This is the third installment in a 鶹ý series on sexual harassment in medicine. The first story, "When Mentor Becomes Aggressor," examined the reasons why women frequently don't report incidents of harassment. The second, "Could the 'Pence Effect' Undo #MeToo," addressed a potential adverse unintended consequence of the movement. Here we discuss efforts to keep harassment from occurring in the first place.
The Association of American Medical Colleges (AAMC) has policies that "call for professionalism in the learning environment," according to the group's chief healthcare officer, Janis Orlowski, MD. All accredited medical schools must document their reporting mechanisms and prevention efforts. There must be at least one person at each school whose job it is to deal with harassment complaints, she said.
But a on sexual harassment in technology fields, including medicine, suggests "we have to dig deeper," Orlowski said.
One of the strongest predictors of harassment is the perception that it's tolerated by an organization or institution, noted the report and several researchers interviewed by 鶹ý.
"Many institutions have policies in place that say that they do not tolerate sexual harassment, but the reality is that the climate says that it's tolerated," said Frazier Benya, PhD, who served as study director for the report.
Culture is defined as the policies on paper, while climate is how those policies are lived and experienced, Benya explained.
While what women experiencing harassment want most is for that behavior to stop so they can continue their work undisturbed, they often perceive that formal reporting systems don't always achieve this goal, Benya said. As a result, most targets of harassment are more likely to tell close family members or friends about their experience than an official at their institution.
In some cases, targets experience what researchers call "institutional betrayal," where the reporting and investigation process snowballs, requiring multiple witnesses to confirm that an event happened, and that can "re-victimize" the person.
Additionally, reporting may not even stop the inappropriate and harmful behavior, Benya added.
When people witness or experience sexual harassment, they often have a kind of "deer in the headlights" reaction, said Timothy Johnson, MD, a co-author of the NASEM report and a professor at the University of Michigan. "We need to get them past that."
Medical students and staff ought to be warned that "if incidence of harassment is 40%, 50%, 60%, that's going to happen to many, if not most of them," he said.
Targets of harassment and bystanders need to have the language and the skills to respond immediately, he said.
Role-playing is one way to train medical professionals about harassment. Doctors are accustomed to difficult discussions and it should be possible to "train people to be comfortable with language that will allow them to move forward in a productive way."
He said online training has not been "terribly effective," but he also said that elaborate sessions with "a semi-professional group of people doing a mini drama" is probably overkill.
What About Prevention?
What's important, Johnson emphasized, is for health systems and private practices to invest real time and resources in addressing harassment.
Potential aggressors need training too, said Sharon Stein, MD, president-elect of the Association of Women Surgeons and associate professor of surgery at University Hospitals in Cleveland.
"We can't just tell people, 'You've done something bad.' We need to be proactive ... Some of those behaviors that were tolerated for a long time in society are not acceptable at this point," she said.
Stein suggested "professionalism training" could be part of the maintenance of certification.
While different medical groups have held thoughtful sessions during certain conferences focused on the #MeToo movement, these are often poorly attended, she said.
"A lot of the people who are hearing that message are not necessarily the people who are most in need of that message," she added.
Institutions must ensure that everyone in their organization knows that perpetrators of sexual harassment will be punished and build mechanisms to uncover the problem.
"What organizations can do is become more transparent about their policies and clearly disseminate their approaches to addressing harassment and regularly measure and disseminate the evaluation of workplace culture," said Reshma Jagsi, MD, DPhil, a radiation oncologist and director of the Center for Bioethics and Social Sciences at the University of Michigan in Ann Arbor.
This means publishing annual reports that show the number of harassment complaints reviewed, the number formally reported, and the number uncovered through anonymous surveys. The reports could also include the number of investigations launched and sanctions taken, Jagsi continued.
And while anonymous reporting systems sometimes get short shrift, Jagsi sees them as "powerful."
Giving someone a chance to come forward is an important step, especially if at least one other person has made a similar complaint against the same person.
Just as physicians don't need to know every patient's individual story to understand how to treat one person's condition, by accumulating evidence, even anonymized evidence, hospitals can advance the movement.
"I think that's really the way forward," said Jagsi.
Not Gonna Take It
On Feb. 28, more than 50 women in healthcare started to advance "new policies and decisions that result in more balanced, diverse and accountable leadership; address workplace discrimination, harassment and abuse; and create equitable and safe work cultures," according to a press release.
Partners in TIME'S UP Healthcare include the American Medical Women's Association, American College of Physicians, National Medical Association, Service Employees International Union, American Nurses Association (ANA), and the Council of Medical Subspecialties.
One of the group's founders, Jane van Dis, MD, medical director for the Maven Clinic in New York City, said that past efforts to end workplace discrimination and harassment, such as creating an office of diversity and inclusion, often lacked teeth.
For her, the solution lies in the data.
"It's not enough to gather the leaders together and look at reports, you have to ask every member of the workforce, 'What does it feel like to work in that environment?'" van Dis said.
And if CEOs, deans, and administrators don't like what they hear, they need to change the climate. For van Dis, real accountability means dollars.
"Why not tie executive and dean compensation to metrics on this?" she asked.
Data points could include the number of sexual harassment claims filed, the number of gender discrimination claims filed, and pay and promotion gaps, van Dis said.
"You have to hold leadership accountable, otherwise you will just continue to have symbolic compliance," she said. One part of that accountability, she added, is that reporting systems need to be trustworthy and safe for victims. "That's on the institution," she said.
Another way to create change seems obvious to many: "Put more women in leadership," van Dis said.
While even the concept could trigger a backlash around mandatory quotas, she said the data show it works. "When there are more women in leadership, there are fewer cases of sexual harassment," she said.
In this same vein, the pay gap only exacerbates issues of harassment and discrimination, said Roberta Gebhard, DO, president-elect of the American Medical Women's Association and co-chair of its gender equity task force.
"As long as women are being paid less than men, then we are valued less than men. So, therefore men think its okay to treat us poorly," she said. "Pay equity is part of the movement."
Such conversations may be difficult, but they are necessary, van Dis stressed.
than ever before and more mothers are encouraging their daughters to join the field, but one in two will be sexually harassed.
"I don't think that's fair to our daughters," she said.
Medical Societies Take Notice
Melissa Garretson, MD, a pediatric emergency physician in Texas -- and one of the co-authors of an emergency resolution calling for a review into the American Medical Association's own protocol for dealing with harassment, which passed this November -- said she'd like to see a big national meeting focused exclusively on harassment as a first step.
"That's one of the things that we're good at, bringing experts together to talk about solutions," she said. "Use the same approach with harassment in medicine to root it out."
Garretson continued, "Then we need to share it, what worked and what hasn't worked, and how we did it better."
A #MeToo meeting could include law firms, experts in education to talk about safe mentoring, victims' experts, and perhaps targets of harassment, who can explain how they worked through the issue and moved forward, Garretson said.
In Australia and New Zealand, the Royal Australasian College of Surgeons a few years ago, Stein pointed out.
It examined the entire population of surgeons and surgical residents in the two countries to identify prevalence of bullying, discrimination, and harassment, and from it developed an action plan in 2015.
David Hoyt, MD, executive director of the American Colleges of Surgeons, said his organization is currently developing a multi-year study on harassment in the field. One goal is to find groups and institutions where harassment is less of a problem and determine what they're doing right.
In more academic phrasing, it will identify "cultural elements that can be understood and ultimately controlled to reduce the prevalence of" harassment, he told 鶹ý.
In December 2017, the ANA launched the to curb physical and verbal abuse against nurses. It that the initiative would not neglect sexual harassment.
The Medical Women's International Association will convene its centennial meeting this summer and , where members can share best practices for addressing sexual harassment around the world.
And the AAMC is also hosting a leadership forum in June where sexual harassment will be one of the key topics.
Next week: Patients can be harassers, too.