#162 Gender & Sexual Harassment in Medicine, #MeToo

July 22, 2019 | By Leah Witt

Women In Medicine ep3 with Reshma Jagsi MD, DPhil of TIME’S UP Healthcare

Dr. Reshma Jagsi, @reshmajagsi (TIME’S UP Healthcare; UMichigan) schools us on sexual harassment and describes the systemic and cultural changes that need to happen to effect real change. She unpacks the definition of sexual harassment, describes the state of the #MeToo and TIME’s UP movements across the science and medicine fields and highlights how we all can recognize/respond to harassment.

This is the third episode of our Women in Medicine series. Last August, you heard us talk to Dr. Vinny Arora about the paucity of women in leadership positions, finding sponsors for career advancement, and being bold about career decisions. In December, we spoke to Dr. Susan Hingle about work-life integration. Her advice? Stop worrying about what other people think, acknowledge that being a doctor is hard, especially for women due to disproportionate out-of-work responsibilities, and define a beautiful life that is individualized to you. 

Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.

Credits 

• Written and produced by: Leah Witt MD, Shreya Trivedi MD, Nora Taranto MD, Sarah P. Roberts MPH.
• Editor: Matthew Watto MD
• Hosts: Shreya Trivedi MD, Chris Chiu MD, Leah Witt MD
• Guest: Reshma Jagsi MD, DPhil
• Special thanks to: Hannah Abrams MS4, Beth Garbitelli MS2, and Molly Heublein MD

Time Stamps 

• 00:00 Intro, disclaimer and guest bio
• 03:10 Guest one-liner, WIM moment of awakening, Dr. Jagsi’s advice to her younger self
• 10:40 TIME’S UP Healthcare, how to get involved
• 13:10 Picks of the week: This American Life (podcast); The Bon Appétit channel (YouTube), The Nocturnists (podcast); Twitter
• 17:05 Defining sexual harassment
• 21:05 A case of sexual harassment; Predictors of harrassment; Duty to report
• 27:30 Creating a system that makes reporting easy
• 30:19 How pervasive is sexual harassment?
• 34:33 Why/how does bad behavior go unreported?
• 36:22 Pregnancy, parenting and promotion 
• 39:10 How is gender equity related to harassment? What can we do in our day-to-day?
• 42:13 An example from Radiation Oncology
• 46:43 How gender identity intersects with many other identities (e.g. religion, sexual orientation) 
• 48:15 Examples of how institutions are changing academic culture and addressing gender equity
• 53:28 Anonynmous reporting of sexual harassment
• 58:01 Take Home Points
• 60:25 Outro

#MeToo, Gender & Sexual Harassment Pearls

Harassment is underrecognized in medicine, perhaps because we become desensitized to extreme work conditions and environments 

Overt sexual harassment is the tip of the iceberg, we must also pay attention to gender harassment (e.g. put downs such as derogatory comments about one’s ability to perform in a job related to gender)

Harassing behaviors thrive in an environment of gender inequity, therefore it is critical that we address inequity in organizations (e.g. increase the number of women in leadership positions)

Fix the system, not the woman! Encourage your organization to sign up for Time’s Up Healthcare, and model organizations who are working to foster an equitable work environment (#OrgInspo)

Sexual Harassment Show Notes

Dr. Jagi’s Path to Gender Equity Research

Early on in her career, she thought that gender equity was a problem addressed by her mom’s generation. In residency, her mentor opened her eyes to how few women were in senior positions in medicine, and encouraged her to understand this issue. In 2006, she kicked off her research in this area in a NEJM article about the gender gap in academic authorship (Jagsi NEJM 2006) and followed this work up by demonstrating that women who received K awards were not receiving RO1s at the same rate as their male peers (Jagsi Annals 2009).

TIME’S UP Healthcare 

Founded to provide safe, equitable and dignified environments for women in healthcare. Dr. Jagsi is a founding member– catch Dr. Jagsi on Twitter, where she shares her thoughts on gender equity: @ReshmaJagsi!

What can you do?

Ask your institution to become a signatory organization! They must commit their organization to the core values of TIME’S UP Healthcare, and work with the organization to measure and track metrics regarding gender equity

What is sexual harassment?

Sexual Harassment in Medicine 101

Check out the National Academies excellent report: Climate, Culture, and Consequences in Academic Sciences, Engineering, and Medicine.

Particularly valuable is their iceberg figure, in which they define not only the overt types of harassment that we are most familiar with, but also the subtle gender-harassing behaviors that create hostile work environments.

Examples of sexual harassment:

• Sexual assault
• Unwanted touching/groping
• Quid pro quo (promising a reward for a sexual act)

Examples of gender harassment:

• Vulgar name calling
• Insults to mothers who are working
• Put downs/Insults based on gender (e.g. women are not as good at math or science)

Case 1: Dr. Blackwell mentors a resident, Dr. Ida Wells 

Dr. Wells is a second year resident with an interest in heme/onc. Dr. Blackwell is now a junior faculty member who is an advisor and mentor to Dr. Wells. Dr. Wells is finishing her heme onc rotation, and enjoyed working with her most recent attending: Dr. Malfoy, the division chair of the heme/onc department. Dr. Wells hopes that he will write a letter of recommendation for fellowship.  At the end of their time on service, Dr. Wells asks Dr. Malfoy for feedback, and he invites her to an off-service dinner where he says he’d like to deliver the feedback, with other members of the team present. Dr. Wells goes, but no other trainees attend. Dr. Malfoy spends the dinner talking about his open marriage and asking Dr. Wells personal questions about her prior partners. Dr. Wells finds a way to excuse herself out of the dinner early.  Over the next week Dr. Malfoy texts her repeatedly, inviting her to concerts and lunch, and discloses he may be getting a divorce. She spoke to her co-residents– several of them said, ‘everyone knows Dr. Malfoy likes to flirt with female residents’. Dr. Wells turns to you, Dr. Blackwell, her residency mentor, for advice. She feels she needs a letter from Dr. Malfoy and is pressured to go to these events, but feels uncomfortable with his behaviors.

Is this sexual harassment?

Yes! This is pretty clear…but devastating that this sort of thing still happens.

What should she do?

Reacting to this is not the sole responsibility of the woman receiving harassment. Best practice is to fix the system not the woman. She’s doing the right thing, to seek a mentor’s help! Ideally, the mentor will help to confront the offender or report the behavior. 

What should institutions do?

At the organizational level, there should be dissemmination and enforcement of sexual harassment policy (Choo et al Lancet 2019)! Systems should provide a variety of reporting processes (formal & informal) and contingent anonymous reporting (e.g. don’t contact me unless x other individuals also come forward).

How common is sexual harassment in medicine?

In 2016, Dr. Jagsi surveyed physicians selected for NIH career development awards (K-awards) between 2006 and 2009 about their experiences with gender and sexual harassment. When participants were asked “in your professional career, have you encountered unwanted sexual comments, attention or advances by a superior or a colleague?” the study found that 30% of the women physicians said yes–compared to only 4% of men surveyed (Jagsi et al, JAMA 2016). 

2018 National Academies report: Female medical students were 220% more likely than students from non-STEM disciplines to have experienced sexual harassment by faculty or staff. 60% of female trainees report having been sexually harassed.

Why does harassment persist in medicine?

Unfortunately, sexual harassment is probably worse in medicine. The medical field features many predictors of sexual harassment such as hierarchical organizations and gender inequity in leadership positions. Additionally, medicine and medical training is replete with egregious behaviors/treatment we’ve been socialized to tolerate and consider normal. Additionally, women in medicine have worked very hard to become physicians, and may fear stigma in reporting episodes of harassment (Jagsi NEJM 2018).

Case Two: Dr. Blackwell navigates career/family planning

Dr. Blackwell is in her second year as an attending, and recently announced to her division that she is 6 months pregnant. She is learning about maternity benefits. She’d love to take 3 to 4 months for maternity leave, but she has started to get comments that make her uncomfortable. For example, her medical educator mentor recently said to her “you won’t be able to keep on target for promotion with small kids at home”. Is this sexual harassment?

Is this harassment?

Probably not. Her mentor may mean well here, but it is a problematic example of gender bias, and is making a bunch of assumptions. But we’ve talked about this before– women–and women in medicine–typically shoulder the greater burden of domestic responsibilities.

In the same sample of K awardees, these women were spending 8.5 hours more per week on parenting and other domestic responsibilities.

What should her mentor do?

Instead of telling her that she won’t be able to keep on target, the mentor should give her resources that the institution provides to mitigate these issues.

What about organizations?

While not all women in medicine may choose to have children, it is necessary to recognize the reality of the collision of a woman’s professional and biological clock. 

Medical organizations should incorporate policies advocated by the medical staff they employ. Example: parental leave policies in medicine, particularly for trainees, are out of line with the policy recommendations of many of our own professional societies..

The inequity/harassment vicious cycle: gender inequity is the environment in which harassment thrives!

16% of US medical school deans are women. Addressing this leadership gap, and the leaky pipeline, is key to mending environments in which harassment flourishes (AAMC 2019).

The call to action:

Even if you aren’t in a leadership position, there is plenty you can do!

Lead from the middle and from the grassroots level to write editorials, advocate for change in your professional societies, create social media campaigns, and network across the country and globe (find your #WIMsquadgoals).

Recognize the unique needs of diverse groups of women. Women who are inhabiting multiple minority identities will have different perspectives and needs, and are likely facing even greater hurdles. The power of social media networking can be particularly valuable here (future episode to focus on diversity, equity and inclusion!).

Men, this is your battle too. 

In considering work-life fit, equity, and burnout for men and women, we were struck by a recent New York Times editorial by Dr. Danielle Ofri, “The Business of Health Care Depends on Exploiting Doctors and Nurses”. Dr. Jagsi advocates that the solution to this problem lies in a more equitable division of leadership positions. Women come with a different perspective and unique solutions, and will say: “Why does it have to be the way it has always been?”

Lastly, change happens in part because people with privilege use their relative power to help level the playing field. While gender is not the only aspect of one’s identity that lends an individual more or less privilege, overwhelming data has shown that women in medicine disproportionately endure gender-based harassment relative to their male colleagues. Men have a moral imperative to recognize and respond to gender and sexual harassment (and all biased/bigoted behaviors) and to advocate for women colleagues. 

Now for some #OrgInspo:

University of Pennsylvania: developed a method to measure and operationalize workforce inclusion

University of Michigan: their advance program has a STRIDE committee with tactics to recruit diverse candidates

Stanford University: reported data from a pilot study on rewarding women for otherwise unreported/”thankless” service tasks, such as committee membership, mentorship, and grant review. Stanford recognized participants with credits, that could be redeemed with various services such as home food delivery or grant writing support.

Massachusetts General Hospital: created the Claflin Scholars program–small grants for women during child bearing/rearing years to support scholarly work when they are facing extraordinary extra-professional obligations

Take-home points – Gender and Sexual harassment, #MeToo

1. Sexual harassment is a problem that disproportionately affects women and has to be addressed at the systems level by organizations
2. Individuals are citizens of this profession, and we all have a duty to step up to create,  disseminate and enforce policies that will not allow sexual harassment to occur
3. An environment of inequity is what causes sexual harassment to thrive
4. We must integrate women in each level of organizations, to end up with a structurally egalitarian workplace where men and women are equally sharing in authority

Goals

Listeners will learn about sexual and gender harassment in medicine.

Learning objectives

After listening to this episode listeners will…

1. Define sexual harassment
2. Recall the prevalence of sexual harassment in medicine 
3. Learn to recognize implicit biases
4. Be activated to challenge inappropriate behavior when they witness it, and learn to be agents of change, at any leadership level, in their organization

Picks of the week 

Leah: LaDonna, episode of This American Life podcast

Chris: Bon Appétit YouTube Channel

Shreya: the NOCTURNISTS podcast

Reshma: her daughter interviews Elizabeth Warren about sexism!

Links

Links from the show are included above.

Disclosures 

Dr. Jagsi reports stock options as compensation for her advisory board role in Equity Quotient, a company that evaluates culture in health care companies; she has received personal fees from Amgen and Vizient and grants for unrelated work from the National Institutes of Health, the Doris Duke Foundation, the Greenwall Foundation, the Komen Foundation, and Blue Cross Blue Shield of Michigan for the Michigan Radiation Oncology Quality Consortium. The Curbsiders report no relevant financial disclosures. 

Citation

Jagsi, Resham. Guest, expert. “#162 #MeToo, Gender & Sexual Harassment”. The Curbsiders Internal Medicine Podcast http://thecurbsiders.com/episode-list/. July 22, 2019.