicine than ever before, experts see an opportunity to investigate and then implement solutions to combat sexual harassment in medicine.

The reporting problem

Despite the well-documented prevalence of sexual harassment, Dr. Jagsi said she'd hoped to find a lower incidence of sexual harassment in medicine “because an altruistic impulse drives us to the field.” But she also suspected that academic medicine's hierarchical power structure might abet such misbehavior. In a January 2018 New England Journal of Medicine perspective, she recounted experiences of harassment that female physicians shared with her after her study was published, ranging from unwanted touching of breasts and backsides to rape by a superior.

None of the women who shared their experiences reported them to authorities, said Dr. Jagsi, who is professor and deputy chair in the department of radiation oncology and director of the Center for Bioethics and Social Sciences in Medicine at the University of Michigan in Ann Arbor. “This idea that if one reports, one will be marginalized or stigmatized or face retaliation—those are very real considerations,” she said.

The potential repercussions of speaking up are particularly daunting for trainees, said Fatima Zahara Syed, MD, MSc, FACP, immediate past chair of ACP's Council of Resident/Fellow Members and a second-year fellow in endocrinology at Thomas Jefferson University Hospital in Philadelphia. “From a resident and fellow perspective, you're especially frightened because you're the lowest of the lowest on the totem pole,” she said. “Your job is to get the work done and to deal with the hardships of residency, and some people think that these issues are part of those hardships, and it's unfortunate because they shouldn't be.”

Learners may need letters of recommendation from faculty (potentially even from the perpetrator) or want to stay on after training to become faculty themselves, noted Francis Nuthalapaty, MD, professor of obstetrics and gynecology at the University of South Carolina School of Medicine in Greenville. “All of those things make it very, very difficult for them to feel confident in reporting and following through on having these issues addressed,” he said.

In similar fashion to Dr. Jagsi, Dr. Nuthalapaty wrote an editorial detailing several real examples of sexual harassment in academic medicine, published in March 2018 by Obstetrics & Gynecology. One example included a senior faculty member who made regular sexual comments about a senior female resident, both in her presence and around male residents. Another report of a male faculty member also included comments on the female residents' appearances—in addition to sexual jokes about anesthetized patients in the operating room.

“The reason I know about those concerns is that in many cases, people came to me as someone that they could trust,” said Dr. Nuthalapaty, a 25-year veteran educator.

Some institutions and individuals are reluctant to address incidents because they perceive them as cumbersome and detracting from their overall missions, Dr. Nuthalapaty said. “This whole #MeToo movement in particular, it's been about things that people have known about. In their heart of hearts, they've known it's not right, but … when people read this [editorial], they may feel like it's going to open a can of worms they'd rather not deal with,” he said.

Efforts to identify and punish sexual harassment also face some active opposition. Dr. Jagsi said she received one email arguing that sexual attraction will naturally occur in the workplace and therefore does not merit too rigid of a response. “I think this is mistaking what sexual harassment actually is. It's not about sex; it's about harassment. It's about abuse of power. It shouldn't all be about blaming the victim,” she said.

Furthermore, simply looking attractive should not cause a person to experience unwanted attentions at work. “There are boundaries, particularly in a professional culture. It's not like we go into the hospital on a date; you go into the hospital to fulfill your professional role as a physician or a resident or an educator,” said Deborah Grady, MD, MPH, a professor at the University of California, San Francisco.

Other critics might question why a victim didn't do more to evade a situation or speak up in the moment. Dr. Nuthalapaty compared the situation to experiencing inappropriate racial comments. “I can't explain it, but sometimes you just don't know what to say,” he said. “It could be so shocking, or you feel so threatened and vulnerable that you don't know what to do.”

Still others will rationalize sexual harassment by saying that a perpetrator has a “blind spot” and doesn't realize that what he's said or done is wrong, said Dr. Nuthalapaty. “It's not fair to say that they're blind spots because those types of views and behaviors are going to be deeply rooted in something,” he said. “They are an expression of what that person has in their ethos—they somehow think that maybe there is some justifiable inequality between different groups of people, whether that's based on gender or race or social status.”

In this context, so-called blind spots may be another term for implicit gender bias. ACP detailed several recommendations for achieving gender equity in physician compensation and career advancement in a wide-ranging policy position paper published in April by Annals of Internal Medicine.

Among these is a recommendation for hospitals, practices, academic institutions, and other physician employers to provide regular, recurring implicit bias training for all leadership. ACP also recommends that organizations increase the number of women in faculty and leadership positions: In 2015, only 18 of 118 internal medicine department chairs (15%) were women, according to the AAMC.

A path forward

Despite the challenges surrounding sexual harassment in medicine, experts agreed that there are solutions, with the first step being to acknowledge the problem.

“We need to shine a light on the problem and stop victim blaming if we are going to be able to change the culture,” said Cynthia (Daisy) Smith, MD, FACP, Vice President of Clinical Programs for ACP. “We need to empower people to speak out, not only on their own behalf, but when they see their colleagues being mistreated.”

Compared to past trainees, current female residents are more willing to speak about the problem, and male residents are much more aware of it, according to Dr. Grady. “That's promising because it takes both of those things: It takes the women feeling empowered to speak out, and also the men feeling motivated to limit the ‘old-boy’ talks as a kind of permissiveness for discrimination,” she said.

When situations do arise, it's helpful to have a support system. Especially for trainees, Dr. Jagsi said a useful first action is talking with a trusted senior mentor who knows how to navigate the system and the specific players and issues involved. “That can help minimize the risks of speaking out, but also help so that women do have the ability to speak out so that this doesn't continue to occur to more and more women,” she said.

The ultimate decision about whether to report sexual harassment belongs to the victim. Even after sharing the situation with a trusted ally, many will not be fully transparent in the interest of self-preservation, said Dr. Nuthalapaty. “All I can do is offer them a path forward … and sometimes you also have to offer an apology. As a representative of the faculty, you have to say, ‘I am so sorry that this has happened to you,’” he said.

The reporting process, however, is becoming easier thanks to new technological approaches. One type of reporting software, called Callisto, allows victims to electronically report sexual harassment or abuse, with the option of creating and saving a secure time-stamped document, even if they're not ready to report to authorities. The platform, which launched in 2016 and is in use on more than a dozen college campuses, also gives victims the option to submit an official report only if someone else reports the same offender.

“I think that's a very powerful tool. … Two or three or more reports of harassment by the same person is usually taken much more seriously than a single report,” said Dr. Grady. Another reporting tool that's in the works, AllVoices, allows victims and witnesses to anonymously report sexual harassment, discrimination, and bias directly to their employer's CEO and company board. Distressed employees can also receive professional advice through another startup, Bravely, which offers phone sessions with neutral third-party conflict coaches.

As the conversation about this issue heats up, leaders have begun to listen. While sexual harassment victims responded in droves to Dr. Jagsi's survey, her perspective piece prompted correspondence with men and leaders of professional societies, departments, and institutions.

“They have said, ‘How absolutely horrifying. What can we do to help? What should we be doing to make this better?’” she said. “I found that heartwarming because the first step toward culture change is actually recognizing that there's an issue there to discuss.”

When Dr. Jagsi replies, she offers several recommendations: hosting workshops, symposia, or panel discussions that call attention to the resources that their institutions have in place; asking for open dialogue; making it clear that respect and civility are expected; and emphasizing that there are many people committed to ensuring all employees are treated with dignity.

Organizations and professional societies could also consider formal interventions to highlight the presence of allies. Dr. Jagsi ends her perspective with an example from academic astronomers who have created a formal system of “astronomy allies,” senior female astronomers who wear buttons at national scientific meetings and offer help to colleagues when harassment situations occur.

“It's those kinds of thoughtful, innovative solutions that we have to seek out wherever we can find them,” she said.

An increasing focus on lateral leadership could also help, according to Dr. Smith. “I am very hopeful that we can move medicine from a culture that elevates individual physician expertise, achievement, and power above all else to one that fosters the wisdom, relatedness, and mutual respect of the clinical team,” she said, “with the focus always on how to improve the lives and relieve the suffering of the patients we serve.”

The ultimate response to specific incidents of sexual harassment, when uncovered and confirmed, is to remove offenders from their leadership positions, said Dr. Nuthalapaty. “Let's give them the opportunity to go and get counseling, to do self-reflection to find out why they have this ‘blind spot,’ and then when they reconcile that, let's re-evaluate whether they need to be back in the leadership,” he said.

Dr. Jagsi said she is hopeful for the future, especially because individuals in positions of power want to fix the problem. “As more and more institutions and societies have realized that they would like to start this conversation, I've been giving a lot of talks, and I have to say that one of the most wonderful things is seeing how many men have come out to support the women, just by their presence. By listening,” she said.