March 8, 2016 was International Women’s Day, a day of celebration worldwide that recognized many topics, including wage gap discrimination, gender-biased abortions and reproductive ethics.
In light of this recent occasion, I would like to draw attention to the sexual harassment of a particularly vulnerable population that is a result of a unique power dynamic: they have no income, they have amassed significant debt and they depend on the subjective opinion of their abusers for validation of their work. Most frustrating, is that many of the corrective actions taken over the last 25 years have had a limited effect on changing this specific culture of abuse. This specific population is medical students.
In 1990, Dr. Silver’s team was the first to survey an entire medical student body about mistreatment. Some of the comments they published were troubling: “The chief resident stated that I could now come and ‘service’ him and the third-year resident in the call room.” Since then, investigators have collected more data on the matter and have characterized the types of mistreatment and sexual harassment. A 2003 AAMC survey reported that 0.3 percent, or 41 students, said that they were asked to exchange sexual favors for grades or other awards. Four percent, or 564 students, were directly subjected to offensive or sexist remarks. While these percentages seem small, even 50 students asked to exchange sexual favors for grades signifies a toxic culture. Moreover, this has serious consequences for the next generation of providers, trainees and patients.
Some medical schools and regulatory bodies did take action quickly after the publication of these reports. One of the first medical schools to attack this problem was the David Geffen School of Medicine (DGSOM) at UCLA. In 2012, they published a report outlining the results of their 13-year effort to eradicate medical student mistreatment. Like many universities across the nation, DGSOM implemented a committee to explore how to best educate students, inform policy and train staff. They looked at all forms of abuse: physical, verbal, sexual harassment, ethnic and power. They also took all the reports and characterized them as mild, moderate or severe abuse. In the end, 64 percent of all cases of abuse were ranked as “severe” by the authors. DGSOM saw a large drop in verbal harassment, but the percentage of “severe” comments and reported sexual harassment remained stable over the years despite the introduction of mandatory sexual harassment training for faculty. Although DGSOM should be applauded for its courage, leadership and transparency in battling this issue, the problem has not been solved. A 2014 meta-analysis published in Academic Medicine not only reports that the incidence of sexual assault was 33 percent, but they also found no evidence of a decline over the years.
Such persistent and ubiquitous levels of abuse can only be explained by a toxic culture, where victims are made to feel powerless and flawed. One surgery resident described her experience in a qualitative research project examining the psyche of abuse victims:
“You are kind of vulnerable … and you can’t really do anything … and he patted me on the butt … and that, the ﬁrst time I thought, maybe he was just slipping a hand, or that, maybe I was just being too sensitive, but then it just like went on and it went on and it went on like several times and I really felt uncomfortable and I didn’t know what I should do, what should I say? I didn’t know what to do because like if I like say something, they’re going to go, ‘whoa, she’s a real bitch, she’s sure uptight, she’s sure sensitive…’”
In addition to making the victim feel flawed, the current system of reporting mistreatment puts the victim in a difficult position. We know that underreporting is rampant and that more than a quarter of victims don’t report mistreatment because they fear retaliation. Victims may also be subject to accusation of their character, discrimination and relocation to inferior clinical sites. On Student Doctor Network, an individual seeking advice was warned:
“Now, realize this is the equivalent of thermonuclear warfare in the medical world. You may end up blacklisted in some departments. Your evaluations may stink. Your school may side with the attending doctors because they’re afraid of other doctors not taking students.”
When students do find the courage to report, sometimes they discover that the complaints fall on deaf ears. This is a story from a project about the abuse called “I’m too used to it”:
“When students told-when numerous students told the course directors about this, the course directors were like, ‘yeah, there’s not so much we can do.’ In some cases, clerkship coordinators appeared to be aware of the reputation of some male faculty members and warned students in advance of rotations. However, such warnings seemed to place the onus of addressing inappropriate attending behavior on the student. As one participant described, ‘We were warned actually by [program administrator].’ He said, ‘Doctor [Y] sort of has a reputation for being inappropriate. It’s part of his personality. We try to keep him in line, every now and then he slips back out of line. Just let him know if he’s going out of bounds.’ This participant then proceeded to recount inappropriate and sexist jokes that this attending engaged in throughout the rotation.”
What are harassed students supposed to do? Report the incident and get moved off the service? Have their career and education compromised? Continue to suffer in silence? Submit a form and hope someone gets reprimanded? Wait for another study to be published? Hope the perpetrators retire? No one should have to make these choices.
Despite decades of research, surveys, interviews, learning environment committees, passionate faulty and laudable effort on behalf of the AMA, AAMC and LCME, we still have no meaningful reduction in the sexual harassment of medical students. We need a culture change and it has to start with us. It begins by recognizing that sexual harassment thrives when abuse and self-depreciation run rampant. As students, we are strong, brave, diligent, creative, hardworking and worthy of respect. The culture where this abusive behavior is expected and accepted can go on no longer. We cannot be the victims who pass this toxicity to the next generation.
We have dedicated our lives to helping others and the time is now to stand up for our peers who are suffering in silence.
Author’s note: A word on gender: This article is mostly about women and sexual harassment. However, there is also significant harassment among men.