After a dinner at a professional society meeting, a prominent surgeon accosted Reshma Jagsi, MD, DPhil, in the cloakroom and repeatedly demanded to walk her to her room.
“He winked at the cloakroom attendant and said, ‘She loves surgeons,’” says Jagsi, professor at the University of Michigan and director of the school’s Center for Bioethics and Social Sciences in Medicine. “At the same time, a female surgeon walked by and I said, ‘I do adore surgeons, which is why I planned to walk back with her.’” The female surgeon recognized Jagsi’s discomfort, took her by the arm, and escorted her away from a potentially dangerous situation.
Long before the #MeToo movement, women in medicine have instinctively banded together to counter a culture that too often tolerated harassment. Many can describe situations where faculty, principal investigators, or attendings made sexually explicit or demeaning comments, brushed up against breasts or buttocks during surgery, or requested sexual favors in exchange for career advancement.
The National Academies of Sciences, Engineering, and Medicine (NASEM) documented this culture in the groundbreaking report, Sexual Harassment of Women: Climate, Culture, and Consequences in Academic Sciences, Engineering, and Medicine. When the report was released in June 2018, it unleashed a torrent of publicity, including statements from the AAMC, the AMA, the NIH, and others condemning sexual harassment.
While many leaders within academic medicine knew the problem was significant, they didn’t know the extent. “To see the prevalence laid out like that was shocking,” admits Esther Choo, MD, associate professor of medicine at Oregon Health and Science University and co-founder of Equity Quotient, a private company that specializes in metrics around workplace culture.
According to the NASEM report, the prevalence of sexual harassment in academic medicine is almost double that of other science and engineering specialties, with almost half of all trainees at surveyed institutions reporting harassment from faculty or staff. For victims, the result is job dissatisfaction, burnout, increased stress, and poor performance. In fact, sexual harassment poisons the water around an entire medical team. According to NASEM, “the cumulative effect of sexual harassment is a significant and costly loss of talent in academic science, engineering, and medicine, which has consequences for advancing the nation’s economic and social well-being and its overall public health.”
“Doctors in training work in high-stress, life-or-death situations, often late into the evening when hallways are empty,” says Timothy Johnson, MD, professor of obstetrics and gynecology and women’s studies at the University of Michigan and a co-author of the NASEM report. “It’s a perfect storm for aggressive sexual behavior and harassment.”
In the wake of the report, institutions from Mayo Clinic to the University of Michigan are upping their game, launching initiatives aimed at preventing sexual harassment, and creating a culture of safety, respect, and equity.
Defining the problem
Like any wrongdoing, there are degrees of sexual harassment, from microaggressions to sexual assault and coercion. Gender harassment includes both verbal and nonverbal behaviors that treat women or men as second-class through hostility, objectification, or exclusion. Unwanted sexual attention ranges from unwelcome sexual advances to overt assault. And sexual coercion occurs when career advancement is contingent on providing sexual favors.
“Not all sexual harassment is the same,” explains Katherine Sharkey, MD, PhD, assistant dean for women in medicine and science at the Warren Alpert Medical School of Brown University. The attending who tells dirty jokes to medical students is not the same as the principal investigator who promises research dollars in exchange for sexual favors. “Both behaviors should be addressed, but they warrant different consequences,” she adds.
But whether the offense is an inappropriate comment or a sexual assault, reporting among trainees in particular is shockingly low. According to the AAMC’s 2017 Medical School Graduation Questionnaire, only 21% of students who experienced harassment or other offensive behaviors reported the incidents to faculty members or administrators. The reasons they didn’t report the behavior ranged from “I did not think anything would be done about it” (37%) to “The incident did not seem important enough to report” (57%) to “fear of reprisal” (28%) and “I did not know what to do” (9%).
Lynn Fiellin, MD, associate professor of medicine at Yale University School of Medicine, believes that “trainees are afraid to report.” The risk of being shamed or retaliated against is high and could cost residents coveted recommendation letters or career advancement. The result is that offenders at the highest levels of an institution seem to be the most protected.
“As physicians climb up the ladder, the rules change,” explains David A. Acosta, MD, chief diversity and inclusion officer at the AAMC. “You have a faculty member who is very valuable to the institution, or a director who brings in revenue from grants, or a principal investigator who holds a Nobel prize. They seem untouchable. But we know that we can and must change that perception.”
Take Yale’s Michael Simons, for instance. The decorated cardiologist and researcher held on to his endowed chair even after an oversight committee concluded he was guilty of sexually harassing a junior colleague in 2013. But it wasn’t until five years later, when more than 1,000 faculty members, medical trainees, students, and alumni signed a petition — and the case hit the New York Times — that leaders stripped Simons of the honor.
The culture is particularly toxic for women when men dominate the leadership at an institution, Jagsi says. Research confirms sexual harassment is more likely to occur when women leaders are in short supply. That’s certainly the case in academic medicine; AAMC data reveal that just 15% of department chairs and 16% of deans are women.
Fortunately, the tide is slowly starting to change. At Mayo, the number of women in leadership positions has doubled since 2010. The University of Pennsylvania’s FOCUS on Health and Leadership for Women strives to systematically increase the number of female leaders — and boasts one of the strongest budget lines of any Women in Medicine (WIM) program in the United States. And Yale recently brought on a female to chair the Department of Surgery, a historically male-dominated specialty.
“Having more women in leadership creates a huge cultural shift,” says Sharonne N. Hayes, MD, cardiologist and director of Mayo Clinic’s Office of Diversity and Inclusion. “Women have a different leadership style, they set a different tone, and having a great female leader has downstream direct and indirect effects to help mitigate sexual harassment.”
A changing climate
The authors of the NASEM report liken sexual harassment to a “chronic debilitating disease” in the field of medicine, with a focus on prevention. Changing the culture, they say, would replace the current system of “waiting for full-blown, metastatic manifestations of harassment.”
“It’s really no different than Hollywood,” says Julie Silver, MD, associate chair in the department of physical medicine and rehabilitation at Harvard Medical School. “It seems like medicine has a ton of perpetrators, but that’s not really true. Instead, it’s a small number of people who behave badly and a whole lot of people who are complicit, who see the behavior but don’t intervene — and that creates a workplace culture where sexual harassment is accepted.”
While Title IX and Title VII efforts have prompted institutions to establish policies and training on sexual harassment to comply with the law — and avoid liability — they don’t prevent sexual harassment from occurring in the first place. Instead, the culture changes when people see real consequences.
“The greatest predictor of sexual harassment is perceived organizational tolerance,” says Johnson. “To really move the needle, leaders need to make explicit statements about sexual harassment, including appropriate and escalating disciplinary consequences for perpetrators who violate harassment policies.”
Mayo has done just that, conducting numerous investigations in response to concerns about sexual harassment since January 2018. The institution substantiated two-thirds of the reports, took corrective action in matters where policy violations occurred, and in several cases, terminated employment of staff members at all levels of the organization when appropriate.
The University of Michigan is surveying the landscape, too, asking all faculty members, residents, and students to complete a validated questionnaire that includes detailed questions about sexual behaviors and harassment. The organization is also investigating alternative ways for victims to report incidents.
“If people don’t want to report because they’re afraid of retaliation, we need to fix mandatory reporting policies,” says Johnson. “This is not about due process. It’s about establishing a record so if the perpetrator exhibits the behavior again, there’s evidence to remove them.”
With each of these efforts, the goal is to create a cultural shift where medical students and residents feel emboldened to call out microaggressions, even ones in which they are not the intended victims. “That comes from training,” says Johnson.
To that end, a number of institutions are developing educational modules that include short video vignettes to guide medical students. Mayo’s expanded training includes videos, articles, reference cards, and other materials that specifically address sexual harassment.
University of Michigan medical students and residents are given language to reject inappropriate behavior when it happens. And a strategic initiative arising from the Harvard women's leadership course Be Ethical Campaign focuses on workplace culture and gender disparities.
“Every doctor wants to be viewed as ‘ethical,’ so looking at these issues through an ethical lens is really important,” says Silver. “Am I able to sleep at night if I let someone off the hook who I know is a serial predator? Is that ethical behavior?”
A national effort
Across the country, thought leaders in science and medicine also are coming together to establish a climate of respect and inclusion. The American Association for the Advancement of Science approved a code of conduct stating that individuals who behave inappropriately can be removed from a meeting and barred from future meetings. The National Science Foundation announced that it may terminate funding to grantees who engage in sexual harassment. And the National Institutes of Health says it will treat sexual harassment the same as research misconduct.
“The message is that sexual harassment is not only unethical, but it’s also on par with data confabulation because of its adverse effects on the people and the science,” says Hayes.
The AAMC, too, has launched a series of initiatives designed to curb sexual harassment in medicine, including a set of “Foundational Principles of Inclusion Excellence” to help member medical schools assess the institutional culture and climate. “This set of nine benchmarks acts as a sort of roadmap to help institutions develop strategic action plans that will move them toward building a more inclusive learning and workplace environment,” says Acosta. “The toolkit will have an assessment tool and a rubric score card along with resources and examples of schools that are doing some great work related to each of these benchmarks.”
And on Feb. 15, 2019, the AAMC, along with the American Association for the Advancement of Science and the American Geophysical Union, established the Societies Consortium on Sexual Harassment in STEMM. The Societies Consortium, consisting of 53 member societies representing the STEMM fields (science, technology, engineering, mathematics, and medicine), will focus on preventing and responding to sexual harassment within their respective disciplines.
“Combating sexual harassment in academic medicine and across the STEMM fields requires a multipronged, ongoing, and sustained approach,” says Acosta. “The Societies Consortium will help our organizations — and in turn, our respective member institutions — see across the landscape of STEMM as we work together to develop the strategy and tools needed to foster a more inclusive learning and workplace environment.”
“We grew up with the fallacy that you can’t stop the people at the top,” adds Acosta. “From the #MeToo movement, we’ve learned that’s not true. If you’re in solidarity, if you find your voice, and if you’re protected, the culture can change.”