By Gary Evans, Medical Writer

It will surprise few employee health professionals that healthcare is no exception to the shocking incidents of sexual harassment being reported nationally in various industries by the #MeToo women’s movement.

Indeed, one of the largest jury awards for a single sexual harassment claim was to a physician assistant who faced continued abuse even after she reported the behavior. The allegations included recurrent sexual language and slaps on the buttocks by a surgeon.

Though that instance was later settled for an undisclosed sum, the $168 million ruling against Catholic Healthcare West in San Francisco in 2012 showed that “juries across the country are responding with a certain anger toward these allegations,” said Andrew L. Zwerling, JD, a partner with the firm of Garfunkel Wild in Great Neck, NY.

“Another example is a $1 million award given to a physician who was found to be wrongfully terminated for complaining about the existence of sexual harassment,” Zwerling said in a recent webinar1 on the issue. “Another $1 million award was given to a nurse who was terminated for complaining about an affair between a hospital’s chief medical officer and a hospital director.”

In a recent development, a lawsuit filed on Dec. 13, 2017, by a nurse in Los Angeles alleges assault and sexual harassment by a surgeon. In an incident caught on security video, a man in full PPE attire — allegedly the surgeon — can be seen pushing the back of the nurse’s head as she leaves the operating room. The suit alleges the surgeon told her, “I know I can do this because I know you like the abuse.” (The lawsuit is available online at: http://bit.ly/2n0NsLe.)

Like other aspects of a dysfunctional work culture, sexual harassment in healthcare can adversely affect employee health and, by extension, patient safety.

“As far as broader consequences of such behavior, [it causes] a toxic work environment, decreased staff morale, and diminishment of patient care quality and a greater risk of medical errors,” Zwerling said.

That is due, in part, to disruptions in communication and breakdowns in teamwork, as workers “on guard” for sexual harassment may lose focus on important clinical tasks.

“We have empirical data that shows a direct link between disruptive behaviors and sexual harassment to adverse patient outcomes, medication errors, and so on,” he said. “If you have lower staff morale and higher turnover, you’re going to have diminished productivity, [and that] affects bottom-line revenue.”

A Teachable Moment

Given this logic, there is every reason for an emphasis on training workers and implementing sexual harassment prevention programs in healthcare. The continuing revelations about nationally known figures exposed by the #MeToo movement is adding further impetus. Given the available data and anecdotal reports, it appears that a similar movement in medicine would generate a substantial number of personal accounts of sexual harassment. If nothing else, this is a teachable moment.

Though nurses have power in numbers as the predominant workforce in healthcare, they have long experienced sexual harassment from both colleagues and patients. A contributing social factor is thought to be the “sexy nurse” stereotype in pop culture and annual Halloween costumes. The author of an article2 on the issue concluded by urging nurses to “stop the line” and point out the behavior when it occurs.

“Report any incidents of harassment that you see occur or experience yourself,” the author concluded. “Involve your supervisors and peers in reporting. Empower all professionals to be able to say without fear, ‘No! This behavior isn’t okay,’ or ‘I feel uncomfortable with this conversation.’”

Somewhat surprisingly, given their perceived power in the work culture hierarchy, 30% of female physicians surveyed in a study3 reported having personally experienced sexual harassment by a superior or colleague.

“Female physicians face the same challenges as other women in fearing adverse consequences after reporting their experiences,” said lead author Reshma Jagsi, MD, DPhil, in the department of radiation oncology at the University of Michigan in Ann Arbor. Indeed, they have devoted many years of their lives to education and training needed to practice independently as a physician, making them want to avoid “any threat to one’s professional well-being,” she said.

As she recently described in a commentary4 about medicine and the #MeToo movement, Jagsi gave up a scholarship opportunity to avoid future contact with a surgeon who harassed her at a professional society meeting.

After “politely rebuffing sexual advances” at a dinner, she managed to exit with a female colleague, escaping from “what was rapidly evolving from an uncomfortable situation into something potentially worse.”

As described in her commentary, Jagsi experienced the stigma of reporting and fear of being cast as a victim in a field in which she aspires to leadership.

“Having come of age in the era of Anita Hill’s testimony against Clarence Thomas during his confirmation hearings for the Supreme Court, I know that women who report sexual harassment experience marginalization, retaliation, stigmatization, and worse,” she wrote. “Even in the #MeToo era, reporting such behavior is far from straightforward. … The brave physicians who’ve contacted me say they remained silent and questioned their self-worth after their experiences, wondering whether they brought it on themselves.”

Reports of such feelings are common in all fields, and 59% of respondents in Jagsi’s study reported a loss of confidence in themselves as professionals.

“When one is objectified, it makes a woman wonder why the harasser could not see her as a complete human being, with important ideas and intellectual contributions as a professional,” she told Hospital Employee Health.

Jagsi’s commentary in the New England Journal of Medicine drew comments from other female physicians that were posted online by the journal.

“It’s about time,” commented Louise Rutledge, MD, a neurologist. “Women have had to defer to a variety of sexual harassment issues forever, and yes, it exists in medicine as well as other fields. In the dark ages when I was a medical student, women occupied 20% of the seats in med school. Much better than the previous generation of female MDs, but still a minority. During one lecture, a Playboy image was put up on the screen in front of the class. One brave young woman began to loudly hiss, and the rest of the women joined in — hissing and booing. The professor was perplexed, since previous classes had not stood up to such nonsense, and you could tell that the professor really did not understand how offensive his action was at that time. About half of the men thought it was hilarious until the women protested.”

Deborah Duitch, MD, a psychiatrist, recalled being called “little girl” in medical school and described a demeaning incident.

“I was asked to clean the instruments, just as the women assistants were after procedures,” she commented. “I noted the male medical students were not asked to help out. I verified this, asking several male student colleagues. They said ‘Of course; we were never asked.’ I asked why I was asked to clean the instruments when the men were not, and received a D [grade] for my complaint. Thankfully, it did not affect my residency choice.”

Severe Incidents Reported

In the study, Jagsi and colleagues surveyed recipients of academic career development awards from the National Institutes of Health.

“The vast majority of these individuals have MD degrees,” she said. “As for comparison to other industries, these data seem generally similar. Because we focused only on harassment by a superior or colleague, and we didn’t include harassment by patients, the rates we observed would be even higher if one included patient harassment.”

Among women reporting harassment, 40% described more severe forms, which included “unwanted sexual advances, subtle bribery, or threats to engage in sexual behavior, and coercive advances,” she said.

Overall, 47% reported that these experiences negatively affected their career advancement, with some of that likely because they avoided working with the harasser and sought other opportunities.

Although the 30% of female physicians was a lower proportion reporting sexual harassment than in the historical literature, the results come at a time when women are strongly represented in medicine, with more than 40% of medical students now female. In other words, the increase of female workers in healthcare did not provide the expected protective effect for these physicians, running counter to the general perception that as women comprise more of a given workforce, they are less likely to be subjected to sexual harassment.

“There is, indeed, an expectation, based on the broader literature on workplace harassment, that women are more vulnerable to harassment when the workplace is predominantly male,” Jagsi says.

Of course, female physicians in certain fields and individual settings could be outnumbered by their male colleagues.

Overall, 1,066 recipients (62%) responded to the survey, about half of which were women. Of men responding, 5% reported experiencing sexual harassment. Women (70%) were more likely than men (22%) to report perceptions of sexual harassment in their work environment. Indeed, the law on sexual harassment is gender-neutral for both the victim and the perpetrator, Zwerling said.

“The gender of the harasser is irrelevant in terms of deciding whether harassment has taken place,” he said.

Legal Eagles

A legal definition of sexual harassment is “unwelcome sexual advances or requests for sexual favors whether verbal, physical, or even visual,” said Marianne Monroy, JD, a partner with Garfunkel Wild and co-speaker at the webinar. “It becomes unlawful when submission to such conduct is made implicitly or explicitly a term or condition of employment.”

Likewise, employment decisions made on the basis of agreement or objection to such practices also are sexual harassment, she said. Thus, if an employee’s declination of a dinner invitation by a supervisor results in unfavorable work conditions or compensation, that could be considered harassment, Monroy explained.

“Or, if it has the purpose or effect of reasonably interfering with the individual’s work performance and creating a hostile environment,” she noted.

Lawsuits may include allegations of invasions of “personal space” or unwelcome acts of affection like shoulder rubs, she said. A common theme is complaints about people entering behind someone at a work station, blocking their exit.

“Be mindful of respecting everybody’s personal space,” she said.

Sexual harassment generally falls under either quid pro quo [“this for that”] or a hostile work environment.

“You really want to have training sessions with staff and warn them to be mindful of their communications, because what they say can be taken by employees and used against them in a claim or lawsuit,” she said.

This includes inappropriate language, jokes, asking a person about sexual preferences, and even terms of endearment.

“You may think it’s innocuous, friendly, or maybe one person doesn’t mind, but not everyone wants to be called ‘honey,’” Monroy said.

Leering and staring is also coming up more in claims, she adds, including allegations by those who are transgender or in gender transition.

Impact trumps intent, meaning someone who claims they were just trying to funny can still be liable to claims of harassment, Zwerling said.

In addition, the effect of harassment can go beyond the intended victim to include co-workers who are disturbed by witnessing the incidents.

“Even a person who consents to sexual activity or conduct that may be considered sexual in nature can legitimately claim afterward they were a victim of sexual harassment,” he said. “Because, very importantly, submission to sexual activity is not a defense to a sexual harassment claim where the employee submits to pressure from the harasser.”

In addition to loss of reputation, the sexual harasser may face suspension or loss of medical licensure, he added.

“Sexual harassment constitutes a form of professional misconduct,” he said.

Supervisors also can be found liable if they don’t step in when they become aware of harassment, as there is a responsibility and accountability in the hierarchy of the workplace.

A common scenario is that an employee may tell you she is being “hit on” by a department supervisor, but she doesn’t want you to do anything about it, Zwerling said.

“She just wants to go on record as having told someone, but she is going to take care of it herself,” he said. “She wants you to promise not to tell anyone about it. We have encountered this scenario may times, and the answer we tell everybody in response is once you are aware of it, you have an obligation to step in.”

If it results in litigation, the employee often cites the fact that she told someone, he said, advising against agreeing to total confidentiality in such situations.

“You might need to talk to HR about the individual who has confided in you,” he said.

In any case, the general perception that sexual harassment is relatively rare in the medical workplace may have actually contributed to the stigma of reporting, Jagsi said. As these incidents are recognized as shockingly common, this dogma is crumbling and there is an opportunity for increased reporting and intervention. It is important to train employees, raise awareness, and remove the stigma of reporting.

“I am heartened by the conversations that I see happening, including ones initiated by leaders in the field,” Jagsi said. “Ultimately, culture change will require the collaborative efforts of many individuals, united in their commitment to make these behaviors a thing of the past.”

REFERENCES

1. Sexual Harassment In The Medical Profession. Garfunkel Wild webinar, December 2017. Available at: https://youtu.be/La6Foxbetno. Accessed Jan. 26, 2018.

2. Lockhart L. Sexual harassment in the workplace. Nursing Made Incredibly Easy 2016; 4(6):55. doi:10.1097/01.NME.0000499744.97997.d9

3. Jagsi R, Griffith KA, Jones R, et al. Sexual Harassment and Discrimination Experiences of Academic Medical Faculty. JAMA 2016;315(19):2120-2121.

4. Jagsi, R. Sexual Harassment in Medicine — #MeToo. New Engl J Med Dec. 13, 2017: DOI:10.1056/NEJMp1715962.