When the perpetrators are patients

Most female physicians have stories about “those patients.” In the #MeToo era, here’s what teaching hospitals and medical schools are doing to protect their own.
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When Mayo Clinic cardiologist Sharonne N. Hayes, MD, was a resident, she recalls male patients making comments like, “You’re too beautiful to be a doctor,” then describing, in detail, what sexual acts they wanted to engage in with her. At the University of Michigan, Reshma Jagsi, MD, a professor in the department of radiation oncology, had a patient regularly call her “Dr. Sexy.” And psychiatrist Kali Cyrus, MD, recalls a student reporting that a male patient grabbed her crotch during a physical exam. 

Sadly, these are not isolated incidents. Most female physicians have a story about “those patients” – the ones who harass, demean, or mistreat them in an exam room. In fact, a 2018 Medscape survey of more than 3,700 physicians and medical residents reported that 27% of physicians have been sexually harassed by a patient – and that’s only among doctors who report the incidents. 

“This has been one of medicine’s dirty little secrets since women began practicing medicine,” says Hayes, who is the director of Mayo’s Office of Diversity and Inclusion. “Victims are predominantly young women. As physicians, they’re quick to deflect even overt sexual harassment with excuses like, ‘Oh, he’s old,’ or ‘He’s demented,’ or ‘His comments are harmless,’ and that’s part of why we haven’t seen anything being done about it.” 

Instead, sexual harassment has been viewed as a hazard of the job – something women should expect and deal with while also providing the highest quality care to patients who are mistreating them. But “bucking up” and caring for a disrespectful or abusive patient not only puts the doctor’s own well-being at risk, it could also compromise patient care and produce a toxic health care culture. 

The scope of the problem

In 1993, researchers in the New England Journal of Medicine reported that up to 75% of female doctors were sexually harassed by patients. In 2014, a meta-analysis of 59 studies published in Academic Medicine reported that nearly 60% of medical trainees had experienced at least one form of sexual harassment or discrimination during their training (patients and patients’ family members initiated more than 50% of these episodes).

Behaviors range from subtle microaggressions, such as gender bias and problematic compliments, to blatant harassment. In the Medscape report, the most common behaviors described included overt sexual harassment (17%), repeatedly asking for a date (9%), and unwelcome touch, groping, and crotch-grabbing (7%).

When you consider the setting, it shouldn’t be surprising, says Kim Templeton, MD, professor of orthopedic surgery at the University of Kansas Medical Center and past president of the American Medical Women’s Association. Young female physicians or residents are alone in a room with a patient who may or may not be fully clothed. They’re discussing intimate topics in a small, confined space. And they’re professionally obligated to prioritize their patients’ needs above their own. In fact, medical training emphasizes doctors’ obligations to patients and provides detailed expectations and sanctions for physicians who abuse that relationship.

“Everyone understands there are boundaries for physicians. They have to be appropriate and respectful in their interactions with patients,” explains Janis Orlowski, MD, chief health care officer at the AAMC.

Unfortunately, there’s no corresponding rubric for patients. Instead, patient misconduct often goes unacknowledged or unreported. Sometimes, it’s even dismissed, particularly when the patient is suffering from mental illness. “Often, there are physiological explanations for people who behave inappropriately, especially with conditions like post-traumatic stress disorder, dementia, or traumatic brain injury,” says Jagsi, who is the director of the University of Michigan’s Center for Bioethics and Social Sciences in Medicine, a center that acts as an intellectual “water cooler” for professionals focused on improving individual and societal health through scholarship and service. “But just because behavior can be explained, doesn’t mean it should be tolerated.”

Monday, October 22, 2018

ERASE mistreatment by patients

There’s no right way to address mistreatment by patients. Instead, the goal is to arm doctors with real-world strategies they can implement in the moment. Kali Cyrus, MD, MPH, is part of a team of psychiatrists at Yale School of Medicine who run 90-minute workshops to help doctors learn to use the acronym ERASE to navigate mistreatment in practice. Here’s how it breaks down.

  1. Expect. With more than one in four doctors reporting patient-initiated sexual harassment, it’s important for doctors to expect misbehavior to happen – and come up with a plan for protection. “Watch where you stand, come up with a way to signal for help, or bring a male resident into the room with you,” suggests Janis Orlowski, MD, chief health care officer at the AAMC.
  2. Recognize. Check in with yourself and pay attention to how patients treat your colleagues. Does the encounter feel innocent and does the patient seem to be making an attempt at small talk? Or does it feel icky and uncomfortable? “If you see something that doesn’t feel right with you, say something,” says Cyrus.
  3. Address. Come up with a script so you’re able to address the mistreatment when it happens. “Something as simple as, ‘Your comments are making me uncomfortable,’ or ‘I feel offended by that,’ can go a long way toward curbing harassment,” says Cyrus. If you set boundaries early, you may be able to avoid the incident escalating.
  4. Support. Check in with your colleagues when you see misbehavior. “Something as simple as, ‘That was a challenging situation …  how are you feeling?’ or ‘I saw what happened back there … you okay?’, can go a long way,” says Cyrus. You should seek support from your supervisor or Human Resources department, too, if you’ve been a victim of mistreatment.
  5. Establish/Encourage. Approach your institutions about developing workshops and training modules for how to handle patient harassment.

What institutions are doing to curb harassment

Fueled in part by the #MeToo movement, female physicians are realizing they don’t have to put up with sexual harassment. They’re also learning the importance of reporting sexual harassment – even when they can “handle it.” And institutions are increasingly coming to their aid in a number of ways.

Encouraging reporting. Recognizing and addressing mistreatment when it happens is the first step toward curbing the behavior. Organizations have to create a cultural shift where doctors feel empowered to step up and say, “This is not appropriate,” says Orlowski. At Georgetown University School of Medicine, administrators created a communication guidance tool to help female physicians and medical students respond to abusive behavior. The first step: Stop all communication and report the behavior to an attending.

Training bystanders. Kali Cyrus, MD, MPH, is part of a team at Yale School of Medicine that educates students about how to respond to mistreatment. As part of that effort, called Speaking up for Students, Cyrus conducted an informal poll among medical students and discovered that supervisors often dismissed incidents of misconduct by patients. But training bystanders to navigate these encounters more appropriately is one of the most powerful things a teaching hospital can do. “If a patient harasses a resident and no one on the team acknowledges it, the victim assumes the behavior is okay,” she says. “But mistreatment of any form is not okay.” The supervisor or attending physician is charged with addressing it, even if only with the victim.

“The newest term to describe these witnesses is upstanders,” adds Brian M. French, RN-BC, PhD, director of the Maxwell and Eleanor Blum Patient and Family Learning Center and the Knight Simulation Program at Massachusetts General Hospital. “They’re not standing by targeted individuals. They’re standing up for them.” Bystander/upstander training is part of a suite of sexual harassment educational tools being developed at Harvard to address patient and visitor misconduct, French says.

Developing policies and procedures. In the Medscape study, only 23% of reported incidents resulted in any investigation or action. In fact, of the 40% of physicians who reported mistreatment, 37% said their organizations did nothing and 27% said institutions trivialized the incident. But more than half said that reporting the incident negatively affected their job.

“This is an area that most institutions have not yet addressed, presumably because few realize it’s a real concern among young doctors and residents,” says Templeton. Instead, hospitals and medical schools often provide a blanket statement in their patients’ rights and responsibilities documents.

But institutions such as Mayo Clinic and Georgetown are breaking new ground by creating policies, procedures, and codes of conduct for patients, victims, and witnesses. Mayo has a toolkit on their its Intranet to help employees manage patient misconduct, sexual or otherwise. And Georgetown provides medical students with a step-by-step guide to streamline the reporting process with their Stop, Talk, and Roll (STR) campaign:

  • S: Stop the conversation.
  • T: Talk through the patient encounter with a supervising resident or attending.
  • R: Roll out and get support through peer mentors, the Office of Diversity and Inclusion, and counseling and psychiatric services.

Providing resources. Reporting and addressing sexual harassment can be challenging. Mayo Clinic has created more than three dozen training modules ranging from a 90-minute facilitated discussion about how to deal with sexual harassment to bystander training and scripting with role-play scenarios. These simulated patient encounters help doctors develop confidence in their ability to respond to inappropriate behavior, including seemingly harmless comments like “I’m so lucky to have such a pretty doctor,” or “I would like to take you out some time.”

“Deflecting the comment and redirecting the patient to a health care issue is often enough to stop the behavior,” says Hayes. “Most sexually inappropriate comments are meant as a compliment, so if someone is not predatory, he’ll get that hint.”

Georgetown, too, provides medical students and residents with phrases they can use to diffuse contentious situations, as part of their STR training tool. “We don’t want our medical students to be paralyzed in terms of what to do or say,” says Susan M. Cheng, EdLD, MPP, senior associate dean for diversity and inclusion at Georgetown, who is developing a training module that includes short video vignettes to guide medical students.

Changing the culture

In 2017, for the first time in history, more women than men enrolled in medical school. But even as more women enter the field, female doctors and trainees may find it tough to strike a balance between providing appropriate and effective care and safeguarding their own health and well-being.

“We’re still living in a sexist culture, so misbehavior is not just going to go away,” says Cyrus. “With #MeToo, people are more careful and women who are doctors are more empowered to speak up for themselves.”

And while several academic medical centers have developed clear policies on sexual harassment by patients, more needs to be done, Templeton says. “When national medical organizations rise up and develop standard policies that all health care institutions and medical schools can adopt, we may begin to see a real shift where women physicians feel empowered.”  

Adds Hayes: “We have to take care of our own so they can take care of everyone else.”