COMMENTARY

How Can Medical Trainees Combat Sexual Harassment?

Nicole B. Saphier, MD; Janine L. Knudsen, MD; Rosalyn E. Plotzker, MD, MPH

Disclosures

January 09, 2019

Nicole B. Saphier, MD: Hi. I'm Nicole Saphier. I'm a radiologist at Memorial Sloan Kettering Cancer Center here in New York City, where I'm an assistant professor and also the director of breast imaging at a regional site of Monmouth.

Today we're at the Medscape office here in New York, and this is a Medscape Live on Facebook event. Today we'll also be talking about sexual harassment in the medical profession. I invite you to take part in the discussion on Facebook. At any point during our discussion today, send us questions. We will regularly be addressing questions from the audience.

Sexual harassment is a large and upsetting problem in society today, and it's especially prevalent within the medical profession. What exactly is considered sexual harassment? Of course, it is rape or any sort of sexual attacks. It also includes many other behaviors, including unwanted groping, someone fondling him- or herself in front of you, unwanted sexual emails or texts, unwanted hugging, comments on body parts, continually asking for a date, propositions to engage in sexual behavior, and other sexually related behavior that makes you feel uncomfortable.

Medscape surveyed over 6200 physicians and clinicians, asking if they had experienced or witnessed sexual harassment of physicians in medical offices or hospitals within the past 3 years.[1] Overall, 7% of women physicians said that they had been harassed by medical personnel, 4% of male physicians said that they had been harassed by medical personnel, and in 47% of the cases, the perpetrator was another physician.

We have two physicians here today to discuss this serious issue. Dr Janine Knudsen is a primary care physician at Bellevue Hospital Center, faculty at NYU School of Medicine, and the medical director of population health at NYU Health here in New York City.

Dr Rosalyn Plotzker is the University of California San Francisco sexually transmitted disease fellow for the California STD/HIV Prevention Training Center and the California Department of Public Health STD Control Branch. She also has a master's of public health in health promotion and disease prevention.

Welcome, both of you. Thank you so much for being a part of this very important discussion. Let's just dig into this subject right now. Again, for anyone watching today, feel free to type in any questions and join the conversation; we're going to talk about whatever you send.

I'm going to start with you, Janine. Is it your impression that sexual harassment is a serious problem in the medical field?

There's a culture in the medical profession of sort of grinning and bearing it that's led us to really not talk about it.

Janine L. Knudsen, MD: I definitely do think it is, and I'm really glad that there's been more light shed on this issue, both through the survey and through publications in the New England Journal and other journals that have really been talking about it. I think that there's an issue in terms of physicians, especially trainees, being harassed by their colleagues and also by their patients. There's a culture in the medical profession of sort of grinning and bearing it that's led us to really not talk about it. I'm glad we're here today having this really important discussion.

Saphier: Thank you. We're very glad you're here as well. Rosalyn, what's your take on it?

Rosalyn E. Plotzker, MD, MPH: I completely agree with everything that Janine said. I think that sexual harassment is something that, unfortunately, is common across many professions, and we tend to assume that medicine might have less of that just by the nature of the field. It's important to recognize that sexual harassment is also happening in medicine, especially with physicians who, as Janine said, might feel the need to kind of grin and bear it and get on with their day. I'm also very grateful to be having this discussion.

Saphier: Both of you are fresh out of training and young. For people who are in training or fresh out of training and are afraid of being kicked out of a program, who don't have a lot of life experience or standing up to people in authority, or just don't have that self-confidence in general, how would you recommend that a younger physician deal with these situations?

Knudsen: I definitely think that is a particularly vulnerable group. When I was in residency—I just finished my training—we felt like there was really not much conversation happening around this topic. We hosted a town hall event with our leadership and our residents to talk about it openly. It was the first time that residents really felt listened to and felt like there was a space for them to bring up these issues because, in the past, it was the kind of thing where, if something happened where a patient exposed themselves in front of you or you got an unwanted hug or an inappropriate comment, you just really wouldn't say anything. There is really no understanding of how to escalate it or what to do.

Even our attendings didn't feel comfortable in this thoroughly, stepping in and intervening in those moments. When we finally started having that conversation, there was this feeling that there was definitely a huge vulnerable population whose needs weren't being met in terms of talking about sexual harassment and knowing what to do about it.

Saphier: As an attending now, do you think that having these conversations is the right thing to do with your trainees?

Plotzker: I think that it's definitely something that can be helpful, and that mentorship and support are absolutely crucial for a trainee to feel like they have an ally in this kind of a situation. Like Janine said, when the residents felt heard, that was absolutely necessary for them to move forward and navigate how to respond in these situations, and also to recognize that they're not alone in it.

Saphier: Absolutely. If you're just joining us, we're Facebook Live. Please feel free to send in any questions, engage in this conversation, and we will read your questions live and talk about it.

The Medscape report that we talked about said that 39% of people told the perpetrator to stop, 20% told the perpetrator how they felt, 55% did not do any of the above, but 40% reported the behavior. It seems like many people said that they were reporting it or they told them to stop. And many people actually did report, but 40% is obviously the minority.

Where do they go? Who should they go to? Not only trainees, but anyone. Where do you recommend they go to? We do all of those modules saying that we should go to HR, but do you feel that that is the right step, or is there something interdepartmental to be done first before going to HR?

Knudsen: Rosalyn mentioned the important piece of mentorship, and I think that's huge. Sometimes these are situations where you don't necessarily want a whole process to be set into motion that ends up penalizing someone, but you'd rather just have someone to talk to or someone to support you. In more serious situations, obviously, there should be a process and a way forward. Just having a mentor, like Rosalyn said, to converse with is helpful.

The report highlighted some situations where people felt like it was a superior that they couldn't stand up to, so you really need someone to bounce ideas off of and figure out what to do next, because it can be a really thorny issue.

Saphier: I think it's a good idea. What do you think, Rosalyn?

Plotzker: I think that having someone to bounce ideas off of is definitely a great first step. One thing that is hard for a lot of trainees is understanding what kind of routes are available. Most hospitals have an ethical code of conduct, and that's something that a lot of trainees aren't aware of or they don't know where to find it. Being able to consult the ethical code of conduct is helpful to understand what the standard of behavior should be. Sometimes I think trainees are a little confused about whether this person is being affectionate or if this is something that's actual harassment and feel uncomfortable.

Having a little bit of time to reflect on the importance of your emotional safety when you are in a training environment is important and should be appreciated. That can also be hard to navigate when you're in hierarchical systems like residency. I think mentorship is crucial. In terms of how a trainee should respond to perceived harassment, [they need] to figure out if this actually falls into that category via the ethical code of conduct and then reach out to the mentor and explain that they feel emotionally unsafe and discuss how to proceed.

Saphier: I think that's great advice. Let's take some questions from the audience and see what they have to say. One issue that has been discussed in the press is what actually constitutes harassment and whether some people are too sensitive.

Do you think there is validity to that train of thought? Before we go into this, obviously, this is a controversial topic and everyone has very different opinions, so we have to make sure that we acknowledge that there is not a right or wrong answer. What do you think?

Knudsen: Rosalyn just brought up a great point: that there really is a spectrum, and sometimes we don't know if what we experienced or what someone else experienced really is at the line or beyond the line. We do know that it made us feel incredibly uncomfortable, and that's where I think it is a spectrum. It's really important to be clear that there's a gray space. That's why you need someone to really discuss it with.

I think the more that people hear about their colleagues' experiences, the more comfortable they'll be, knowing where that line is and when to escalate. The more that we keep it to ourselves and hide our experiences, I think, the worse it is for everyone. That's why having conversations is really the very first step.

Saphier: I agree. Rosalyn mentioned that and she said you want to make sure that it does fall within what is harassment or part of the code of conduct. In 47% of cases, the perpetrator was another physician. Rosalyn, what's your reaction when you hear those figures?

Plotzker: It makes me incredibly sad and disheartened. Unfortunately, I'm not very surprised because that's who doctors interact with. They interact with other doctors and they interact with nurses and other clinicians. It's not surprising, given the fact that trainees are typically interacting with fellow trainees, chiefs, and attendings, that that's where a large source of harassment would come from. I'm sure that it varies also by specialty. There are some specialties where it might be more prevalent or less prevalent, but in general, it's not particularly surprising to me that it's that high.

Saphier: You both just finished training within the past few years, but I would say 20 years ago or even 10 years ago during training, it may have been different interactions between the male and female attendings or trainees. Right now, the Medscape survey shows that the majority of people being harassed are women by men, but there are some men being harassed as well.

Do you think that maybe the male-to-female harassment is getting any better? Are the men who are being harassed being taken as seriously?

Plotzker: In my opinion, I wouldn't call it better. I would say that any harassment is not good. Having more men represented could be an indication that men are recognizing that they are being harassed, whereas historically, they might not have identified that way. Having an environment where male physicians are able to express that they have been harassed is positive. I don't know; it's a tough call, to be honest.

Saphier: It truly is. Janine, Debbie from Facebook—thank you for your question—asked, "Do you think harassment is any worse in medicine than in any other profession?" It's hard to say because we're in medicine, not other professions, but we know that we do see what else is going on.

Knudsen: That's a great question. There is a sort of sense of exceptionalism in medicine. I don't know the answer to specifically compare it, but I do know that medicine has some unique features that are important to recognize. There is this huge hierarchy in training where you're locked into a program or you're a new faculty and you really want to rise up through your career. There's a ton of pressure in medicine—similar to other professions, I'm sure.

Also, there is that sense that we have to do everything in the service of the patient. When it's patient-facing— I've talked about this with other providers at my clinic—we don't always want to give up that relationship that we have with the patient. We know it's in their best interest, so we'll put up with certain things that we would never put up with in our normal lives.

Saphier: You're touching on a very good point, because in the Medscape survey, they surveyed physicians about sexual harassment by patients, and 27% of physicians said that they had been targets of sexual harassment by patients. Is this something you see as a current issue, and how can we shy away from it?

Plotzker: I think that, especially as a young woman physician, that's definitely something that you experience. I am an STD fellow, so I see patients in an STD clinic, which is an especially sensitive context. Being sexually harassed by patients is something that is difficult to confront because it could mean that you are not willing to take care of certain patients and that could be perceived as bad. As a young physician, it's something that people could be hesitant about.

At least when it comes to how patients are treating you and if you're feeling threatened by a patient, in my experience, luckily, my colleagues are very supportive of my comfort in my work environment. Yes, you can be harassed by patients, but I don't think that it's as difficult to talk with colleagues about in that sense.

Knudsen: I would have to agree with that.

Saphier: We have more questions coming in from our audience. We're going to take some of them. Jan from Facebook has a comment, which every one of us agrees with or we have the same concerns.

She says she's afraid that if she says anything, she will get a reputation as a complainer and it will reflect on her instead of the perpetrator. Any advice? That's a tough question because I think that's what the far majority of people fear when they are feeling that they have been harassed, and that worry of retaliation or just being visualized in a negative light.

You've done a lot of research on this. Do you have any advice for what she should do?

Knudsen: I definitely think that's a huge concern and that's part of what leads people to not say anything, especially when it's with a colleague, where you don't necessarily want to be the one to get your colleague in trouble or report bad behavior that other people may know is going on but you don't necessarily want to be the one.

I have seen, just in general, that when people step forward and start sharing their stories—whether it is something really small, like a daily transgression of a patient being inappropriate or something bigger like a major incident in a hospital—just having people starting to speak up is actually a positive thing in this moment. There's just such a need for people really talking about it. I've actually seen the opposite so far, at least in my residency training, where the people who spoke up were actually appreciated because they were finally giving a voice to everyone else who had had experiences.

Saphier: I would say, too, if you're absolutely feeling that something inappropriate is going on and you have that concern, there are anonymous channels that you can reach out to—people who can start doing some investigations to see if maybe you're not the only one who's brought this up. [It's different in every environment], but the bottom line is that you have to talk about it. You have to mention it because it's not good for you and it's not good for everyone else there if you don't speak up. You have to find that right channel. There are mentors all around you. I recommend doing what you can.

Plotzker: I also would add that, in most HR programs, if you do file a formal complaint, you are protected from retaliation. That's something a lot of trainees don't realize. If you are being harassed or you think you're being harassed and you file a report, if that person, once they are notified, does anything that could be perceived as retaliation, then that's a count against them. They are informed of that, too.

Saphier: We also have to remember, though, that we know that that's the legal side of it. As she was saying, she did not want to be viewed as a complainer. If you do put something forth, yes—legally there can be no form of retaliation, but it will get out there that maybe there has been a report. In the subjective sense, she doesn't want to be seen as someone who complains about something that maybe other people overlooked. All I can say is that you just have to get over that because you have to be true to yourself and do what you feel is right for yourself and for those around you.

Again, anyone just joining us, we are Medscape Live. We are here in New York City at the Medscape studios. Please type in questions and join this conversation. It's a great conversation. Let's keep going.

About half of physicians report that their workplace conducts sexual harassment training. Do you sense that this is useful? I have my own opinions on this.

Knudsen: I think I know what you're going to say, but I think it's such a thorny issue and a really important one to talk about. We've all done HR trainings. They are usually slideshows that you sort of flip through or multiple-choice questions that you get through as quickly as possible. I just don't think that cuts it.

There's been a lot of interesting work being done in simulation training in medicine in general. Most medical schools now have a sim center where they sort of mock difficult situations out. I think this is no exception. This would be a great opportunity—and maybe there are programs already doing this—to really put people in a situation, not obviously of sexual harassment, but of that situation where they need to escalate or they need to have a conversation with a colleague or they need to maybe approach their mentor for support.

I think those are really important things that, in the moment, no one usually knows what to do and they're overcome with emotion, so it's really important to have that kind of training in advance. I wish that we could move toward that kind of an approach.

Saphier: Rosalyn, what's your take on these modules that we do regarding sexual harassment?

Plotzker: I think it's good that they're included. I think that it's something that shows that the institution is recognizing that it's an important thing to talk about, but I would agree—I don't think that they are sufficient.

We need more anonymous routes when it comes to reporting, because that's the first step to getting people to report these issues.

Saphier: So, I can tell you that I'm inundated. Maybe I've just been doing this a little bit longer so I'm a little burned out from all of the modules that we do and all of the clicking, but I'm inundated with all of these. For me, it's every September of every year. I have a stack of about 20 different modules that I have to complete, including safety training, sexual harassment, gender issues, sex trafficking, and opioids. There are so many things that we have to do and it is just another checkbox.

I don't necessarily think that that's moving the bar on anyone. I think more discussions need to be made. I think we need more anonymous routes when it comes to reporting, because that's the first step to getting people to report these issues. We don't really have a lot of time to just sit and talk about it during our work day, and a lot of people aren't going to be comfortable with doing that.

Instead of having a survey on someone telling me that I'm not allowed to tell someone that they look good today, maybe you could just ask me if I feel comfortable in the workplace in an anonymous way. I think that would move it a little bit more forward.

Next question from the audience. Amy from Facebook asked, "What about training the potential harassers?" I'm not quite sure what that means, but maybe she's saying train them on their behavior instead of just having punitive measures. Maybe that's what she's referring to.

Maybe they don't recognize that they're even harassing someone. We do have colleagues that may say, "Oh, I like your outfit today" or "Your hair looks really nice today." For some, if that makes you feel uncomfortable, that is a form of harassment. They may not realize that. Maybe their wives have told them that you have to comment on a woman's hair, so maybe they don't realize they're making you feel uncomfortable. What's your take on that?

Knudsen: I think this gets at the important issue that you can't always expect the victims or the people who are really suffering from these things to be the ones to act up. We should really put the responsibility on the people who are actually perpetrating the action, whatever level it is. I completely agree with the sentiment of this question—that we need to put the responsibility on everyone, really, to solve this issue.

Saphier: Do we need to make them understand more? Do we have to help them understand that certain behaviors actually do make people feel uncomfortable?

Knudsen: Exactly. I think it is important to educate people on the spectrum of harassment and that sexual harassment is not only inappropriate touching or rape; there's so much more to it. I think that is a really important point. There needs to be more education. If someone is being reported or being complained about, we need to have a really good mediation approach for them.

In many cases, we don't draw the line with patients and we need to have a better way to do that. We need to make it clear to patients that their doctors are people who need to be treated appropriately and that there are rules—sort of like a contract that you really can't break.

Saphier: That's great advice. I have a controversial question. I'm going to start with you, Rosalyn. How do you think men are feeling about the #MeToo movement? Do you see any sort of bias or unfairness towards men?

Plotzker: Number one, I'm not a man and I can't speak on behalf of all men. I have had this discussion with several male friends, and I think there's a wide range: from an increased awareness, sympathy, and allyship towards women, which is phenomenal; to oblivion; to "That's not me and it's terrible that other people would do that." Some men feel a little nervous, like they're walking on eggshells. It really spans the gamut. In general, at least among my friends who I've spoken with, it's been garnering more support, sympathy, and allyship, so that's incredibly reassuring.

Saphier: That's great. Moving forward, is there anything else that you would like to touch on regarding this topic and really get out your message?

Plotzker: I think that with sexual harassment, it's important to feel strong enough to stand up for yourself. Even if you have concerns about retaliation or about people thinking that you're a whiner or something like that, you should really remember that you're not alone and that feeling emotionally unsafe at work is: (1) not sustainable for you; (2) not great for your patients; and (3) you're probably not the only one. If you do have those concerns, please reach out to a mentor, get support, and go down whatever route you need to feel safe at work.

Saphier: Great. Janine, what is your message? At the end of all of this, in conclusion, what advice do you give to women physicians who feel that they may be being sexually harassed or how can they avoid it?

Knudsen: I really agree with everything that Rosalyn just mentioned in terms of doing it for yourself to prevent your own burnout. I think it's hugely important to be addressing these issues and to have someone else to talk to. My feeling is that the more we talk about it, the more things will naturally improve. People will start coming up with better ways to report, better ways to train people, and better ways to deal with situations. We have to keep that conversation going because without that, we will be stuck in the same situation we've always been in.

Saphier: I agree. My final thought on this—you guys have been great, you are the experts. For me, I don't want to see so much polarization between the genders. This isn't women versus men, especially when it comes to the medical community. I have amazing male colleagues and I have amazing female colleagues. I just want us all to work together in this.

I know that a lot of my male colleagues, if they ever knew that they were doing something that made me feel uncomfortable, they would change that behavior. If I don't tell them, then how are they going to know? Of course, there are outliers who have inappropriate behavior, and that does need to be taken care of. You have to get rid of any of those fears of retaliation, fears of being labeled as weak or a whiner, because this is your life. We only have one shot at it, so you want to be as happy as you can be.

I'm going to take one more question because we're getting toward the end here. Sibila from Facebook asked, "When should we involve the law?" That's a great question. That's a very serious question. I'm going to start with you, Rosalyn.

Plotzker: Before you go down legal routes, HR would be a really important place to start. If you feel like you're being harassed and you try personal communication, it's important to document everything if you're thinking about a legal route. For example, if you have a conversation with the person who you're having a conflict with, you can email them afterwards and say, "Thank you for this conversation. I'm glad we established X, Y, and Z."

Before you get the law involved, I would first go through the HR department in your institution because they have their own procedures of investigation and remediation, if necessary.

Saphier: You can also consult a lawyer because an attorney can help guide you. They will tell you if this is something worthy of going forward with or not. But I agree. If you feel comfortable enough going through your route through the hospital, that might be the way to go first because it can get ugly really fast once you involve the law. Would you agree with that?

Knudsen: Yes, I completely agree with that. I think there are formal processes in place to make it easier on people so that they don't feel the need to escalate quickly. HR will not only tell you the process but they'll also counsel you and make sure you're connected to the right resources. I think it's a really good point.

Saphier: One thing on that: There are actions that should just go straight to the law and shouldn't go through mentorship or to HR. Again, we're talking about a spectrum. The majority of what we've been talking about here is more on the—I'm not going to say benign spectrum of things, but maybe the less invasive.

If you have something that is legitimately breaking the law, obviously you don't go through these other channels; you go straight to the law. I think everyone agrees.

We're having more questions coming in now, so we are going to stay a few minutes longer because we like to engage.

Destiny from Facebook is asking, "Are there any details that should be included in a report when you do report?" What would you recommend that you put down? What's important to make sure that you include?

Knudsen: Yes. This gets to Rosalyn's point that you really need to document everything. As much as possible, if something happens that you're uncomfortable with, write it down before you forget. If there are people who were there that witnessed it as well, it's helpful to write that down in case you need to draw on their help later on.

Saphier: Dates, times, locations, and surrounding people.

Knudsen: Exactly. As many hard facts as you can. It's really important.

Saphier: Anything to add?

Plotzker: Those are all very important points. I would add that, especially with sexual harassment, you want to be very clear with your language in terms of your experience. You could say, "I felt threatened" or "I felt intimidated." Also, try to use objective language—just the facts, ma'am, as in, "He said this. I said that. I felt intimidated. He raised his voice." I think those are all very helpful when people are reviewing reports.

Saphier: I agree. That sums it up for all of us. Thank you very much. Rosalyn Plotzker from UCSF and Janine Knudsen from Bellevue, here in New York City. Thank you, everyone, for watching, engaging in the questions, and joining in. Check out the report[1] and follow Medscape on Twitter and Instagram.

If you want to look at the whole sexual harassment survey that we've been discussing, you'll find it in the link on our Medscape Facebook page.

Engage—that's the best thing. You are not alone. If you are feeling any of these ways, everyone's here for you. We have a ton of resources, so reach out. Thank you, everyone, for being here. I really appreciate it.

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