When a middle-aged male patient told Ersilia M. DeFilippis, MD, that he would like to see her in a bikini, she “half-smiled before finishing [her] examination and walked expediently out of his room,” she wrote in a recent perspective piece published in JAMA Internal Medicine.1 A few days later, the same patient invited Dr DeFilippis a to wear a bikini at his pool and kissed her on the cheek as he left the room at discharge, leaving her frozen in embarrassment and disgust.
Yet, as Dr DeFilippis and several other female physicians have described in recent journal articles, these experiences are far from rare.
“Sexism exists in many forms from blatant harassment to implicit bias,” Dr DeFilippis, an internal medicine resident at Brigham and Women’s Hospital in Boston, Massachusetts, told Medical Bag. “Whether from a patient or a colleague, it is equally important to address.” The solutions may differ according to the offenders, but addressing these problem requires naming them.
“Reporting rates are horrendously low, which makes it difficult to combat,” Dr DeFilippis said. “It is even more complicated when the perpetrators are patients. As physicians, how do you report a patient when your job is to provide patient care?”
Reshma Jagsi, MD, DPhil, of the University of Michigan at Ann Arbor, told Medical Bag that, “physicians may tolerate egregious harassment from patients” because of their sense of duty in putting patients’ interests ahead of their own. In her January #MeToo article published in the New England Journal of Medicine,2 Dr Jagsi recounted some of the sexual harassment and assault women have experienced from fellow providers.
“Harassment from colleagues or superiors in the workplace seems distinct from [harassment by patients], and the power dynamics are quite different — but, of course, both forms of harassment can have tremendous negative effects on the confidence and well-being of the victims,” she said. Women often avoid reporting such incidents because of frequent subsequent “marginalization, retaliation, stigmatization, and worse.”
Fair Treatment for All Genders
Such harassment — and subsequent marginalization for reporting it — is not limited to cisgender women. Hannah Simpson, a transgender woman from New York, entered the Touro College of Osteopathic Medicine in 2012 as a male-presenting medical student excited to become a physician. As she began her transition to being a woman her second year, she told Medical Bag she “absolutely had tremendously supportive faculty and staff.” But, she also experienced such awful harassment — without reprisals — that she left at the end of her second year wondering whether she would ever be a physician.
After a female student squeezed Ms Simpson’s breasts and “jokingly” asked for estrogen, Ms Simpson reported it to the dean, who, according to Ms Simpson, responded by asking, “How much of this are you going to just have to take as students adjust to your situation?”
“I was shattered by that,” she said. “I just felt disgusted.” On another occasion, a male faculty member reached out to touch her legs during a discussion with other students and noted that she was “wearing stockings now.”
Her decision to leave resulted from further discrimination related to her trans status3 on top of the above incidents, she said, but the school leadership’s inadequate response to the physical harassment that Ms Simpson experienced is something to which many women can relate.
In fact, in an Editor’s Note published in response to Dr DeFilippis’s article,4 3 female JAMA Internal Medicine editors wrote that they “were struck by how much we can relate to the author’s anecdotes; these experiences, though not novel, continue to be all too familiar.”
Impact of Sexism and Harassment
The everyday sexist experiences that wear women down do not necessarily involve physical contact. In fact, they often don’t — which obscures the problem, Dr DeFilippis said.
“Egregious instances of disrespect and sexual harassment are easily recognized as inappropriate by all parties,” said Dr DeFilippis. “Yet, the insidious day-to-day experiences, in some ways, are much worse since they go unrecognized more easily.”
These microaggressions are the “everyday verbal, nonverbal, and environmental slights or insults” that women and other groups experience. “They may be intentional or unintentional, but nevertheless [they] can be demeaning, threatening, or even intimidating,” Dr DeFilippis said.
They affect patient care, too. When a patient repeatedly asks a female doctor whether she is a nurse or where the doctor is, it reveals a mindset that hampers care.
“When we take care of patients who do not view us as their doctor and visualize us in that role, it inherently affects the patient-physician relationship, a relationship built on trust and mutual respect,” Dr DeFilippis told Medical Bag.
Over time, accumulating microaggressions can also contribute to burnout and feelings of inadequacy among female physicians, Dr DeFilippis said. She added that research shows that “stereotype threat” — when members of a stereotyped group perform below their abilities when their membership in the stereotyped group is emphasized — can result in “stress, negative mood, and decreased motivation, leading to impaired performance and career advancement.”
Microaggressions probably also play a role in the male-female achievement gap within medicine’s highest ranks as well, Dr DeFilippis added.
Men’s Role in Addressing #MeToo
Not long after #MeToo stories began proliferating, so did concerns about backlash or other unintended consequences from the discussion, such as fear regarding how to define appropriate behavior.
“I think there are certainly good people who are struggling to figure out what they should do, and that angst paralyzes them,” Julie Story Byerley, MD, MPH, of the University of North Carolina School of Medicine in Chapel Hill, told Medical Bag. “There are people who are just going to say, ‘I’m going to put my head down and do my own work because I don’t know what the right move is.’ What a loss that would be if we all become more individualistic because we’re afraid of what might happen if we relate to one another.”
In her own JAMA article,5 Dr Byerley expressed concern that some women may miss out on beneficial mentorship from well-intentioned men who fear accusations of mistreatment — and that some women, “will be passed over because it’s simply easier for men to supervise men during this challenging time.” She mentioned wonderful male mentors she has had, the value of male mentorship for women, and the need for men to actively address sexism.
“Individuals who behave professionally should be acknowledged,” Dr Byerley told Medical Bag. “Often in medical education, it’s very easy to point out what people are doing wrong and how they should do things differently, but there is learning gained when we point out how to do things right.”
Dr Byerley gave specific examples of what doing right looks like: “exemplary professional behavior during and outside the work day, never compromised by alcohol consumption or flirtatious interactions”; behaving “comfortably but as if others are watching, demonstrating integrity”; refraining from physical touch except hugs of greeting in large gatherings; never discussing others’ appearance; and avoiding “generalizing comments about gender.”
However, she cautioned, that is not a complete list or the end of the discussion. “It’s more about being open to having conversations about professional behavior,” Dr Byerley said. “Some of this is complicated. Some of it is real straightforward. Some of it becomes more nuanced.”
Coming Together With Solutions
Dr Byerley and the other authors offered strategies that may help address sexual harassment, but no single answer exists, and the effort requires commitment from individuals of all genders. Progress occurs when male leaders respond actively to sexist situations and demonstrate concrete support for any female mentees and other women, Dr Byerley wrote.
“Men with power must name the issue of sexual harassment and make it clear that harassing behavior is never acceptable, and also invite the mentee to call out behavior that causes discomfort in any way,” Dr Byerley wrote. “Men who openly address the issue of mistreatment of women in a confident and respectful manner empower women and advance our organizations to be more inclusive and productive work environments.”
Dr DeFilippis said her institution is creating a toolkit of resources for female residents regarding how to address workplace bias.
“Oftentimes, it can be hard to come up with a response in the moment that is constructive and yet remains professional,” Dr DeFilippis said. “Therefore, we are hoping to devise potential statements that female physicians can use and adapt depending on whether the source of sexism is a patient, a patient’s family member, or a colleague. We also hope these tools can empower bystanders (male or female) to speak out when they witness harassment or implicit bias.”
Dr Jagsi added that some institutions are considering “rights and responsibilities” documents that explicitly outline appropriate behavior. The document will require that both patients and staff sign it because this issue affects everyone.
“Harassment reduces the ability for physicians to focus on their critical professional functions and may lead to burnout and attrition,” Dr Jagsi said. “A highly functioning physician workforce is critical to promote the public health, so anything that reduces the well-being or availability of physicians requires attention.”
- DeFilippis EM. Putting the “she” in doctor. JAMA Intern Med. 2018;178(3):323-324.
- Jagsi R. Sexual harassment in medicine — #MeToo. N Engl J Med. 2018; 378:209-211.
- Simpson H. What It’s Really Like to Be a Trans Woman Using a Public Bathroom. Refinery29. http://www.refinery29.com/2016/05/110395/transgender-bathroom-law-discrimination. Published May 10, 2016. Accessed April 17, 2018.
- Shakil S, Lockwood M, Grady D. Persistence of sexual harassment and gender bias in medicine across generations—us too. JAMA Intern Med. 2018;178(3):324-325.
- Byerley JS. Mentoring in the era of #MeToo. JAMA. 2018;319(12):1199-1200.