Change the Things You Can

Sexual harassment is defined by the US Equal Employment Opportunity Commission as “unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature” that “explicitly or implicitly affects an individual’s employment, unreasonably interferes with an individual’s work performance, or creates an intimidating, hostile, or offensive work environment” (1).

A national survey of mostly female ophthalmologists and ophthalmology trainees showed that 59 percent had experienced sexual harassment during their careers, most commonly during training (2). Of the ophthalmologists who reported experiencing sexual harassment, 45 percent had been harassed by patients. Few had reported their most significant experience with sexual harassment to an authority – in part because they were not taught how. 

Terra incognita

I know this because it happened to me. Over and over again. As a first-year resident, I found myself in one-on-one situations with patients who were incredibly inappropriate. Some insisted on calling me by my first name, despite my having been introduced as “doctor.” Others commented on my body while in the exam lane.

One had even looked me up on the Internet and started commenting on my physical appearance and hobbies. I remember telling people what happened, shocked and embarrassed. They laughed or rolled their eyes or told me to ignore it, but nobody challenged it. It just happened over and over, sometimes multiple times per day and distracted me from clinical learning.

It seemed that there were no consequences – and that bothered me. I wanted to do something about it, but I wasn’t quite sure what could be done. My supervisors, who were mostly men, agreed that it wasn’t right, but didn’t know what could be done about it either. This came as no surprise, because institutional training at the time focused on harassment initiated by supervisors or workers and guidelines on responding to sexual harassment initiated by patients and their families were virtually nonexistent.

One day, it happened to a junior medical student who was working with me. It was one of her first experiences dealing with a patient and she was – rightly – upset. She had assumed all her patients would respect her role as a soon-to-be physician; the fact that an inappropriate comment from a male patient shattered that illusion made me angry.

Around the same time, another patient put his hand on the knee of a team member while she was trying to counsel them about severe vision loss. He had a medical problem that required multiple follow-up appointments and, eventually, surgery. Every time he came in, he would look for me in the hallway to harass me – even though I asked not to see him. I brought it up during one of our grand rounds to get faculty input. Everyone agreed that I should call out the behavior, but nobody knew how – so I decided to find out.

Forms, sources, and the impact of harassment

In my research, I came across an interesting paper. It concerned the Massachusetts General Hospital Department of Surgery, who established the Gender Equity Task Force (GETF) to address gender-based discrimination in the local training environment. In 2017, the GETF surveyed 371 residents at two academic hospitals to better understand perceived sources, frequency, forms, and effects of harassment.

They found that female trainees were more likely to endorse personal experience of gender-based and sexual harassment than men (P<0.0001) across all specialties, with patients and nursing staff the most frequently identified sources of harassment. Although an overwhelming majority of both male (86 percent) and female (96 percent) respondents had either experienced or observed harassment in the training environment, less than 5 percent had formally reported such experiences, most frequently citing a belief that nothing would happen (3). 

These findings are similar to those in a 2019 national survey of U.S. ophthalmology trainees (n = 112) in which 87 percent of female trainees reported having experienced sexual harassment from patients. Among all ophthalmology trainee respondents, only one-third rated their institution’s sexual harassment training as helpful in preparing them to address harassment by patients (4).

These papers gave me a firm foundation to build on and confirmed what I already knew: that sexual harassment disproportionately affects female trainees and that individual training programs have a responsibility to combat and manage inappropriate patient behavior. Although the majority of my harassment came from men – both younger and older – I found that female patients could certainly also be harassers. But although their comments were disrespectful, they didn’t convey the same threat to physical safety. They were also far less common.

I found that my older male patients didn’t like being in a vulnerable position. They were used to having control, particularly in interactions with a younger woman, and sought to invert the power structure by being inappropriate, even at the risk of compromising their care. But the impact of that harassment cannot be understated. Studies have found that people who are repeatedly harassed experience increased rates of depression, anxiety, insomnia, absenteeism, and post-traumatic stress disorder (2).

Among female ophthalmologists who had experienced sexual harassment, 87 percent reported a significant impact on their professional lives, including interference with their ability to work (1). For a person who spends their entire life in a position of relative comfort, inappropriate behavior can be easily dismissed – but for somebody who has not enjoyed the same privileges, it can be shattering.

Assembling the toolbox

As I researched social sciences literature on discrimination and harassment, I found some great resources, including a piece by Diane Goodman. She studied diversity and social justice and created a framework for educators dealing with biased comments from people of privilege, including some undergrads. I adopted her protocol and tailored it to a physician–patient dynamic.

The final document, a Toolkit for Responding to Patient-Initiated Verbal Harassment, available at EyeRounds.org, is designed to supplement existing sexual harassment training and packaged in the most accessible way possible. It is pocket-sized and double-sided. One side tells you what to do if you are the victim of inappropriate behavior; the other explains what to do if you witness inappropriate behavior.

Practice makes perfect

We presented the toolkit to our department last spring in a workshop session focused on script rehearsal. When a patient says something inappropriate, it’s easy to feel like a deer in the headlights. This is when you fall back on the script – a way of communicating clearly, calmly, and respectfully that a behavior is not acceptable. Residents and faculty were put in pairs, with one acting as the patient and the other the physician. We asked all workshop participants to repeat the script in a non-confrontational, nonjudgmental tone at least three times until it felt like a natural response.

In my experience, most patients take the script well. But even when they don’t, I feel better for having said something. Inappropriate behavior is known to escalate; if you let people get away with a small thing, they may try again with a more threatening behavior. It is not difficult to imagine inappropriate comments leading to inappropriate touching.

Harassment is not unique to any one generation or demographic. It is a cultural issue – but one that cannot be changed without buy-in from male leadership. It wasn’t until I led the workshop that I truly convinced my male supervisors that harassment was a problem. It was only then that they, too, began calling it out. Our institution has now incorporated harassment training based on the workshop into transitional professional development for all incoming interns and as part of our medical students’ transition to clinical rotations.

The message is simple: it is okay to speak up. Residents often hesitate to talk about negative workplace experiences, but they shouldn’t. You are entitled to feel safe in your workplace. To give your best intellectual and empathic care to a patient, you need to feel comfortable – and that means calling out inappropriate behavior.

There is no “right” way to report it; create a script that works for you and practice it, so you feel empowered should you need it. In more severe cases, keep a written record of what happened and who was there. This is important if you want to make a case for a pattern of inappropriate behavior.

Before I created the toolkit, male faculty would often say, “If a patient makes you feel uncomfortable, just don’t see them alone. Bring another person into the room.” It’s not always possible to have a male colleague come with you (if, for example, you work in an all-female team) – and you shouldn’t have to. People need to feel equipped to handle such situations on their own, which is why the toolkit is available online for any who need it.

In July 2020, in partnership with Dr Nkanyezi Ferguson, Director of Diversity, Equity, and Inclusion for Graduate Medical Education, we were awarded an Innovation Grant from the American Medical Association (AMA) as part of their Accelerating Change in Medical Education Program to expand the toolkit and workshop to address other kinds of identity-based harassment. The $30,000 will allow us to train new workshop facilitators across our institution, who will help sustain the implementation of this curriculum in the coming years.

We have four key aims: to identify key gaps in knowledge pertaining to the prevalence and forms of identity-based, patient-initiated harassment; prepare resident physicians to respond effectively to patient-initiated harassment; establish upstander training to address the important role of supervisors and colleagues in monitoring and responding to harassment; and create a rigorous and sustainable train-the-trainer educational model to allow formal widespread institutional education on best practices for faculty and resident physicians on responding to identity-based harassment at critical points of entry into professional practice.

Aside from teaching important communication strategies, we hope that these workshops support vital conversations between trainees and faculty on how to improve approaches to diversity, equity, and inclusion challenges as training programs and departments. 

Now, as a chief resident, I continue to receive inappropriate comments from patients, but knowing how to handle them has transformed my experience. Instead of fighting the instinct to flee the room, I calmly address the patient with a phrase from the toolkit. The other week, one of our junior residents told me that participating in the expanded workshop had given her the confidence to call out a patient who had disparaged her ethnic background.

There is much work to be done to improve workplace culture on identity-based discrimination, but these projects can help create a safer, more supportive environment for everyone in our medical communities. Until then, we need to look out for each other. We are all in this together. If we speak up against identity-based discrimination, we can change the culture in our institution and in medicine.