Keywords

FormalPara Subtitles

  • Frequency of occurrence.

  • Breakdown by perpetrator.

  • Trainee issues.

  • Common responses.

  • Effects.

  • Suggested responses.

Introduction

I was eager, young and inexperienced as a new intern in August 2005. It was my second month of psychiatry residency training and the first time I recall a patient making a sexually inappropriate remark to me. I was rounding on one of the two locked inpatient psychiatry units at Rush University Medical Center, where patients with psychiatric issues and substance use disorders were admitted for a few days to weeks at a time. As locked units, this meant that patients could not leave without a physician releasing them. It was a lot of power to hold as a newly graduated physician and 26-year-old woman. Each morning before we rounded with our attending psychiatrist, who supervised our cases, we would go in to see the patients on our own to check on how their night had gone. This patient, who I’ll call Mr. J, was admitted for cocaine use and suicidal ideation, with severely depressed mood being a common symptom when withdrawing from cocaine. I knocked on the patient’s room, said good morning, and asked him how his night was. Mr. J was lying in bed, sleeping, opened his eyes, looked at me, and said he was tired and didn’t want to talk. I explained to him that I needed to see how he was doing so that we could plan his care for the day. Mr. J, becoming visibly irritated, said to me, “Baby girl, just come back later and we can talk then.” Surprised, and not sure how to respond, I said, “Uh, okay, that’s fine,” and quickly left. I did not share the incident with my attending supervisor, though I did later tell my co-intern; we laughed about it and to this day she will still jokingly call me “baby girl.”

A second incident occurred a few months later as I rotated through the emergency room, seeing patients with everything from heart attacks to broken bones to skin infections. One night, at maybe 2 or 3 in the morning, I was asked to see a man who was reporting abdominal pain. I announced myself and paused a moment before I walked into his room and found him lying in bed, openly masturbating. He looked up at me and, despite seeing me standing there, did not stop. I walked out and told my supervising physician. Her response? “You should be used to patients like this, you’re going into psychiatry.” The message was resoundingly clear: this was a normalcy in medicine, and I should stop complaining.

While these incidents may on the surface appear minor and seemingly insignificant, both stand out in my mind 14 years later, and I still regret not responding in some way to them. In retrospect, the first patient was likely trying to disturb the doctor-patient power dynamic (and he succeeded). The second patient may have been affected by psychosis, but his behavior was inappropriate and should still have been addressed and stopped, both for his sake and mine. At the time I also did not have a name for what had occurred: sexual harassment. This lack of recognition is not uncommon among women in academia, especially when the harassment is gender based [1]. What I have learned over the years is that these occurrences are highly familiar and to a great degree expected among women physicians. In this chapter, we will examine the following: the frequency at which sexual harassment toward women physicians occurs, what happens when the harasser is the patient, sexual harassment as it relates to trainees, how women physicians respond to and are affected by sexual harassment (including the effects on burnout), and, finally, what we can do as women physicians to address this ever-prevalent problem.

How Common Is Sexual Harassment Toward Women Physicians?

If you speak to any woman physician, ask her whether she has ever been sexually harassed at work. If you are expecting to hear a “no,” then think again. This is unfortunately, and sadly, all too commonplace. In one survey that was sent out in 2013 to medical students and residents at an academic institution in the Midwest, 81% of the women respondents had experienced at least one incident of sexual harassment by a patient in the past year [2]. This is consistent with other research findings and notably the 2018 National Academies of Sciences, Engineering and Medicine (NASEM) study that found rates of sexual harassment in science, technology, engineering, and medicine (STEM) fields are high, but the highest rates prevail in medicine. Nearly half (49.6%) of women medical students have experienced sexual harassment (especially gender harassment) versus only 40.8% of other women graduate students and 30.6% of women undergraduate students [3]. One landmark study performed in 1993 found that 77% of the 422 women physician respondents had been sexually harassed at least once in their career [4]. Perpetrators of the harassment included patients and colleagues and were primarily men. Since then, circumstances have not improved: a more recent 2018 study indicated that 76% of women physicians have experienced sexual harassment at work [5], with the perpetrators most commonly being colleagues and supervisors, the vast majority of whom were men.

One attending physician shares (All quotes in this chapter were obtained from women physicians in closed online groups and are published with permission.):

I had the medical director ask me what I was doing in the hospital at 10:00 PM and why I wasn’t home getting pregnant…And frankly, it was embarrassing to have the medical director alluding to my sex life, no matter how well intentioned his remarks were. I imagined he was trying to tell me I should go home and meant to be kind.

Interestingly, while the incident was clearly inappropriate, she rationalizes her medical director’s behavior as simply misguided. Another physician tells her story:

A former ICU director (now fired because of sexual harassment) once made a completely inappropriate joke in front of a patient and male resident. I was seeing a patient on the floor (the director was not at all a part of the patient’s care). He was walking by the room and heard me speaking. He came in the room with the male resident who was following him. He tapped my shoulder and said “Excuse me nurse, nurse. I need some help,” then chuckled to himself. He then followed this up while patting me on the back by saying to the patient “just kidding, she’s a good doctor.” He then walked out. Kindly enough the patient followed up with “Who was that jerk?”

So, do we need more research to validate that sexual harassment in medicine exists? Though it may be helpful to further study specific populations such as patients harassing women physicians [6], according to a recent perspective in the New England Journal of Medicine, the resounding answer is “No!” The data now speaks for itself and has spawned movements such as #TimesUp Healthcare,” whose leaders state “We must hold professional organizations, research entities and academic institutions accountable for implementing systemic changes that support women and combat harassment [6].”

When Patients Sexually Harass Their Physician

One unique circumstance for women who work as physicians is that not only are they susceptible to sexual harassment from their supervisors and peers, but they are also subject to harassment from patients and their families. The data on this topic is limited, but several studies validate that women physicians get sexually harassed by their patients. One of the first, and largest, studies to find data supporting this notion dates back over 25 years and demonstrated that over 75% of women physicians had experienced sexual harassment by their patients sometime during their career [4]. While the most common location this occurred in was a private office, in other settings such as emergency rooms and clinics, unknown patients presented a proportionately higher risk. The most frequently reported behaviors included sexual remarks (59%), suggestive looks (53%), and suggestive exposure of body parts (31%) [4]. Despite the doctor-patient power differential for women physicians, this aspect of the relationship seems to be less of a factor than the gender differences. Gender appears to be a stronger contributory factor: one study found that 81% of women medical students versus 37% of male medical students reported at least one incident of inappropriate sexual behavior committed by a patient [2]. Other studies have shown that women students experience sexual harassment by patients at rates three to four times higher than that of male medical students [8, 9]. After training, women physicians continue to experience higher rates of sexual harassment by patients than male physicians; one study found that 33% of women physicians reported sexual harassment from patients versus 25% of men [5]. The higher than usual rate of sexual harassment in this study toward men may be accounted for by cultural differences (the study was conducted in Europe) and the way the question was worded [6].

Most recommendations in the medical literature, when addressing the doctor-patient relationship (even placing the term “doctor” before “patient”) and the power dynamics, are patient-centric and focus on the power that the physician holds, encouraging patients to take charge of their healthcare [9]. However the fact that there is an additional population of potential harassers may be one of the reasons why rates of sexual harassment are higher in the field of medicine than they are in science, engineering, and technology. Women physicians are no different from other victims and are prone to blame themselves for sexual harassment and abuse [10]. Furthermore, it may be difficult to place blame on an ill patient who needs care. According to an attending physician:

An elderly patient actually grabbed my breast one day while I was examining him at the VA but I think he was delirious and actually he died the next day.

Another story from a woman physician:

A patient who was post-stroke and aphasic I was following for aspiration pneumonia issues. He seemed harmless and always wanted a hug after visits. I thought it was fine, until one day when the hug lasted too long, and he pulled me in and licked my ear. I ran out of the room and had one of my partner’s take over his care. It really affected how I am with my patients from then on...I’m Med/Peds trained so hugging is normal for me in patient encounters, but this man ruined that for me.

These anecdotes highlight both the difficulty in identifying a patient as a sexual harasser and the effects that this harassment can have on a physician. While both of the examples above note that the patients have neurologic conditions that may have affected their behavior, it is notable that being harassed by an unwell patient still had a negative impact on the physicians. Sexual harassment from patients can lead to significant consequences that impact not only the person receiving the harassment but can also negatively influence patient care. One survey found that of medical students and residents who reported sexual harassment by a patient, 15% felt this negatively affected their ability to perform their duties, and 14% felt this negatively affected their attitude toward patients [2].

Further, there are numerous stories of patients without psychiatric or neurologic disorders who have sexually harassed their physician: either by asking them out on dates, commenting on their appearance, calling them pet names or other inappropriate behavior:

  • “I was examining patient; patient tried touching my breasts. Patient had history of altered mental status, but I believe he was faking it. Since then I keep my distance and I am more careful with patients while examining.”

  • “A patient in a crowded elevator was groaning and rubbing his inner thigh while facing me and standing very close.”

  • “Patient looking at my chest throughout much of the session.”

  • “Patient made multiple uninvited attempts at requesting my telephone number and complimenting my appearance in an uncomfortable manner.”

  • “Patient came to appointment wearing white shorts, no underwear with testicles showing for part of the appointment. Behavior changed after I confronted him about this. He found my house on google maps. Never stalked me, but it made me uncomfortable.”

  • “Someone tried to kiss me (in front of his wife).”

  • “I have been asked out by patients and other comments.”

Regardless of whether patients carry a diagnosis that in part explains their behavior, sexual harassment can still have a negative impact: in one survey, increased experiences of harassment were independently associated with lower mental health, job satisfaction and sense of safety at work, as well as increased turnover intentions [11]. More research is needed to understand both the prevalence of sexual harassment by patients and the most effective solutions.

Sexual Harassment as It Relates to Trainees

In writing about this topic, I have come across many stories of women physicians who have experienced sexual harassment while working as a doctor. Above all, the most difficult stories to hear are the ones that occur to training residents and medical students, who particularly feel worried and uncomfortable speaking up from the bottom of the medical hierarchy. This bears out in the literature, with one study finding that only 15% of women residents who experienced harassment including sexual harassment reported the incident, most commonly (42%) giving the reason that they felt reporting would not be worthwhile [12]. One qualitative study looking at sexual harassment experienced by medical students found that they often stayed silent due to fear of retaliation, negative evaluations, feeling powerless and helpless, experiencing embarrassment and confusion, not wanting to offend patients and hearing their preceptors laugh along with the patient [13]. Another study found that 69% of women medical students experienced sexual harassment, with 40% experiencing this as distressing [14].

One resident physician tells her story:

I think I have suppressed a lot of the memories because thinking about it too much makes me very angry. I was an intern on a consult rotation in another specialty and was the only woman on a team of men. One day my senior resident told me Indian girls are sluts because his girlfriend used to “do everything” to him and began to laugh. Later he asked me if I named my “beaver” and if I pet it. This occurred in front of a group of male residents. Another day, our conversation turned to sexual harassment (an attending had gotten fired or reprimanded because of it) and he laughed and looked at me and said, “I sexually harass you every day.” At this point in the rotation, I had stopped talking to or reacting to him, especially when he would ask, “Hey, when this is over, are we hanging out?” as I had never given any indication we would. The comment about how he sexually harassed me happened on the last day of my rotation and I remember this rage going through me. He apologized but to this day, I think I should have gone further and reported him. I sometimes fantasize about finding and telling his ex-girlfriend just how racist he was (and probably still is).

There are multiple layers in this story that have a bearing on the situation, including both her race and that she was a resident physician rotating in a different specialty. But ultimately this woman physician, an intern, felt unable to speak up due to the hierarchy that exists in medicine and felt powerless as the only woman on the team. Medical students have similarly reported feeling unable to speak up due to multiple barriers including a lack of trust of those in positions of authority, the risk of poor evaluations, and being labeled weak [13]. This resident also felt a lack of support from her team members when they stood by and said nothing to assist her, which is an example of the well-known bystander response that has been documented in the medical literature [10].

The effects of sexual harassment on medical students and trainees can be significant and can have harmful consequences. One study showed that women who experienced sexual harassment prior to entering medical school were more vulnerable than other women or men to subsequent sexual harassment in medical school, leading to revictimization [9]. Another showed a different effect of sexual harassment in medical school—almost a quarter of the women who had been exposed to gender bias or sexual harassment reported this to be an influential factor in their choice of specialty [15]. Another large survey of medical students showed that when asked about sexual harassment, particularly discrimination, several themes emerged, including a fear of discrimination during medical school and in the future in residency, particularly in some specialties [16].

While all specialties in medicine are affected by sexual harassment and gender discrimination, some specialties are disproportionately affected and have historically reported higher rates. One study in cardiothoracic surgery revealed that 90% of women trainees had experienced sexual harassment [17]. Of women in general surgery training programs, 71% reported experiencing sexual harassment [18]. Another study in vascular surgery showed that 52% of women trainees had experienced sexual harassment, with the surgeon in the operating room most commonly being the perpetrator [12]. Notably this study also reported that 14% of respondents had witnessed sexual harassment (ambient sexual harassment), but did not separate this out by gender or classify this as sexual harassment (see next section for definition of “ambient sexual harassment”). In addition to surgery and surgical subspecialties, there has also been recent recognition of the problem of sexual harassment in other specialties, including otolaryngology [19], radiology [20], emergency medicine [21], dermatology [22] and obstetrics and gynecology [23].

Notably, perception of harassment (including sexual harassment and gender discrimination) has been found to decrease over time with training, as medical students have a higher perception than residents and fellows of the same behaviors [24]. This indicates that either trainees learn to normalize harassment as part of the culture of medicine, or they develop a sense of learned helplessness in order to make it through the grueling years of residency. We explore this further in the next section.

How Do Women Physicians Respond to Sexual Harassment?

After repeatedly experiencing sexual harassment in the workplace, to the point that it creates a hostile working environment, physicians—women in particular—most often do nothing. Previous data has shown that women physicians and medical students are typically very tolerant of sexualized comments and behaviors from male patients, often minimizing or denying any subsequent emotional impact [25]. Of surgery trainees that experienced sexual harassment, 93% did not report it, with 62% rationalizing that the harassment was harmless, 48% noting that reporting would be a waste of time, 38% being too busy and 32% feeling uncertain whether the behavior “counted.”

One woman, a medical student, notes:

I blew it off because of people joking about patients doing this kind of thing. I didn’t really think of it as inappropriate or abnormal at the time.

Women physicians may also confide in colleagues who urge them not to say anything. As previously noted, sexual harassment by patients may be excused by attributing the behavior to a neurologic or psychiatric diagnosis. Furthermore, there may be a lack of awareness of ambient sexual harassment, most commonly defined as “the general or ambient level of sexual harassment in a work group as measured by the frequency of sexually harassing behaviors experienced by others in a woman’s work group.” [26] Women physicians may not know that, while not necessarily directed at them per se, this type of sexual harassment is in fact still illegal and harmful [3] and therefore important to consider. Other reasons for doing nothing can be fear of retribution for reporting behavior that has historically been accepted within the culture of many institutions, feeling embarrassed or fear of being labeled as too sensitive or a troublemaker [13]. This is particularly an issue in medicine when supervisors and program directors are responsible for writing recommendation letters for future jobs. Unfortunately, the concern about reporting due to the power differential is valid. While one physician eventually won a lawsuit, she never returned to a career in medicine after being dismissed from her residency program in 2009 in Indiana for reporting sexual harassment by her program director [27]. This can be just as difficult for bystanders; in 2011 a male emergency medicine physician in Illinois was fired after he reported a colleague for sexually harassing residents and medical students. He was eventually awarded $1 million as compensation [28].

Another reason for not reporting is that victims may lack confidence that they would receive help [8] or believe the claims will not be taken seriously or even worse will be viewed as the cause of the problem. I have seen this time and time again in medicine. To illustrate the point of victim blaming, a physician states:

I reported it to my male supervisor and he just gave me advice to stop wearing skirts on days I was working with this person.

Such comments reinforce the message that it is not the harasser's responsibility to deal with his own inappropriate behavior. Women physicians and medical students also report concerns about “covert retaliation,” particularly for those that wish to pursue careers in academia. Covert retaliation is defined as vindictive comments made by a person accused of sexual harassment about his or her accuser in a confidential setting, such as a grant review, award selection or search committee [29]. More subtle than overt retaliation, covert retaliation is understated and therefore more difficult to identify, however, can be equally damaging to one’s reputation or career.

In those instances where sexual harassment is reported, the response can be inadequate. One study of medical students showed that those who reported sexual harassment to their preceptors felt that they ignored, condoned or dismissed their complaint; as a result, the students suffered feelings of shame, self-blame, confusion, humiliation, disrespect, fear or self-doubt [13]. Resident physicians who have experienced sexual harassment have also reported higher rates of ethical or moral distress, and lower levels of vitality, or being energized by work [30]. A different study surveying academic medical faculty showed that of women who reported severe forms of sexual harassment, 59% perceived a negative effect on confidence in themselves as professionals [31].

How Does Sexual Harassment Affect Women Physicians?

In considering how sexual harassment affects women physicians we must consider both the psychological impact and how it influences their future behavior:

When I think about it, if I had been around that forever I would have lost my way in medicine. As trainees, we are lucky rotations come to an end. As an attending working in a rural region and now having experiences with racism and occasional sexism, I am already planning to leave as soon as my student loans are paid off which is a persistent thought that gets me through difficult days.

One study surveying medical students and residents showed that those who experienced sexual harassment also reported negative effects on feelings of safety and comfort at work, attitudes toward patients, ability to perform duties and general mental health [2]. As recently as 2019, another study showed that in response to sexual harassment, medical students described feeling vulnerable as learners, being concerned about receiving poor evaluations and generally feeling powerless [13].

Another physician notes her feelings of bewilderment and humiliation, as well as the disappointment in not having anyone stand up for her:

I was at work today in the physician work room when a random doctor made a reference to me being an expert on human sex trafficking because I must have been a sex trafficking victim myself. I was in a room filled with other physicians and in the middle of staffing a patient. I was mortified and had no idea why he said this. I barely know him.

There have been multiple studies showing associations of sexual harassment with burnout. A study which surveyed surgeons showed that those experiencing sexual harassment had higher rates of burnout, as well as increased likelihood of declining or leaving a job [17]. Another study found an association between women physicians experiencing sexual harassment and lower job satisfaction [32]. Similarly there has been an association linking burnout to a decrease in job satisfaction and reduction in professional effort and the number of hours worked [32]. As early as medical school, mistreatment including sexual harassment of students has been linked to higher rates of burnout, particularly when the mistreatment is recurrent [33]. Furthermore, another study showed that while medical students are able to cope with trauma related to patients, when it comes to their own mistreatment they have higher rates of depression and stress and lower rates of resilience [34]. Recently new data has emerged showing that indirect harassment experiences increase burnout in women faculty and that social support does not mitigate burnout in women the way it does with men [35]. In one survey of women radiation oncology residents from 2019, 27% reported experiencing some type of sexual harassment, and 95% of the residents reported experiencing varying degrees of burnout [36]. Even more concerning is data showing that work stresses including harassment may increase the risk for suicide in women physicians, [37] particularly when we know that physicians are already at higher risk for suicide than the general population and that they are less likely to seek care for mental health issues [38]. It is clear that the issue of burnout in women physicians is complex and that we need thoughtful and effective strategies to address it.

In one survey looking at discrimination perceived by physician mothers, maternal discrimination (specific to pregnancy, maternity leave and breastfeeding) was associated with higher self-reported burnout (45.9% burnout in those with maternal discrimination vs 33.9% burnout in those without) [39]. Additionally the prevalence of attrition has been noted to be higher among women resident physicians than men in some specialties; in general surgery programs, for example, 25% of women compared to 15% of men leave residency, most commonly due to uncontrollable lifestyle changes [40]. Other factors accounting for this difference include lack of role models for women residents, perceptions of sex discrimination, negative attitudes toward women in surgery and sexual harassment; residents most often switch to specialties that are characterized as offering a better lifestyle [40].

While there have been studies looking at physical health outcomes of women in the general population who experience sexual harassment, comparable research looking at women physicians is limited. Although not specific to physicians, recent data has shown that a history of sexual harassment in women is associated with worse health outcomes later in life, including higher rates of depression, anxiety, insomnia, and hypertension [41]. Some of this also holds true for physicians. Internal medicine residents who have experienced all types of bullying, including sexual harassment, have reported feeling burned out (57%), worsened performance as a resident (39%), depression (27%), change in weight (15%) and coping with illicit drugs or alcohol (7%) [42].

We must also consider groups within medicine that face additional disparities, including those who identify as transgender and nonbinary (TGNB) or lesbian, gay, bisexual, transgender, and queer (LGBTQ). In one small study (the first of its kind), 69% of TGNB medical students and physicians reported experiencing sexual harassment, specifically gender discrimination [43]. Another study showed that women residents who identified as LGBTQ reported rates of sexual harassment at three times higher rates than those who did not (19% versus 6%) [44]. While there is limited data focusing specifically on sexual harassment of women physicians of color and physicians in the TGNB and LBGT communities, we would expect that any disparities and negative consequences would be amplified in these more vulnerable populations. Further research in these areas is needed.

Legal Aspects of Sexual Harassment in Medicine

Taking legal action is generally considered to be the last resort for addressing sexual harassment in the workplace and is typically pursued only if other measures, such as speaking to the perpetrator or internally reporting the situation, have failed. In 1964, the United States passed Title VII of the Civil Rights Act which makes it illegal to discriminate based on race, color, religion, sex, and national origin in the workplace, and later passed Title IX of the Education Amendments of 1972 in reference to institutions of higher learning [45]. Because there are two laws that may apply to trainees and physicians at academic institutions, there has been a lack of clarity as to which law takes precedence [46]. According to the U.S. Equal Employment Opportunity Commission, sexual harassment is illegal and can take place in two forms: “quid pro quo” (requiring a sexual favor in exchange for a work condition) or creating a hostile work environment [45]. While individual comments or isolated incidents in the workplace may not qualify as harassment, they can when they are frequent or severe enough to lead to a hostile working environment [45]. Retaliation against a person bringing to light such behavior is also illegal [45]. Despite these laws having been in existence now for decades, discrimination based on sex as well as sexual harassment continues to persist in medicine. Further, the NASEM study notes that academic institutions have focused on creating policies that comply with these regulations in order to primarily avoid liability, rather than prevent sexual harassment [3]. The study concludes that institutions must take greater responsibility and become proactive in addressing reports of sexual harassment [3]. The culture in medicine as it relates to women physicians must also be transformed, with efforts required from academic institutions including medical schools, as well as professional societies and organizational bodies [47, 48].

Solutions to Sexual Harassment in Medicine

In order to prevent and address sexual harassment of women physicians, and potentially drive lower burnout rates, I propose a multipronged approach. Strategies should be directed at individuals, academic institutions and healthcare organizations, professional societies and accrediting bodies, and, lastly, society. At the individual level, prevention strategies must be communicated to both men and women physicians and trainees. Information regarding reporting channels must be readily available [48]. Education strategies should include awareness of sexual harassment, whether for oneself or ambient sexual harassment (when witnessing the sexual harassment of another person) [36, 48]. It is also imperative that the topic of sexual harassment, including by patients, be given more attention in training [2, 4, 6, 8]. There have been some recommendations in the literature as to how physicians should respond to sexual harassment perpetrated by patients, including ensuring the safety of physicians and trainees, addressing the behavior or if feeling unsafe then leaving quickly [49]. To date, these have not yet been widely implemented in training. Were it to become a requirement for accreditation, this type of education would become commonplace in medical training. I propose the training and implementation of a memorable pneumonic and have developed the following illustrated below:

  • Notice if a patient is sexually harassing you or someone else.

  • Identify any possible safety concerns in the room.

  • Compose yourself in order to determine next steps.

  • Exit when feeling unsafe; express yourself if feeling comfortable.

  • Talk about the behavior and not the person.

  • Repeat and redirect as needed during the discussion.

  • You have a right to a safe and comfortable work environment.

Secondly, academic institutions and other healthcare organizations must contribute to preventing and addressing sexual harassment. Support must be offered to women to navigate their careers successfully, given that women are highly underrepresented in leadership positions [47, 48]. Conversely, support must be provided to women physicians, including physician mothers, in all aspects of their work and lives, in order to target burnout [39]. At most, institutions tend to address the individual but rarely the hierarchal system that contributed to the harassment [13]. Education for employees must include specific examples of what constitutes harassment, including ambient sexual harassment. In addition to educating physicians and other staff, academic institutions and other healthcare organizations must also foster a culture that allows for reporting without fear of retaliation, including anonymously, and their policies should reflect this [7, 48]. While all hospitals have a sexual harassment policy for employees, there are no guarantees that reporting will be effective or result in a positive outcome. Legally, all academic institutions must investigate formal complaints of sexual harassment, but they can additionally develop procedures to assist those who may be afraid to file a complaint, including interim measures such as separating the parties [48]. Institutions should also address recurrent patterns of behavior by specific individuals over time even without formal complaints [48]. Other strategies to prevent harassment and retaliation include medical schools and healthcare organizations declaring that there is zero tolerance for harassment and to require sexual harassment training.

Thirdly, professional societies and accrediting bodies have a duty to set standards tackling the issues around sexual harassment. While some professional societies have begun to address harassment within their own councils and annual meetings, many others have not yet followed suit [48]. The culture in medicine as it relates to women physicians must also be transformed, with efforts required from these same institutions. For example, the National Institutes of Health recently updated its sexual harassment policies, which is a step in the right direction [50].

Although there have been calls for action in the way that sexual harassment is reported in the medical setting [2, 3, 7], little policy or guidelines have been implemented by governing bodies for our most vulnerable population, resident physicians and medical students, despite that much attention has been paid to other issues impacting their well-being. One stark example is that the accrediting body for residency programs, the Accreditation Council for Graduate Medical Education (ACGME), has extensive and specific guidelines for sponsoring institutions for fatigue management for resident physicians [51]. These requirements include complying with duty hour limitations, monitoring duty hours closely, adjusting work schedules for fatigued residents, maintaining a working environment that facilitates fatigue mitigation providing adequate sleep facilities and safe transportation options for fatigued residents. There is a requirement that faculty and residents both demonstrate an understanding of their role in the recognition of impairment including from fatigue. ACGME has a provision stating that residents may be excused from their duties due to fatigue “without fear of negative consequences for the resident who is unable to provide the clinical work.” Programs are required to educate both faculty and residents about recognition and mitigation of fatigue, and this education must come in the form of an annual educational program [51]. In addition to these specific and detailed policies, the Clinical Learning Environment Review (CLER, which is a part of ACGME) has published a 12-page issue brief in 2017 on the topic of fatigue management, mitigation and duty hours [52].

In contrast, the ACGME has one simple requirement about sexual harassment during residency training: that sponsoring institutions must have a policy, not necessarily GME-specific, that applies to all types of harassment and allows trainees to raise and resolve complaints as per applicable laws [51]. Similarly, the Liaison Committee on Medical Education (LCME), which accredits medical education programs leading to the M.D. degree, maintains within its standards a general antidiscrimination policy and a requirement that medical schools have policies against student mistreatment; however LCME standards do not contain any language specific to sexual harassment [53].

Likewise, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the accrediting body for healthcare organizations, has extensive regulations for sexual abuse and harassment of patients, but does not have a specific workplace violence policy for healthcare workers [54].

Finally, change must occur at a societal level. The recent #MeTooMedicine and #TimesUpHealthCare social media campaigns have brought attention to the ever-prevalent issue of sexual harassment that women physician and trainee experience, as well as efforts at organized change [55]. This has included raising money for a legal fund to assist with costs for specific cases of sexual harassment or related retaliation in the healthcare workplace [56]. While nearly 50 healthcare organizations and academic institutions have signed on as allies to the movement, it is unclear as of now what this will tangibly translate to in the future [57]. States can and should also require training; for example, as of January 1, 2020, all professionals including physicians who wish to renew their license in Illinois will be required to complete sexual harassment training first [58]. Other states should do the same.

In 2019 the NIH director himself publicly called for an end to “manels,” otherwise known as all-male panels [59]. Women in medicine need more men in leadership positions to take similar positive stances and set an example for others.

Men also need to be educated and supported. An unintended consequence of the #MeToo movement has been that some men now have a fear of being falsely accused and therefore have backed away from mentoring women [60]. It is important, however, to note that relatively few claims of sexual assault are found to be false and ranges from 2% to 10% of all claims [61]. One academic center that summarized its own responses to sexual harassment complaints discovered only one unfounded claim in 10 years [62]. Men must also be trained in management of sexual harassment, including the bystander effect, in which if they see something, they say something. They must be made to feel empowered and obligated to intervene without a fear of punishment when they inevitably witness sexual harassment.

Sexual harassment has significantly negative effects on women medical trainees and physicians, as well as the system around them. There has been a recent upsurge in the literature examining sexual harassment in medicine and offering solutions. What is clear is that no one is exempt from responsibility in confronting this pervasive problem, and we will all lose if we allow it to continue.