The Problem That Would Not Be Tolerated Elsewhere

Think hard. Except for a few high-profile cases, how often have you heard of students demonstrating outside a medical school about being propositioned, threatened, inappropriately touched, unnecessarily bullied or denied positive recommendations? In most cases, probably never.

In recent months, however, the case of Larry Nassar, former physician to many of America’s most talented gymnasts, has reminded us that even doctors can be guilty of sexual misconduct. In his case, more than 150 women and girls were finally able to break their silence before a judge sentenced Nassar to 40 to 175 years in prison.

But he’s only one person. His behavior could be just an anomaly. Right? Wrong. Recently, it was reported that a staff gynecologist at the University of Southern California frequently touched patients inappropriately and made suggestive comments, even though they and co-workers had complained about his conduct for decades.

The vast majority of physicians -- people who work grueling hours dealing with challenges most of us would not consider for any amount of money -- are beyond reproach. Nevertheless, there are the few for whom the adulation leads to entitlement, to the individual’s conviction that he deserves special privileges and treatment. Combined with power, it is the foundation for sexual harassment.

Higher education institutions have, for at least two to three decades, endured demonstrations and legal challenges from students accusing professors and other superiors of engaging in or ignoring harassment, but one sector of academic education stands out for its relative silence: medical schools. To their credit, many and probably most physicians are becoming increasingly concerned about that silence and the challenges it poses for the profession. At a meeting of the Canadian Medical Association’s general counsel last year, several voiced criticism of what has been called the “bullying culture” of medicine. “I would liken our issues with intraprofessionalism to a chronic disease,” said one. Others commented on the vulnerability of trainees for whom toleration of abuse is typically part of medicine’s “hidden curriculum” since “there is so much power physicians can hold over [students].”

Four years earlier, the United Kingdom’s first published survey of bullying and harassment was titled “It Would Not Be Tolerated in Any Other Profession Except Medicine.” Although most of us would deny it, the power that educators can have over students is astonishing, and the survey’s title might be correct. Perhaps sexual misconduct toward both male and female students in medical colleges “would not be tolerated in any other profession.”

“Misperception” and Silence

Over time, researchers have published surveys about sexual harassment in medical colleges, but obviously not enough have emerged so far to provoke significant student response or public concern about the extent of the problem.

As early as 1985, pediatrician Henry K. Silver did a study that penetrated the silence about what he and a co-author termed “Medical Student Abuse: Incidence, Severity, and Significance.” The survey of 519 members of an entire medical class included focus on sexually harassing behaviors by superiors, and Silver became noted as a pioneer who brought sexual harassment to the attention of the medical profession.

A decade later, the David Geffen School of Medicine at the University of California, Los Angeles, sensed a problem and began a 13-year effort to analyze and eradicate mistreatment of its students. Three of the areas in which students identified abusive behavior were “(1) power mistreatment, (2) verbal mistreatment and (3) sexual harassment.” All three, of course, can be defined as harassing behavior. As expected, there were gender differences. In the first period of the study, males reported 5 percent of harassment, while the female response was 31 percent, dropping to 20 percent in subsequent years. Equally predictable was that few men or women who reported mistreatment indicated having sought help or making a formal report to the institution. Only 13 percent of students did so for verbal mistreatment and 15 percent for power mistreatment and sexual harassment.

Most disturbing was the study’s conclusion: that despite the school’s proactive efforts to improve the environment, there was no serious evidence mistreatment had decreased, and that insofar as sexual harassment was concerned, “mandatory training introduced in 2005 had no discernable influence on [its] incidence.”

The situation appears to have changed little since then, as a limited number of additional studies have demonstrated. In 2016, the Journal of the American Medical Association published a prominent study of harassment during academic medical education. In its 2014 survey of 1,066 men and women receiving career development awards from the National Institutes of Health, 4 percent of men reported having being harassed and as many as a third of women described having experienced sexist remarks, unwanted advances, coercion, threats, bribery and other behaviors. Moreover, 66 percent of women and 10 percent of men said they had suffered some form of gender bias in their careers.

The lead author of the survey, Reshma Jagsi, commented in a later publication, “I had a misperception that overt sexual harassment was largely a thing of the past, a vestige of another generation.”

So why the “misperception” and silence when so many professions and businesses seem finally to be “getting” the necessity of dealing with inappropriate and predatory behavior? The reasons are multiple. The path to medical school and beyond is extraordinarily arduous and expensive, and the journey does not end until an undergraduate degree, four years of medical school, three years of residency (more to become a specialist) and a license have been achieved.

The Princeton Review reported that the average GPA for medical school entrance in 2016-2017 was 3.71 over all. And, according to the Association of American Medical Colleges, the average price for a year at a public medical school was $34,592 and $58,668 at a private one, not including books and living expenses. Seventy-five percent of medical school students graduating in 2016 left with median total education debt of $190,000.

For those students who are admitted, wrote Nathaniel Morris in a 2016 Washington Post article, “Medical school can be brutal [and] make many suicidal.” Unknown to most people, the bullying culture of medical schools is in its rigor and exclusivity unlike any other. According to the resident in psychiatry at the Stanford University School of Medicine, the power structures in medical schools’ hierarchical and self-protective culture reinforce victims’ reluctance to complain and can be related to survey findings that approximately 10 percent of medical students report having considered suicide in the last year. Similarly, Medscape reported that, even though accurate estimates of suicide within the medical profession are impossible, it consistently ranks at the top of professions with the greatest risk of suicides.

A 1993 study, “Sexual Harassment in Medical Training,” identified the authoritarian and hierarchical nature of medical school as a major factor in exposing trainees to sexual harassment, but characteristics of medical students also influence their willingness to endure harassment and silence. These young people are among what higher education recognizes as its “best and brightest,” which suggests they are either by nature or necessity highly competitive academically and reliant on instructor approval. Conscientious and persistent, most have seldom encountered serious academic competition prior to medical education.

When sexual harassment occurs, evaluation of how to handle it can be secondary not only to the student’s fear of retaliation by the harasser and his colleagues but also to how they will be perceived by peers and superiors if they seek help. To protest is to appear weaker or less competent than others. And even sympathetic peers, concerned about their own careers, may be unwilling to risk support. The years of struggle to reach and remain in medical school and the burdens of debt reinforce the silence.

Equally explicable is the degree to which both students and harassers may identify with popular stereotypes of physicians. For decades, doctors have ranked in the top tiers of the most prestigious and trusted professionals. A recent New York Times article reported that perception may, however, be changing: more than 75 percent of Americans in 1966 had great confidence in medical leaders, whereas only 34 percent of contemporary Americans share the impression.

Although determining the extent of a decline in trust or stature is unrealistic since too many variables are involved, it is probably accurate to assume that the majority of medical students still respect and identify with the “physician on a pedestal” stereotype. Thus, the long journey to medical school and the hierarchical nature of the environment can render victims not only reluctant to complain but even to misperceive harassment or instead to explain it away as unintentional.

A Severe Crisis

In 2016, the Atlanta Journal Constitution analyzed public records from every state dating back to 1999 to identify cases of physician sexual misconduct. It found accusations against 3,100 doctors but described these as “only a fraction [of total] sexual violations.”

The reasons for the silence were numerous. Among the 11 that the paper listed were: hospitals, other physicians and regulators refusing to report misconduct; medical boards issuing only private letters of concern or agreeing to confidentiality with accused physicians; time limits used as means of refusing to investigate; and doctors in some states avoiding sanctions by entering “impaired physician” programs.

While the newspaper report did not focus on medical schools, its point is generalizable: like other institutions and the medical profession in general, medical schools confront a severe crisis that mandates fixing. The newspaper described the lack of transparency in stark terms as “a broken system” that gives a guilty minority “a license to betray.” Even more disturbing is that the silence protecting the guilty may teach students that “betrayal” is acceptable.

Recognizing the seriousness confronting medical schools, Jagsi and other distinguished physicians published in 2017 “It Is Time for Zero Tolerance for Sexual Harassment in Academic Medicine.” The article suggested “mechanisms” to combat sexual harassment, including informal reporting processes, mandatory training for medical personnel, sanctioning and monitoring of individuals accused of harassment, eliminating “locker room humor” in medical education, and encouraging professional societies to address the issue and develop policies banning retaliation. It also advised medical schools and the profession to gather more information on the prevalence and severity of harassment, as well as the outcomes of investigations and responses by harassers to intervention.

When respected professionals offer advice, they deserve respect. I am not a physician and do not mean to be antagonistic, but in some respects, such strategies seem too little too late. Surely, if the last 30 years -- closing in now on a half century -- have taught us anything, it is that efforts to eradicate harassment deserve far more stringent and culturally targeted efforts.

Higher education has long since moved beyond need for repetitive prevalence studies and vacuous promises that unethical and illegal behaviors will cease. Despite a silence that is “brutal,” the profession has known for decades that significant numbers of students are being sexually harassed on medical campuses. Educators and physicians have also known that fear of retaliation keeps students in all sorts of academic settings from telling us when those who should be protecting them victimize them. So how much more effort must go into measuring what we know we don’t know?

If the supposedly smartest people in our culture haven’t figured out by now that “locker room humor” is unacceptable in professional settings, they never will. If educated professionals don’t understand the costs of sexual harassment by now, they never will. If medical societies haven’t developed policies banning retaliation by now, the public needs to know why. If students don’t trust “cookie cutter” training that promises protection from retaliation and ensures severe and transparent sanctioning of even the most powerful, tolerance becomes the cultural message.

What too few people in higher education have faced is that victims, especially the young, cannot solve the challenge of sexual harassment for us. Policies, procedures and promises do not prevent misconduct. People do that. If medicine is, as it is often called, a “self-regulating” profession, it is time to get on with it.

Students should be encouraged to acknowledge misconduct, but the greatest responsibility for eradicating sexual harassment lies with the powerful whose priorities should not be ignoring and shielding blameworthy colleagues and reputations of institutions or maintaining inflated concepts of their profession. They should be protecting and providing ethical role modeling for the young who are being trained to care for us in the future.

Professional cultures differ, and only medicine can determine how it deals with the challenge it faces. Although it is difficult for laypeople to understand, some of the exacting behaviors that occur in medical education may be justified. But the right to harass is not one of them.