As institutions struggle to find solutions, some women are taking matters into their own hands.
This article was first published on Sunday. January 5, 2020 in MedPage Today.
By Shannon Firth, Washington Correspondent, MedPage Today
In February 2019, MedPage Today launched a #MeToo Medicine series, which examined how entrenched hierarchies and a climate of intimidation, retaliation, and fear discourage targets from reporting sexual harassment. In this follow-up, we take a new look at the situation.
Institutionally, at least, 2019 saw the problem being taken seriously:
- On March 1, more than 50 women launched the TIME'S UP Healthcare movement to foster the development of "more balanced, diverse, and accountable leadership" while at the same time responding to workplace discrimination, harassment, and abuse, and promoting "equitable and safe cultures."
- In May, the National Institutes of Health Advisory Committee to the Director Working Group on Changing Culture to End Sexual Harassment held a "listening session" to explore the ways individuals are "adversely affected" by sexual harassment.
- In June, following an in-depth assessment of its own practices, the AMA adopted a new policy for responding to and preventing harassment at AMA meetings.
- Also in June, the Association of American Medical Colleges (AAMC) held a Leadership Forum that explored institutional barriers that prevent alleged harassers from being adequately investigated and disciplined as well as the difficulty of enacting a broad and sweeping cultural change.
- In November, the National Academies of Science, Engineering, and Medicine (NASEM) held an Action Collaborative on preventing sexual harassment in higher education, which highlighted new initiatives focused on reducing power differentials that allow harassment to persist, and ways academic institutions can foster support for targets and block perpetrators of harassment from transferring positions -- i.e., ending the "pass the harasser" phenomenon.
Medical journals also gave voice to individuals' grievances. Last month, the Journal of General Internal Medicine published an essay by University of Michigan medical student Anitha Menon in which she described being peppered with questions about her age, marital status, and where she was from by a middle-age male patient complaining of a testicular bulge. The patient then turned to her attending and asked, "So where can I get myself one of these pretty assistants?"
"To my dismay," wrote Menon in December, "the attending -- without missing a beat -- replied, 'Well, they send them to us every month – they're medical students.'"
Holding back tears of anger and frustration, Menon completed the exam. "To this day, I wish I had not," she wrote.
She recalled other examples of harassment, from a patient repeatedly asking for her phone number, to an attending telling an operating room nurse to leave a patient's nipples visible, "because he 'had a fetish.'"
"[S]exual harassment, especially in the form of gender harassment, is rarely about sex -- it is about power," Menon wrote. "It reinforces a gender hierarchy that has become normative and serves to remind women that we are seen as objects, not physicians."
Most harassment wouldn't qualify as criminal behavior, but the daily microaggressions that target experience can have "terrible consequences for women in academic medicine," said Reshma Jagsi, MD, DPhil, deputy chair of the Department of Radiation Oncology and director of the Center for Bioethics and Social Sciences at the University of Michigan Medical School, in an AAMC press release on the Leadership Forum.
The ripple effects of these inappropriate behaviors include lost productivity, physical and emotional distress, depression, and women choosing to leave an institution or leave the profession altogether, Jagsi said in the release.
Nearly a quarter-century ago, Canadian researchers reported that among female physicians and trainees who had experienced sexual harassment, waning interest in their studies and "intrusive memories" were common, and one in three considered quitting medicine.
Engaging Leadership, Bystanders
"There are already rules in place about not harassing people, not discriminating based on gender or race, and so the question is ... how do you make the culture change so that those rules are enforced?" asked Janis Orlowski, MD, AAMC's chief healthcare officer.
"And the answer is that you don't tolerate it," she told MedPage Today.
The whole community has to be educated about this shift and a clear signal sent by the leadership, so that if an incident does occur, the school has to deal with it appropriately, "so that people know the school means business," Orlowski said.
Timothy Johnson, MD, professor of obstetrics and gynecology and of women's studies at the University of Michigan -- and a co-author of NASEM's landmark 2018 report on sexual harassment -- said the first step is defining the problem.
"And I think that's what the National Academies report did," he said.
"I think, more and more, we're asking ... senior faculty to say something, so that if a patient says to a medical student, 'Hey, you're too cute to be a medical student' ... it's up to the attending to say, 'Hey, that's not appropriate language.'"
Clinicians, historically, have been taught "that we have to love our patients and they have to love us [but] ... sometimes you just have to say, 'Excuse me. I understand you're sick ... but this behavior's not appropriate.'"
Similarly, an attending has to be able to interject if a chief resident "says something obnoxious," or vice versa, Johnson added.
But culture change takes time.
"Changing culture doesn't occur just by changing a rule or enforcing a rule," Orlowski said, adding that "we're talking about a 10-year horizon" to work and keep up the pressure.
Raising Awareness, Learning to Intervene
Creating this kind of culture shift takes work and requires "more than just watching a video," Johnson said.
But role-playing, and working through potential scenarios of harassment face-to-face, can be very effective, he noted.
Doctors don't intrinsically know how to take a patient's history. It's learned and practiced, he said.
Johnson said that early in his career as a gynecologist, "it was very uncomfortable for me to say things like, 'Do you have sex with men or women or both?'"
"I mean that didn't roll off my tongue the first hundred times I said it."
Similarly clinicians aren't going to wake up one day and magically know the right words to say to intervene when they see harassment.
"You have to ... give people the words and make them comfortable saying the words and internalizing the words," Johnson said.
At the AAMC's June forum, participants had a chance to participate in bystander training, where they were taught both direct and indirect intervention tactics. Direct interventions included asking the harasser to stop or telling a supervisor, while more indirect strategies included telling a student she's late for class or having a clinician paged.
Roberta Gebhard, DO, president-elect of the American Medical Women's Association (AMWA) and a member of the TIME'S UP Healthcare advisory board as well as the AMA's Women Physician Section, agreed with Johnson that face-to-face training far exceeds online programs.
She also noted that such training is particularly powerful if the CEO of an organization or the dean of a medical college participates.
"There are not a lot of bad actors, but there are a lot of bystanders that can be educated on how to be allies," Gebhard said.
Harassment -- A Learned Behavior
"People are not born perpetrators; they learn this over the course of a career," said Kristina Larsen, JD, who has worked in university administration and employment law for 20 years, and who was one of the panelists at the NASEM Action Collaborative on sexual harassment prevention.
A frequent pattern in medicine, Gebhard told MedPage Today, is that a person who's accused of harassment may make a lateral move to another institution mid-investigation, or even be transferred to a higher position. The harasser escapes blame and then puts students and faculty at his new institution at risk.
The strategy is so common it has a name: "Pass the harasser."
And one reason harassers continue this pattern of behavior is that nondisclosure agreements at some academic institutions or hospitals require that certain information about an academic's behavior be kept confidential.
"And what we have to do is for someone who is disciplined or who is known to be a harasser, we can't let them move forward without that information being given to the next institution," Orlowski said.
If a university or institution of higher learning really wants to address sexual harassment, it needs to include an individual's conduct as one of the factors it weighs during its promotion and tenure process, Larsen said.
She noted that in nearly every sexual harassment case she's been involved in, at no point in that individual's career did the person receive "meaningful consequences for any conduct."
Because of this "zero-to-60" paradigm in compliance, academics receive either no feedback or they're pinned with a formal accusation or investigation -- and "this is really not good for anyone," either victim or perpetrator, Larsen said.
"In the past people were able to harass, but if they did good research or ... they were good educators or they were great surgeons, they were allowed to move forward in their professional career," Orlowski noted. "What happens now, or what should happen now, is even if you do all those other things well, but you're a known harasser your career should not continue to flourish."
Larsen said the more comprehensive evaluation isn't simply about the individual being evaluated, it's about everyone else who's affected by promotion and tenure decisions. "[H]aving people see that the university is willing to defend this [process] because it's the right thing thing to do will send such a powerful message, she said -- particularly to graduate students aiming to join university faculties themselves one day."
At the NASEM Action Collaborative panel discussion, Sheila O'Rourke, JD, of the University of California Davis, described a pilot program, which began at the university in June 2018, that requires in-depth reviews of job applicants seeking tenured positions. Applicants must sign a release form agreeing to give UC Davis access to any past disciplinary records from previous employers.
The authorization includes language allowing the university to have access to documents typically considered confidential, such as separation agreements or forms where an individual agreed to a particular sanction.
This approach is "[m]aking it clear to our hiring committees that these things matter in the evaluation of a candidate," O'Rourke said.
While programs aimed at weeding out harassers before they become tenured professors unfold -- the University of Wisconsin is testing a similar model -- some women have taken it upon themselves to warn others of known perpetrators.
In private Facebook groups, "whisper campaigns" warn women about individual harassers at different institutions, Gebhard said. Many of the groups allow members to post anonymously through the group's administrator, to protect that individual's identity, Gebhard wrote in a follow-up email.
One closed Facebook group has more than 70,000 female physician members.
Women can also share stories about which institutions -- medical schools, residency programs, and hospitals -- are failing women and which ones treat women equitably, Gebhard said.
As a member of one closed Facebook group and the founder of AMWA's Gender Equity Task Force, Gebhard wrote a letter to one institution letting the leadership know that a "bad actor" was being transferred there, "that he was trouble and that we'd be monitoring his behavior."
As for other channels for reporting inappropriate behavior, the University of Michigan now has at the top of its homepage a button for reporting sexual misconduct, Johnson noted.
Both the Accreditation Council on Graduate Medical Education, which provides accreditation for residencies and fellowships, and the Liaison Council on Medical Education, which decides whether medical education programs meet established standards, serve as more formal watchdogs for residents and students, according to Gebhard.
Both organizations can survey students and intervene if problems of sexual harassment occur, as a matter of student safety, Gebhard said.
Any action by these bodies would require the students to disclose problems with sexual harassment, but "since this could ultimately result in the closing of their program, it's not always in their best interest," Gebhard said in an email. She said at least one residency has been shuttered for not providing a safe, equitable workplace.
Reducing Power Imbalances
One key recommendation of the 2018 NASEM report was to reduce the power differentials between harassers and potential targets.
"[E]nvironments where people are isolated because of significant differences in power are more likely to foster and sustain sexual harassment," the document stated, also noting that the more power a harasser has over a target the greater the negative consequences the target endures.
One of the strategies for diffusing such power differentials in medicine and in academia is to promote multiple mentorships, explained Maria Lund Dahlberg, co-editor of another NASEM report, "The Science of Effective Mentoring in STEMM."
The model can be as simple as a triad with two mentors to a mentee, or two mentees to a mentor. In the latter model, often there's a kind of "vicarious learning" among the mentees who may be at different stages in their career.
If an individual establishes trust in a multiple mentorship model and that trust is broken with one individual, there is still at least one other individual to provide the psychosocial support and guidance "to process the loss of that relationship" and ideas on ways to move forward.
Another way to enhance mentoring relationships is to establish mentoring agreements as a way of explicitly stating what each person expects to get out of the relationship -- "they can help steer the relationship back on track, should it get derailed," Lund Dahlberg said.
When mentor-mentee pairs are selected by the Gilliam Fellowship at the Howard Hughes Medical Institute (HHMI) for funding, mentors are required to attend a year-long culturally aware mentor training program, explained Sonia Zárate, PhD, HHMI's program officer for Science Education, in an email.
Applicants to the program are also required to outline a "conflict resolution plan" as part of a broader mentoring plan.
"By having to reflect on what they would do, the expectation is that they will be able to manage situations in real-time before they escalate," Zárate said.
Given privacy concerns and the threat of retaliation, advocates for change told MedPage Today that in some cases the best option for an individual target, usually a woman, is to leave her program or employer.
This frustrates Lauren Powell, currently director of health equity for the Virginia Department of Health, who will become TIME'S UP Healthcare's executive director later this month. She spoke with MedPage Today over the phone with a press representative also on the line.
"Placing the blame or the onus on a survivor to find somewhere else to work or, in some cases, find a totally different career, is completely unacceptable to me because that completely absolves us of looking at the system that created these conditions," she said.
One of the goals of TIME'S UP Healthcare is to create policy change, including making it easier to report problems and enforce consequences, she said.
Additionally, the TIME'S UP Legal Defense Fund provides financial and legal assistance to women who experience sexual harassment.
Nearly 4,000 individuals have reached out to the fund, which has provided financial and/or public relations support (but not legal services) for 250 cases including five paramedics in Chicago and for a nursing student in North Carolina.
"But," said Powell, "it's not lost on me that there has to be more discussion about ... what to do [about] retaliation and how to move organizations away from making it so hard to come forward to just tell the truth."
Most harassment wouldn't qualify as criminal behavior, but the daily microaggressions that target experience can have terrible consequences for women in academic medicine.'
The ripple effects of these inappropriate behaviors include lost productivity, physical and emotional distress, depression, and women choosing to leave an institution or leave the profession altogether.