The ocean in which we float
In the days leading up to the 2021 annual meeting of the American Society of Clinical Oncology, The Cancer Letter published an article focusing on Axel Grothey’s unethical sex with women he mentored at the Mayo Clinic.1
While this news has been viewed by some as shocking, science tells us it is quite the opposite.
The National Academies Sexual Harassment Iceberg provides a framework for identifying harassing behaviors and categorizing them into the three main forms of sexual harassment: gender harassment, unwanted sexual attention, and sexual coercion.2
The threshold of the waterline of public awareness and awareness separates gender-based harassment, which is the most common but least publicized form of sexual harassment “underwater”, from the last two, which are sexual harassment. flagrant acts less common but often highly publicized by people in power.
So was Grothey’s sexual misconduct, the rare and exposed tip of the iceberg that is making headlines and sounding the alarm.2 Yet it is not the exposed part of the iceberg that poses the greatest threat, rather it is what lies in the depths; it’s the ocean we all float in that allows icebergs to form in the first place.3
Organizational psychology establishes that harassment is common in historically male dominated fields where there are differences in hierarchy and power, a perfect description of modern medicine.
Lilia M. Cortina [professor of psychology, women’s studies, management and organizations at the University of Michigan] and Reshma Jagsi [deputy chair of radiation oncology, Newman Family Professor of radiation oncology, residency program director, and director of the Center for Bioethics and Social Sciences at the University of Michigan] eloquently describe these ‘icebergs below sea level’ events as ‘scraps’ rather than ‘comers’ in their 2018 Annals of Internal Medicine perspective.4
Almost daily examples of harassment from women’s experiences include maternity harassment (“you can’t do this job with three children”), sexist slurs (“women have no place in the room). of operation ”), crude remarks on the body of women, and infantilization (“ baby ”,“ honey ”).
There are also unconscious biases, leading female physicians to be misidentified (female physicians have repeatedly approached untitled5 or identified as auxiliary staff) and to have fewer opportunities for professional advancement.6
This is not to say anything about the amplified experience of those people with intersectional identities as people of color, LGBTQ +, or other under-represented minority groups.
Change the ocean
The pervasive harassment leading to increased turnover intentions and decreased job satisfaction, as we’ve shown, should be the data institutions need to invest in solutions.
In 2016, the cost of boarding a new doctor was $ 200,000 to $ 300,000,7 which does not take into account the costs of recruiting or the opportunity costs of lost revenue. Investing in active solutions that retain physicians pays off.
Institutions have many opportunities to be agents of change. Policies regarding sexual harassment need to be clarified to both delineate reporting procedures, describe potential disciplinary actions harassers would face, prohibit retaliation and ensure confidentiality.
Choices must exist within the organization to file complaints both formally and informally with similar levels of confidentiality and accountability among a wide range of people across organizational positions with varying ages, genders, gender identities and backgrounds racial.
Focusing on responses to acts of harassment, such as reporting systems, is insufficient – many studies show that even when best practices are used, the vast majority of harassment goes unreported – so we need to prevent harassment to happen in the first place.
Focusing on responses to acts of harassment such as reporting systems is insufficient – many studies show that even when best practices are used, the vast majority of harassment goes unreported – so we need to prevent harassment from happening. produce in the first place.
The ultimate cultural transformation relies on transparency and, as in the spirit of “you measure what matters”, annual reports should be published, consolidating data on the number of reports filed, results and ranges of penalties imposed.
Such reports will make it clear to everyone that the organization is committed to zero tolerance. Institutions should also measure and report on their recruitment, promotion and integration of women into organizational leadership as they strive for gender equity.
Transparency in promotion and compensation measures benefits women and under-represented minorities.
Finally, as we saw in the Grothey case1, organizations are co-dependent and must come together to empower and equip the community at large for equity.
National organizations engaged in health systems financing and accreditation, as well as professional societies and licensing boards, each play a collaborative and interconnected role in promoting zero tolerance for the safety of our workforce. and our patients.
National advocacy efforts by organizations for national physician licensing would not only improve public health care in times of crisis, as is needed during the pandemic to cut red tape and bureaucracy for all organizations. , but, above all, would improve the transparency of ethical breaches.
Stronger organizational interconnection would also likely lead to better solutions for training and education programs, as well as repatriation after disciplinary action.
Harassment, in all its forms, defies fundamental principles of medical ethics, including respect for people, non-maleficence, justice and beneficence.
As ethical practitioners and leaders in the field of health, we are called to move from the status of spectator of harassment to that of “defender”, intervening as an ally for the target of harassment.8
When you witness an offensive act, there are many actions that can help you engage as an ally. Often referred to as “the 4 Ds,” alliance techniques include direct, delay, distraction, and delegation.
For a direct alliance, report the behavior immediately (“that is inappropriate”) or ask the author pointed questions (“did you mean that…”). For a late alliance, express your disapproval to the abuser privately or offer your support to the victim privately.
Distraction techniques involve sidetracking the situation with humor (“since this is not a late night comedy routine, maybe you should rephrase this …”) or pulling the target away from the situation ( “Sorry to interrupt, I need Dr. X in room 12”).
Many of these honest actions, especially direct, delayed and distracting, are more effective in the mild or everyday instances of harassment encountered that may not warrant institutional reporting.
As a delegate, the final D, a critical step in standing up is holding your delegate accountable for the action. Steps of delegation include asking institutions to provide training in general or initiate an investigation in particular, involve other colleagues in the best next steps, or document and report the behavior to internal managers. and appropriate external.
The American College of Physicians has a wonderful series, “I Caught You Upstanding”,9 enabling healthcare workers to practice the skills needed to move from being a spectator to being an honest ally.
As we enter a new era of medicine, healing the post-pandemic healthcare community, newly awakened to the complicit ocean fostering the harassing icebergs faced by women and minorities in medicine by The Cancer Letterreport on the state of harassment in oncology, we hope that we will use our ethics, our professionalism and our humanity to become advocates and leaders of institutional change towards cultures of fairness and respect.
With more risers floating in the ocean, fewer icebergs will form.
- Leading gastrointestinal oncologist Carolan A, Goldberg P. Axel Grothey was kicked out of the Mayo Clinic for unethical sex with women he had mentored. The letter of cancer, Vol.47 No.21, published online 28 May 2021
- National Academies of Science, Engineering and Medicine. 2018. Sexual Harassment of Women: Climate, Culture and Consequences in Academic Science, Engineering and Medicine. Washington, DC: The National Academies Press. do I: https://doi.org/10.17226/24994. Image used with permission.
- Beeler WH, Cortina LM, Jagsi R. Diving Below the Surface: Addressing Gender Inequalities Among Clinical Researchers. J Clin Invest. August 5, 2019; 129 (9): 3468-3471. do I: https://doi.org/10.1172/JCI130901. PMID: 31380810; PMCID: PMC6715381.
- Cortina LM, Jagsi R. What can medicine learn from social science studies about sexual harassment? Ann Intern Med. 2018; 169: 716-717. do I:10.7326 / M18-2047
- Duma N, Durani U, Woods CB, Kankeu LA, Cook JM, Wee C, Fuentes HE, Gonzalez-Velez M, Murphy MC, Jain S, Marshall AL, Graff SL, Knoll MA. Unconscious bias assessment: speaker presentations at an international oncology conference. J Clin Oncol 2019, 37:36, 3538-45
- Jagsi R, Griffith KA, Jones R, Perumalswami CR, Ubel P, Stewart A. Experiences of sexual harassment and discrimination in university medical school. JAMA. 2016; 315 (19): 2120–2121. doi: 10.1001 / jama.2016.2188
- Frenz DA. The staggering cost of physician turnover. Today’s hospitalist. Published online August 2016 and consulted online June 3, 2021 at https://www.todayshospitalist.com/staggering-costs-physician-turnover/
- Mello MM, Jagsi R. Stand Up Against Gender Bias and Harassment – A Matter of Professional Ethics. N Engl J Med 2020; 382: 1385-1387
- American College of Physicians. Accessible to https://www.acponline.org/advocacy/where-we-stand/women-in-medicine/the-i-caught-you-upstanding-series June 3, 2021.