Sexual harassment is rampant in healthcare and responses to it are few and weak. In general, healthcare institutions are ill-prepared to comprehend the problem, to understand the contributions of their organizational culture, and to respond to sexual misconduct with direct, sure action and sufficient resources. They must undertake an array of bold actions to eliminate harassment and create a safe environment. Among these are thoroughly and repeatedly measuring the nature, prevalence, and severity of harassment and discrimination; promoting a clear, comprehensive policy that conveys a firm commitment to safety, respect, inclusion and equality; and pairing policy with clear and consistent action. Victims will only come forward if they feel safe doing so and know their report will result in a rapid, thorough, and fair investigation, and that their harassers will be punished, no matter their rank or reputation. Perpetrators must not be allowed to go on “extended leave,” quietly retire, or accept reassignment at another healthcare system through an under-the-table arrangement: “cover your ass” practices that communicate tolerance of egregious behaviors do nothing to discourage further misbehavior.
Many factors make an organization prone to sexual harassment: a hierarchical structure, a male-dominated environment, and a climate that tolerates transgressions — particularly when they are committed by those with power. Medicine has all three of these elements. And academic medicine, compared to other scientific fields, has the highest incidence of gender and sexual harassment. Thirty to seventy percent of female physicians and as many as half of female medical students report being sexually harassed.
As we wrote in a recent New England Journal of Medicine article, “Imagine a medical-school dean addressing the incoming class with this demoralizing prediction: ‘Look at the woman to your left and then at the woman to your right. On average, one of them will be sexually harassed during the next 4 years, before she has even begun her career as a physician’.”
The efforts of many healthcare organizations and medical centers tend to go little further than avoiding litigation. This needs to change. We propose a number of actions institutions must take to eliminate sexual harassment and create a safe environment that allows everyone in the health care workforce to do their best work on behalf of their patients.
Quantitative and qualitative assessment. The first step is for healthcare organizations to commit to understanding the problem. They must thoroughly and repeatedly measure the nature, prevalence, and severity of harassment and discrimination. Since this is unlikely to happen spontaneously, boards of directors and trustees should require open reporting of aggregate data, forums where employees can share ideas on how to reduce or eliminate harassment, and tying compensation of executives, deans, and chairs to outcomes.
Organizations should use standardized and validated instruments to survey their employees and do so annually, and anonymously. (You can find one such survey available from NASEM and another from the AAU. Our company, Equity Quotient, also offers one.) Survey data, along with aggregated data on reports of harassment, should be reported throughout the organization. Measurement will allow each organization to ascertain where exactly it needs to improve, test hypotheses and solutions that fit its culture and needs, and track progress.
Policy improvement. Every health care organization needs to promote a clear, comprehensive policy that conveys a firm commitment to safety, respect, inclusion and equality. It should contain guidelines for standards of behavior, employee reporting of sexual harassment, and institutional responses to offensive or abusive behavior, discrimination, and retaliation. The Association of Title IX Administrators have examples of such policies, as does the National Council of Non-Profits. Organizations can use these for reference, modifying them as appropriate for their own needs.
In addition, secure methods of reporting harassment should be readily available to employees and supported by initiatives to keep the reporting options visible and familiar to the entire community. Targets of harassment should have ready access to counseling and support, even if they choose not to pursue formal reporting processes. These resources should be available outside of the institution itself, to increase the comfort of people reporting harassment and to remove potential biases that may occur when counselors are employed within the same institution where the harassment occurred.
Follow through. Organizations need to pair policy with clear and consistent action. The NASEM report stated, “Too often, judicial interpretation of [anti-discrimination laws] has incentivized institutions to create policies and training on sexual harassment that focus on symbolic compliance with current law and avoiding liability, and not on preventing sexual harassment.” The key phrase here is “symbolic compliance”: nearly every healthcare organization has a policy, but whether that policy is merely a checkbox or actually functions well in practice is a distinguishing feature of organizations that are serious about the problem.
Human Resources commonly takes the lead in crafting and enforcing a strong policy. HR should be responsible for ensuring, among other things, that leadership has clearly communicated a zero-tolerance position; that employees trust the current procedures; and that reporting mechanisms are easy to understand. A useful list of key questions for leaders to ask themselves about their approach to sexual harassment, from the law firm Cleary Gottlieb, can be found here. It asks, for example, how well senior management communicates its zero-tolerance stance and who should oversee investigations of harassment allegations. While internal processes may provide efficiency, independent external investigations should be undertaken when there is any question about the objectivity of the internal inquiry.
Finally, organizational responses need to be applied with consistency. Victims will only come forward if they feel safe doing so and know their report will result in a rapid, thorough, and fair investigation, and, if misconduct is discovered, that their harassers will be punished, no matter their rank or reputation. Perpetrators must not be allowed to go on “extended leave,” quietly retire, or accept reassignment at another healthcare system through an under-the-table arrangement: all “cover your ass” practices that communicate tolerance of egregious behaviors do nothing to discourage further misbehavior. These provisions will reduce the possibility of retaliation, impediments to professional advancement, and further trauma.
Calculate cost and report. The economic, reputational, and human costs of harassment are huge. The University of Southern California (USC), for example, has faced allegations of sexual assault among its medical staff, in addition to allegations of sexual assault of patients by a USC staff gynecologist, for which USC recently offered a $215 million settlement to the victims. In another case, despite knowing there had been a $135,000 settlement with a woman who had reported sexual harassment and retaliation by Dr. Rohit Varma in 2003, USC leadership installed the ophthalmologist as dean of the School of Medicine. Dr. Varma resigned under a cloud less than a year later when leadership, responding to previously undisclosed information, acknowledged it has lost confidence in his ability to lead the school.
Even aside from the impacts of litigation and restitution of harms, the economic, health and psychological consequences of harassment are grave and have reached crisis levels in medicine. Sexual harassment and discrimination undermine women’s physical and mental health, resulting in increased risk for anxiety, depression, burnout, PTSD, and a host of other negative personal and financial consequences. The negative effects of harassment also affect the well-being and productivity of colleagues and entire organizations. In healthcare, this ripple effect is particularly serious, as it may threaten the quality of patient care. Organizational leaders should strive to calculate actuarial costs of sexual harassment in their institutions — in terms of accumulated absences, lost productivity, compromised hiring and retention, legal costs, and reputational harm, and report those costs to their board of directors/trustees. Leaders’ compensation should be tied to decreasing these costs. To the extent possible, executive teams need to make these costs transparent, so that investments in prevention of harassment are understood to be cost effective.
Clearly it is a challenge to put hard numbers on some of these — how do you measure the dollar value of reputational harm? — and indeed no organization that we know of is doing this yet. Nonetheless, such accounting is an essential element of addressing harassment and every health care organization must start making the effort.
Leadership. Harassment thrives in settings dominated by men. Thus it is essential to increase representation of women in leadership roles and assure accompanying equity in salary and power. Among the initiatives that can help are mentorship and sponsorship programs, which are essential to career progression. For example, Drexel University’s Executive Leadership in Academic Medicine (ELAM) program, a year-long fellowship for women leadership in the schools of medicine, dentistry, public health, and pharmacy, provides skills training, mentorship and a network of ELAM graduates who provide support after the completion of the fellowship year. Health care institutions might also take look at successes in other industries; at Eli Lilly, for example, with a mandate from CEO David Ricks, leadership has embraced mentorship, training, and promotion programs that have dramatically increased the percent of women in the company’s senior ranks.
Sexual harassment in medicine undermines an abiding principle of our profession: First do no harm. This year marked the first time that women outnumbered men entering medical school. Medicine cannot sustain a culture that systematically undermines the authority, physical and mental health, and success of such a large portion of its physician workforce. As a profession, we know a little bit about healing. It doesn’t happen in the dark, without data. It doesn’t happen by protecting or fencing off disease-ridden parts of the body. It happens with scientific precision, objectivity, decisiveness, and consistency. We must take down the traditional hierarchies in medicine that provide a fertile ground for harassment, survey ourselves, and ask the difficult (and sometimes painful) questions about how our culture fails our employees. We must support and strengthen women physicians, and build a climate where transgressions are unacceptable. The time to heal ourselves is now.