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An Invitation to Be Quiet No Longer


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Stephanie L. Graff, MD

Stephanie L. Graff, MD

My male colleagues sometimes broach the topic of #MeToo or sexual harassment in medicine by saying how uncomfortable it makes them. Ah, yes. How uncomfortable the sexual harassment I  have faced for years makes you. I casually bring up microaggressions—subtle verbal or nonverbal slights against any minority, whether intentional or unintentional. In terms of gender discrimination, it can be as simple as not referring to a female colleague as “Doctor” in formal settings or with patients, interrupting women speaking, or using language to describe women that is never used to describe men (“bossy” or “shrill” come to mind). 

They may seem like small insults, but gradually over time, they build up, inculcating the message that you are not enough. Dr. Reshma Jagsi has described the resulting insecurity, stating, “the experience did make me silently question my self-worth: Why was my scholarship not substantial enough for this man to see me as a colleague who has done important research and has worthy ideas, instead of objectifying me?”1

Examples of overt sexual harassment and microaggressions have accumulated over my career. I am sure there are many I did not even notice or no longer recall. 

“I’ve never met such an attractive doctor. How does everyone feel about working with you?” 

“Wow. Not only are you pretty, but you really seem to know what you are talking about.” 

Pervasive and Persistent

Sexual harassment is encountered across all types of professional interactions: with attendings, colleagues, patients, patients’ family members, even among women. It is pervasive. The National Academies of Sciences, Engineering, and Medicine reported that women who experience harassment are likely to score lower grades in the classroom.2 The problem persists in training programs, where female residents perform worse on milestone evaluations than their male peers,3 and female residents get worse peer evaluations after pregnancy.4 Are women behind before they ever get a chance to start?

Sexual harassment is encountered across all types of professional interactions: with attendings, colleagues, patients, patients’ family members, even among women. It is pervasive.
— Stephanie L. Graff, MD

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I have never been physically harmed or assaulted. I have also never reported an incident of harassment. Yet numerous words spoken to me, intended to hurt or devalue women, are etched forever in my memory, and I have held them there quietly. These words and actions are interspersed through my mind. Have they been a weight holding me back? There is an emerging lexicon to describe degrees of sexual harassment—microaggression, implicit bias, gender discrimination, unwanted sexual attention, sexual assault. At what point do we say #TimesUp?

“I love having you consult on my cases. If you ever want to do anything more personal, just let me know.” 

[While I was kneeling to use a computer in a very crowded open work space:] “I love finding a woman on her knees.”

Empowerment and Opportunity

As the #MeToo movement has made waves across varied industries—film, technology, athletics, and science—I have felt empowered by the strength of women standing together to say “this should not be our normal.” I have also felt empowered by the movement to be more inclusive of women in leadership and to develop specific strategies to advance women as well as by men rising as advocates for equality. 

Our training programs and organizations can offer education and training to recognize, respond to, and end discrimination.
— Stephanie L. Graff, MD

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The opportunity exists for continued growth and change in our own industry. The medical community can teach men and women alike how to stand against discrimination. Our training programs and organizations can offer education and training to recognize, respond to, and end discrimination. We can create the cultural shift that allows the youngest generation of oncologists—now 46% women5—to practice in a welcoming environment. 

We know that workplace sexual harassment has a negative impact on career satisfaction and productivity.6 The projected need for oncology expertise is on the rise; now more than ever, we need all of our peers to have long, productive careers. 

We can intentionally create gender and ethnic diversity on panels of speakers, authors, and committees that represent the diversity of our field and of the patients we serve. We have already seen journals7 and professional organizations8,9 take action toward these goals. We can create an environment where reporting of harassment is not punished, particularly for those still in training who may be most at risk. Many of my personal examples of harassment occurred during training. What are the factors that place a trainee at higher risk of sexual harassment, and what safeguards can be put in place to create an environment of safety and equality? One approach, the implementation of online reporting systems, has been shown to increase reporting of harassment and assault in undergraduate environments.10

Women in Leadership

I am privileged to have found an organizational culture that celebrates women in leadership. My current institution has a female Chief Executive Officer (CEO), and of the 59 persons listed on the organizational leadership roster, 33 (55.9%) are women. By comparison, women account for only 20% of full professors in academic medicine and 18% of hospital CEOs.11 

The fact that I faced no harassment within my own team may reflect our strong female culture. How can we encourage others to create safe and respectful environments? How can we create more women in leadership? The University of Michigan has developed innovative new programs for environmental change, including the Faculty Leading Change Program to address issues of organizational climate and diversity12 and the Rudi Ansbacher Women in Academic Medicine Leadership Scholars Program to promote the advancement of women.13 

Maternity Discrimination

Maternity discrimination further augments gender discrimination. In a 2017 survey, 66.3% of women reported gender discrimination and 35.8% separately reported maternity discrimination, including limited or unpaid maternity leave, lack of facilities for breastfeeding, and poor support for the time commitment that breastfeeding requires.14 Approximately 30% of

The fact that I faced no harassment within my own team may reflect our strong female culture. How can we encourage others to create safe and respectful environments?
— Stephanie L. Graff, MD

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female physicians in the survey wanted paid maternity leave, better access to emergency child-care services, or onsite day care. 

The community of female physicians is asking for what they need. How can we support workplace culture expansion to include family leave policies, breastfeeding support, and child-care facilities to the mutual benefit of women and men?

“If you keep wearing skirts to clinic, you’ll have no problems getting honors.”

“Of course they asked you to speak—you are easy to look at.”

Handling Harassment

I particularly struggle when gender discrimination or sexual harassment comes from my patients or my patients’ families. I am utterly unprepared for handling these events. As a breast oncologist, I largely care for a female population. But patients’ family members still regularly place me in uncomfortable situations. 

In one study, 76% of female physicians surveyed reported sexual harassment by patients.15 Survey respondents offered suggestions to mitigate the risk of harassment—“increasing my coldness” and “not asking open-ended questions”—solutions that I find unacceptable. 

ASCO has been a leader in tackling these problems, with strategic initiatives to address women’s and minority issues within our field.
— Stephanie L. Graff, MD

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As I swore in the Hippocratic oath, “I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.”16 Do these offenders not deserve my warmth, sympathy, and understanding? I tend to excuse the comments as innocent and unintentional. Yet the Hippocratic oath16 goes on to remind us, “I will remember that I remain a member of society, with special obligations to all my fellow human beings,” leaving me to ask, what is my responsibility to stand against gender discrimination in these moments? 

Along with numerous other professional organizations, ASCO has been a leader in tackling these problems, with strategic initiatives to address women’s17,18 and minority19 issues within our field. The American College of Physicians has even published a position paper on achieving gender equity.20 Continued analysis and dialogue are essential to effectively meet the needs of individuals who face discrimination. Could we create physician training programs to teach appropriate responses and tools to address harassment from patients? 

“It is awesome that I get to see you feel my wife’s breasts at every appointment.”

“After you have your baby, are you really going to come back to work?” 

Call to Action

I now know that if we are quiet, our broader medical community will not have that opportunity to learn and grow. We need to have these discussions. No one has all the answers, but I will be quiet no longer. I invite you to walk a mile in my proverbial shoes; to feel the discomfort that moments like these create; to realize this is one woman’s voice and, given that less than half

I invite you to create a call to action in your clinic, training program, academic or community circles, and professional societies to develop innovative strategies to end discrimination.
— Stephanie L. Graff, MD

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of female medical students report sexual harassment,2 there are countless others who remain silent. 

I invite you to do better. I invite you to become a #HeForShe or #SheForShe who can stand up to offenders—witnesses need to become allies. I invite you to reflect on my stories; to create a call to action in your clinic, training program, academic or community circles, and professional societies to develop innovative strategies to end discrimination; and to design programs for pragmatic change. I invite you to be quiet no longer. 

#TimesUp #QuietNoLonger ■

Dr. Graff is Director of the Breast Program at Sarah Cannon Cancer Institute at HCA Midwest Health, Overland Park, Kansas.

DISCLOSURE: Dr. Graff reported no conflicts of interest.

Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.

REFERENCES

1. Jagsi R: Sexual harassment in medicine—#MeToo. N Engl J Med 378:209-211, 2018.

2. National Academies of Sciences, Engineering, and Medicine: Sexual harassment of women: Climate, culture, and consequences in academic sciences, engineering, and medicine. Washington, DC; National Academies Press; 2018. 

3. Krause ML, Elrashidi MY, Halvorsen AJ, et al: Impact of pregnancy and gender on internal medicine resident evaluations: A retrospective cohort study. J Gen Intern Med 32:648-653, 2017.

4. Dayal A, O’Connor DM, Qadri U, et al: Comparison of male vs female resident milestone evaluations by faculty during emergency medicine residency training. JAMA Intern Med 177:651-657, 2017.

5. ASCO: The state of cancer care in America, 2017: A Report by the American Society of Clinical Oncology. J Oncol Pract 13:e353-e394, 2017.

6. Willness CR, Steel P, Lee K: A meta-analysis of the antecedents and consequences of workplace sexual harassment. Personnel Psychol 60:127-162, 2007.

7. Editorial: Time’s up for sexual harassment in medicine. Lancet 391:2576, 2018.

8. Klein RS, Voskuhl R, Segal BM, et al: Speaking out about gender imbalance in invited speakers improves diversity. Nat Immunol 18:475-478, 2017

9. Shillcutt S, Silver J: Social media and advancement of women physicians. N Engl J Med 378:2342-2345, 2018.

10. Mangurian C, Linos E, Sarkar U, et al: What’s holding women in medicine back from leadership? Harvard Business Review. June 19, 2018. Available at hbr.org/2018/06/whats-holding-women-in-medicine-back-from-leadership. Accessed September 4, 2018.

11. Association of American Medical Colleges: The state of women in academic medicine: The pipeline and pathways to leadership, 2015-2016. Available at www.aamc.org/members/gwims/statistics. Accessed September 4, 2018.

12. University of Michigan: Faculty leading change, 2016-2017: A yearlong program of positive change. Available at advance.umich.edu/flc.php. Accessed September 4, 2018.

13. University of Michigan: Rudi Ansbacher Women in Academic Medicine Leadership Scholars Program. Available at faculty.medicine.umich.edu/faculty-career-development/programs-awards/women-academic-medicine. Accessed September 4, 2018.

14. Adesoye T, Mangurian C, Choo EK, et al: Perceived discrimination experienced by physician mothers and desired workplace changes: A cross-sectional survey. JAMA Intern Med 177:1033-1036, 2017.

15. Phillips S: Sexual harassment of female physicians by patients. What is to be done? Can Fam Physician 42:73-78, 1996.

16. Lasagna L: Hippocratic oath: Modern version, 1964, in Tyson P: The Hippocratic oath today. Available at www.pbs.org/wgbh/nova/body/hippocratic-oath-today.html. Accessed September 4, 2018.

17. Hudis CA: Highlights of March Board of Directors meeting: Strategic planning. ASCO Connection, March 30, 2018. Available at connection.asco.org/blogs/highlights-march-board-directors-meeting-strategic-planning. Accessed September 4, 2018.

18. Graff S: Takeaways from the women in oncology strategic planning retreat. ASCO Connection, September 21, 2017. Available at connection.asco.org/blogs/takeaways-women-oncology-strategic-planning-retreat. Accessed September 4, 2018.

19. ASCO: ASCO’s health disparities efforts now led by standing ASCO committee. ASCO Connection, February 11, 2013. Available at connection.asco.org/magazine/society/asco’s-health-disparities-efforts-now-led-standing-asco-committee. Accessed September 4, 2018.

20. Butkus R, Serchen J, Moyer DV, et al, for the Health and Public Policy Committee of the American College of Physicians: Achieving gender equity in physician compensation and career advancement: A position paper of the American College of Physicians. Ann Intern Med 168:721-723, 2018.


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