Introduction
Advocacy is often motivated by deep feelings that are quite personal and can be interwoven with a social identity. The development of a social identity aligned with an advocacy movement can support the collective efficacy of the movement itself, but that process of development can involve shifts in perspective over time as an individual gains experience with different strategies, learns about the past and current efforts in the landscape, gains or loses various forms of power and agency, and develops new perspectives on the shifting conditions within which the problem emerges. This chapter is divided into three, bringing different perspectives on the problem of sexual harassment from a medical student, two doctors in training and two medical educators.
May Erlinger describes the personal and emotional journey of becoming mobilised around sexual harassment in medicine as a medical student in Australia. Working towards a career in medicine involves significant costs, part of which are invested in the development of a professional identity where one develops a sense of what a doctor is, then begins to integrate that defined role of ‘doctor’ into a sense of self. Medical students encountering sexual harassment in medicine can thus face threats to the development of that professional identity: what does it mean to discover that your chosen career is rife with toxic workplaces? What do students do with that knowledge? May discusses the ways in which she encountered sexual harassment as a concept and a problem during her time as a medical student: where it was talked about, how it was talked about, what was done about it informally and formally, and the kinds of cultural responses that occurred among medical students. May outlines the challenges and frustrations experienced by medical students in this space, particularly the sense of alienation from policy processes that medical students can feel.
Becky Cox and Chelcie Jewitt describe their own journeys in building an advocacy organisation from a grassroots effort to campaign for cultural change in medicine in the UK. They describe the process of developing their campaign, Surviving in Scrubs, and reflect on the stories they’ve received from survivors, including the challenges survivors tend to face in their own contexts. They summarise findings of their report on the survivor stories they’ve received and draw on these findings to make recommendations for broad changes health organisations might implement to address sexual harassment in medicine more effectively.
Louise Stone and Fiona Moir speak from the perspective of medical education. Both have had careers in medical training, and have deep expertise in wellbeing, safety and professionalism initiatives. In this chapter, they summarise efforts to manage sexual harassment in learning institutions, including addressing misconduct when it arises, and adapting the curriculum and assessment processes to empower students and doctors in training to detect and manage
Beginning the Journey: The Medical Student (May Erlinger, medical student)
An excited group of students pack themselves into a busy lecture theatre, the eager ones at the front and the cool kids at the back. There is a shared nervous tension palpable in the air: it is the first day of medical school. I sat somewhere in the middle, not willing to commit to an identity yet, but when I looked around the room, I noticed something that gave me excited pause: there were so many women. My joy at the ratio was augmented by the presence of the visible, high-profile leadership positions held by women, many of whom gave speeches during our first week of classes. We had a teaching session on bullying and harassment in medicine, which devolved into an informal and engaging conversation about how to respond to lewd, inappropriate, or harassing material. We were asked, in earnest, what could or should we say or do? Who would we turn to, or whether we’d say anything at all? How to reconcile what we might say we’ll do with what we might actually do?
Months later I was still ruminating the questions that had been asked of us. These questions had been posed to us in genuine earnest by powerful women. I couldn’t shake the thought … why are the women at the top of the medical field still asking how to deal with harassment from their own colleagues?
Although I was overjoyed to see that gender equality in medical school now exists in Australia, I’ve also been disheartened to see the enduring historical attitudes of sexism that infiltrate the culture of medicine. I also must note that the gender equity I was excited to see was only representative of cisgender individuals, and in my ruminations and conversations I engaged in while writing this chapter, I wasn’t able to explore the intersection of the effects of the questions posed on gender diverse (trans, gender non-conforming, and intersex) students due to the data not being available. However, even in my two pre-clinical years I learned that this system and its ingrained cultural gender biases create a foundation that silences individuals from reporting sexual harm and perpetuates sexual micro-aggressions, harassment, and abuse, which continues unabated, unreported, and usually with a lack of consequences, with these effects even more compounded for gender diverse students.
We’re told early in medical school that we need to work in teams to solve problems, that clinical reasoning is key to helping our patients, and that by listening to them they will tell us their diagnosis almost as soon as they’ve sat down. We’re taught that when a patient presents to a doctor with multiple comorbidities, is symptomatic, and very unwell, we don’t give them a pill and send them home. Instead, we tackle it as a multi-faceted and nuanced problem, with multi-disciplinary team meetings, differing opinions, and investigations and inquiries. Only then, once we’ve narrowed our differential diagnosis list, and considered which symptoms are most pressing, do we consider what treatments and managements are most important.
Medicine, and the culture of medicine, is sick. It is symptomatic and has multiple comorbidities that are intertwined and difficult to treat: engrained gender biases, an absence of consequences for the perpetrators, a culture that asks for silence as a display of strength, and a corresponding scorn for those who don’t bend to its will. My diagnosis: a resistance to systematic change and diversity of perspectives, a scarcity of supports, guidance, and pathways for individuals to feel safe, and ultimately a culture that allows and enables pervasive sexual harms of doctors by doctors. Others might diagnose Medicine with any number of other illnesses. Some may deny it’s sick at all. But in order to manage symptoms, or even cure it, we have to work as a team, to listen, and to consider our short- and long-term management options.
I cannot claim that the current and incoming cohorts of medical students will fix these problems right away; however, if we are taught that it’s sick to begin with, maybe we can begin to treat it early. As it currently stands, we feel lost trying to figure out where to start and what to do. We understand there is sickness, but just as we have to learn clinical reasoning for our patients, we must learn how Medicine became ill, what previous treatments have been attempted and failed, and what needs to still be done. A generation of doctors needs to be trained in how to push back on the traditional cultural norms and to set the tone of what kind of culture we expect of one another. In medical school, we see the beginnings of how opaque and difficult the reporting systems are, how inappropriate comments from fellow students are brushed off as banter, how senior staff bully juniors and medical students, and it’s labelled as preparation for the worse behaviour to come.
Some students are able to recognise the necessity of pushback against this culture, and they will risk being told they aren’t being team players or being labelled as difficult, while others float along seemingly unaware of the biases, or believing that traditional medical norms are integral to understanding the hierarchy. These concepts aren’t really touched on in medical school curricula, and instead student groups on either side of the fence exist in insular bubbles, not truly engaging on the topics. There are events held by medical societies, which seek to increase student wellbeing, and occasionally host awareness-raising events on the impacts of harassment and bullying, but the bulk of sharing on how to deal with these issues occurs in an informal manner or on social media.
Students warn each other, flag other students or staff, which circulates as well-meaning gossip, but realistically only results in students accepting the ‘every day’ or ‘low level’ harassment. There is an enculturated hesitancy (disguised sometimes as ‘professionalism’), which results in most students leaning heavily on the bold who will advocate on their behalf. This unfortunately builds a space where some students bear the brunt of the behaviour, and others bear the brunt of reporting, with no space to empower either. Ultimately, medical schools and teaching hospitals need to show, in practice, what zero-tolerance policies of sexual harassment/assault look like, and to develop pathways for anonymous reporting and tracking of inappropriate behaviour, that can be actioned if needed. The ethos of medicine should include space for individuals to share their experiences of sexual harm, not necessarily for punitive action to be taken, but rather to demystify and remove some of the burden one carries. When we start to have conversations about sexual harms, from medical school onwards, we begin to note the behaviour that collectively makes us uncomfortable. We highlight predatory behaviour and note that we don’t find it acceptable and won’t tolerate it, not against others and not against ourselves.
Where Harm Begins
Doctors don’t arbitrarily begin acting inappropriately once they are handed their degree; the seeds of their behaviour are planted in medical school and before, forming strong thick roots by graduation. These students who say inappropriate things or make unwelcome advances are often recognised by their peers, they are spoken about in groups, avoided at parties, on placements, or alone in rooms, but rarely are complaints escalated to the medical school. Even when a student’s inappropriate behaviour is reported, they’re usually given second chances, an opportunity to prove they didn’t mean what they did/said, and sometimes they take those opportunities to change and improve themselves, but sometimes they’re clever enough to know they have to get smarter about how they perpetuate this behaviour. Those are the students that become the doctors we are worried about. Those are the doctors that know how to get away with comments or behaviour, pretending it’s a joke, intimidating their victims, or using their status as leverage.
Students aren’t blind to the insidious professional culture that allows for unrelenting sexual harm. However, we are taught, although maybe not explicitly, to allow comments because reacting to them may be considered oversensitive. Similarly, we learn to accept a ‘reasonable’ level of discomfort. After all, we’re acutely aware of the variable power dynamics in medicine, and the weight of a senior’s word against our own. We’re taught to seek out and accept feedback. This is not a bad practice, as it allows us to grow as doctors.
However, with the power dynamics at play, feedback can and does turn dark and dangerous, and yet we’re told to accept it, and more specifically we depend on it to further our careers. We’re not taught how to critically appraise the feedback we receive, nor to question the authority figures around us. Students are enculturated early on to exhibit ‘professional’ behaviour, to rigidly adhere to the social/cultural hierarchy, and to understand that speaking out can jeopardise your standing and label you as difficult. This enculturation is compounded every additional year in medicine, as you begin to see the repercussions of non-adherence to these standards. Unless actively internally resisting, which comes at great emotional and psychological cost, year by year you are disempowered, silenced, and slowly broken to fit the mould that medicine wants you to be.
Reporting Harm in Medical School
Early on in my medical degree I had already begun wondering about the processes of reporting sexual harassment and assault, as have many students in medical schools around Australia. Through my many conversations with students, we’ve each wondered about what to do if a fellow peer makes inappropriate comments or displays inappropriate behaviours. Our thoughts turn to the long days spent in hospital, wondering whether we would dare mention to a colleague, let alone report, if a superior crossed the boundaries we each set.
I’ve had conversations with countless women and men about where the ‘threshold’ should be for reporting sexual harassment and assault in medical school – is it when we feel uncomfortable, after we’ve told them to stop, after rumours have begun, or after it’s happened to someone else? In medical school harmless chatter is interspersed with rumours of harm, making it a difficult landscape to navigate, as students wonder if there is truth to whispered discussion, because surely action would be taken if there was. So for a while these conversations exist as general warnings, with the hope that one day a voice can be strong enough, loud enough, or there are enough voices to create action. In my discussions with medical students around these issues, I’ve encountered the phrase ‘I’d only report in case it happens to someone else’ or ‘… to try and stop it happening to someone else’, more than I had ever anticipated.
Medical students seem to tolerate, and even expect, a level of discomfort, inappropriate behaviour, or assault. Each student seemed to note that they anticipated varying degrees of harassment, and accepted it as a reality, for which they would not report if it affected only themselves, but that if that same harassment or behaviour was targeting or affecting someone else, they’d be far more willing to report it. That greater will to protect others around them is perhaps because of the selfless nature of some entering medicine, or perhaps it is because of a failure of the system to create a space that allows someone to stand up for themselves. Notably there is not a lack of desire to report, to say something, to have a conversation about inappropriate or uncomfortable behaviour, or to change the culture of reporting. There is simply a lack of ability for people to ensure their own safety while reporting.
Although the processes for reporting malfeasance vary from medical school to medical school, and hospital to hospital, the need to be able to report incidents, from microaggressions to assaults, is critical. However, the many conversations I’ve had with students highlight how many failings there are within these processes. Most notably two topics are brought up in each of my conversations: anonymity, and the ability to write down and acknowledge an incident, for future evidence. The need for anonymity in reporting, or even talking about, individuals higher up in the hierarchy who have acted inappropriately is crucial to creating an environment that students feel safe in. Simply being in medical school carries additional quandaries, as the schools are a part of the universities they operate under, in conjunction with varying health services, and are independent entities as well. The interaction of many different external stakeholders creates a confused landscape with differing pathways and systems, meaning medical students are often unsure of what, how, or who to report to, and whether there is anonymity or space to have a conversation about incidents without actioning those conversations.
The lack of clarity, and feelings of safety, in reporting processes during medical school all exacerbate the harm experienced by students who are already some of the most vulnerable in the medical hierarchy. With no stakeholder willing to step forward and claim responsibility over safety (physical or psychological), it teaches students that they are immediately powerless in their careers, that their future is filled with immense uncertainty, because if there is no protection to be given when you’re most vulnerable, why would there be protection later on? Universities and hospitals need to work symbiotically to create an environment that is safe to have conversations about incidents that occur throughout our medical training. Additionally, creating a space where incidents can be acknowledged, either verbally or in writing, without needing to escalate any decisions, is important to establishing a culture where conversations are key to change.
The barriers that exist in medical school around reporting are only intensified once students enter placements. There are fears around retribution; there are concerns of the emotional labour, time, and stress that comes with reporting; there’s consideration of how that report will impact the perpetrator and thereby impact teaching, especially in rural communities where teaching opportunities may be sparser. Mostly there are concerns about how it may impact our future careers. Due to the nature of medical school and training, a lot of the study and work between doctors and students is done in small groups or one-on-one. So, if behaviour is reported, even anonymously, it can be easy for the perpetrator to trace back who did so, even with prolific or serial abusers.
Even still, the students that feel capable, willing, and safe to report quickly learn of the immense time (both in writing the reports, and in the large periods of waiting) reporting requires, alongside the emotional burden of recounting your story multiple times. Rural students are faced with additional challenges where there is not only social and physical isolation, but they must consider the immediate and longer-term impacts of reporting on teaching. Reporting perpetrators in small communities, some of whom may be good teachers, mean there is a decreased quantity and quality in the teaching that is made available to students on placement. These impacts can have long-lasting effects beyond the rotation, especially to long-term rural students. Students begin to internalise personal responsibility for occupational hazards because these barriers all amount to a sense of learned helplessness where students feel that no one can be bothered with them or their safety, so are simultaneously trapped and disempowered by each component of the system.
Ultimately being a medical student is a unique training experience, where you are caught between finding your footing in a densely competitive career, maintaining a sense of ‘professionalism’, feeling like you are learning the entirety of medicine, all while trying not to burn out before you’ve truly begun. This, coupled with the burden of being responsible for your own safety (and sanity), is increasingly difficult in a system that, to students, isn’t necessarily focused on creating reporting processes that are safe. With the structure of medical education being its own barrier to progress and positive change and alongside navigating the workload of study and life (with burn out always looming), even students who haven’t personally experienced or witnessed sexual harm are left with few personal resources to fight for change.
The Future of Medicine
It must be recognised that medicine suffers from institutional sexism, on every level, that was purposefully built into its framework, which contributes to a derisive and insidious culture that historically benefits and fosters opportunity predominantly for straight, cisgendered, white men. Changing this is not an easy task, but it is a necessary one. It can only happen from within, and with that, we require a new generation of medical students, primed with the skills to identify and call out gender bias and inappropriate sexual behaviours from day one. One that fosters opportunities for diverse leadership, that values bystander advocacy and people in positions of privilege using their positions to encourage change, and one that amplifies the voices of the consumers who bear witness to harm which does not instil faith in medicine and doctors to provide compassionate care. The whispers about the sexual predators in medicine, the doctors that students dread to be on placements with, become louder conversations because of strong and courageous women and men who decide that silence serves no one.
We need to build a culture where individuals are willing to stand up and denounce the behaviour, to ask for consequences, and to establish a culture where if anyone was uncomfortable, they are empowered to speak up, for themselves, and not just ‘in case it happens to someone else’. We want to strive for a culture where we actively encourage students to value their own wellbeing and safety and to be able to navigate the delicate skill of changing culture and disrespecting the rigid hierarchy that does serve some purpose in medicine. Culture is changed, in part, through conversation. These conversations about sexual harm in medical school, and in medicine, need to continue, and they need to continue openly and not in the shadows. We need to discuss the multi-layered barriers in reporting and the lack of anonymity while simultaneously having transparency in conversation. We need to discuss what sexual harms are in protected forums, because when a collective comes together to share a safe space, it is easier to mention the leering doctor, the student who touches his peers in inappropriate places, the supervisor who makes uncomfortable comments. Once those conversations begin happening, we recognise the prevalence of the issue, and that it shouldn’t be occurring this often, we begin to talk louder, to call for action from our peers, to ask for accountability from those in charge, and to change the culture.
The sick patient that is Medicine sits in front of us and needs help: it’s our job to ensure they receive the treatment they need. We need to hold our multidisciplinary team meeting to discuss our diagnoses, to consider the comorbidities, to write out our problem lists, and to discuss our short-term and long-term management plans. Not everyone in medicine will believe that the culture is sick enough to warrant treatment; some will cross their fingers and take a ‘wait-and-see’ approach; some will see this as a problem beyond their scope as a practitioner; but some will understand the urgency of treating the patient in front of them. As the medical student standing in the corner of this consultation, I’m desperately hoping the doctor sees what I do and is willing to consider me and my future colleagues’ opinions, perspectives, and ideas, so we can collaborate for effective coordinated care and give our patient the best chance to heal.
Surviving in Scrubs: Using Narratives and Lived Experience to Create Change (Becky Cox and Chelcie Jewitt, perspectives from doctors in training)
Surviving in Scrubs is a grassroots organisation that advocates for the survivors of interprofessional sexual misconduct within the health care workforce, campaigns for cultural change through the engagement of key stakeholder organisations nationally within the UK, and provides training services to educate anyone who works clinically or in health care education or management. The organization was formed in June 2022 by Dr Becky Cox, an academic GP with specialist interests in gynaecology, and Dr Chelcie Jewitt, a specialist trainee in emergency medicine, both of whom have lived experiences of sexual misconduct while working in health care.
Surviving in Scrubs came off the back of a conversation that myself and Becky had following the publication of the Sexism in Medicine survey in August 2021. This piece of work, supported by the BMA, was inspired by my own experiences of sexism and misogyny whilst working within the NHS. I was fed up of working to different goalposts compared to my male peers and I wanted to prove that there was pattern of women in medicine being repeatedly disadvantaged because of the sexist and misogynistic culture that is endemic in health care.
Unfortunately after that report was published, following the initial media attention, the reassuring conversations about sexism and sexual safety in health care came to a halt. That was when Becky and I started wondering what we could do to keep attention on these topics. We had facts and figures, but we realised that it would be survivor stories that would humanise this issue, keeping key stakeholders interested and motivated to bring about positive change. (Dr Chelcie Jewitt – co-founder Surviving in Scrubs)
The core of the Surviving in Scrubs campaign is its website (www.survivinginscrubs.co.uk). This platform enables anyone who works within health care – regardless of their job role, their location, their specialty, their level of seniority or even their gender – to submit an anonymous testimony of their own personal experiences of sexual misconduct within the health care workplace, or incidences that they have witnessed. There is no doubting the power of this collective narrative – with over 200 stories published online at the time of writing – as it has been monumental in ensuring that the sexual safety of health care staff has been frequently reported on by medical and mainstream media since Surviving in Scrubs began.
The need for Surviving in Scrubs to exist as a group is very telling of the cultural issues facing health care workers. There is a lack of support for victims within the reporting mechanisms currently in place throughout the NHS. This often leaves victims feeling isolated, alone and powerless. One of the main motivations for the co-founders in forming the campaign group was to empower the survivors of sexual misconduct by making their voices and their stories heard, as both have firsthand experience of sexism, misogyny, sexual harassment and assault throughout their career, starting as medical students.
Its amplification of survivor voices is what has made Surviving in Scrubs so successful. This grassroots movement has brought the voices and experiences of the many victims to those who are in power. Those stories have evoked emotions of distress in the masses, and it has made many of those in power think beyond the numbers and the statistics that have proved the prevalence of this issue for years (91% of female doctors have experienced sexism; 30% of female surgeons have been assaulted at work). Surviving in Scrubs speaks truth to power, which has enabled representation from the disempowered victims who have been silenced for too long.
Since its inception, Surviving in Scrubs has been invited to speak at several meetings for key stakeholders within health care – NHS England, NHS Education for Scotland, the General Medical Council (GMC), the British Medical Association (BMA), multiple royal colleges, the Medical Schools Council and several medical schools, to name a few. Health care has had an awakening to the fact that there is an issue of sexual misconduct within its ranks, but there is little knowledge or understanding of what needs to be done in order to rectify this issue.
In November 2023, Surviving in Scrubs published its first report – ‘Surviving healthcare: sexism and sexual violence in the healthcare workforce’. This report consists of the summation of the experiences recounted in 150 stories describing sexism, sexual harassment and sexual assault within the health care workforce submitted to the Surviving in Scrubs website anonymously between 2022 and 2023. The stories were submitted voluntarily by survivors and describe incidents of these behaviours, challenged faced and their impact. The key findings are described in Table 34.1.
Key findings
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This report includes stories from a variety of health care professions, working in a multitude of specialties and health care environments, demonstrating that the damaging culture of sexual misconduct permeates through the whole of health care. A key role of Surviving in Scrubs is to ensure that the discourse around these themes is inclusive of all professionals working within health care, as is the case in clinical practice.
As part of the report, the authors have outlined a set of key recommendations for health care organisations to implement in order to bring about positive change (Table 34.2).
Key recommendations
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Education
There is a need for effective mandatory education and training for all staff members who work within health care to ensure there is an awareness of what sexism and sexual misconduct is and how it can be recognised within the health care setting. Active bystander and allyship training should be available to all staff as well as training on how to prevent sexual misconduct and promote positive culture change.
There needs to be tailored education for managers, supervisors, and human resource staff groups on how to respond to first disclosures of sexual misconduct and how to support survivors through the reporting process, with particular attention focusing on how they should respond to reports of sexual violence. There is also an argument to provide trauma-informed consultation skills training to anyone who might act as peer or near-peer support for victims of sexual misconduct, or would be in a role where disclosures fall within their responsibilities.
Research into the Impact
Sexual misconduct within health care has only been discussed openly in the past few years, despite the behaviours and attitudes having always been endemic within health care. As such, the research regarding its prevalence and its impact is very much in its infancy. The data relating to the UK NHS workforce is so far very doctor- and, in particular, surgeon-specific, despite these professional groups not working in isolation. The ‘Surviving healthcare’ report contains stories from doctors, nurses, paramedics, psychologists, administrators, dentists, carers, optometrists, pharmacists, managers, health care assistants and health care students, proving that research needs to incorporate other professional groups. Further research needs to be through an intersectional lens, again as there is minimal data looking into how other protected characteristics are affected.
Moving on from defining the prevalence of sexual misconduct, there needs to be research looking into evidence-based interventions to address the culture effectively, and preventing the attitudes and behaviours that lead to sexual violence. It is important to note that the need for this research should not hinder the development of intervention implementation. It would be appropriate for continuous evaluation of any implementations as they occur. The criteria for assessment will also have to consider that an improvement in culture surrounding sexual misconduct would likely increase reporting of incidences as more survivors feel empowered to raise complaints.
When it comes to the impact of sexual misconduct, this could result in research from multiple angles – the psychological cost to staff, the impact to patient care, the financial cost of staff sick days, staff quitting or even the cost of legal proceedings against health care employers.
Independent Inquiry
Surviving in Scrubs is calling for an independent inquiry at a national level to investigate the prevalence, impact and drivers behind the culture of tolerance relating to sexual misconduct within health care. It would also be of paramount importance to evaluate current reporting practices and how this affects survivors, whether they decide to report or not, and if they do what barriers they face. It is important that any such inquiry is independent, removing any influence of party politics on the outcome.
Improved Support for Survivors
Alongside effective training and education for managers, supervisors and human resources staff members to improve the experience of survivors of sexual misconduct raising complaints, there needs to be improved psychological support for survivors. Ideally, this would be via dedicated access to specialist sexual violence support from independent sexual violence advocates provided by the health care employers, who will help survivors navigate the reporting process if they wish to proceed down that route.
Another intervention would be the introduction of peer or near-peer support, either through nominated advocates for sexual safety in the workplace or through in-person or virtual support groups. These interventions would work towards providing a supportive community for survivors, minimising the feelings of isolation that can occur when being a target of sexual misconduct.
Review of Current Policy
A recent investigative article from the British Medical Journal and the Guardian found that 90% of NHS Trusts in England did not have a sexual safety policy applying to interprofessional sexual misconduct. Of the 10% that do have a policy, there is need to review if they are fit for purpose. The recommendation is that the policy should act to prevent sexual misconduct from occurring with education and open discussion forming part of the workplace culture, but also when such incidents do occur, there should be an easy-to-navigate reporting system that offers psychological support for survivors. There should be clear guidance on what warrants reporting and the formal channels of doing so.
Introduction of Specialist Sexism and Sexual Misconduct Policies
At present, most trusts will incorporate issues of sexual misconduct underneath the umbrella of a bullying and harassment policy. Though it is recognised that sexual misconduct does overlap with some of the issues relating to bullying and harassment, there are nuances to sexual misconduct that warrant a specialist policy in its own right. This links back to the need for specialised support for victims.
Another aspect of these policy reforms is that all trusts should provide an honest and transparent record of the number and types of incidences that are being reported within the trust, and what action was taken. All records should be published within the public domain. The aim of this is to encourage a culture of accountability within health care organisations, and for them to demonstrate they are taking staff safety seriously.
Independent Anonymous Reporting System
Surviving in Scrubs, along with the Working Party for Sexual Misconduct in Surgery (WPSMS), is lobbying towards the implementation of an independent anonymous reporting system, available across the whole of the NHS. This is to ensure that there is a standardised reporting system so that nobody working in health care is at a disadvantage if they wish to pursue a complaint against their perpetrator.
Though there is a need for local reporting mechanisms, a national system would be beneficial for everyone. In particular, it would help the individuals who work within small teams where anonymity and therefore psychological safety of the victim could be compromised. This is particularly pertinent within some general practice settings.
Another benefit of a national reporting system is that the data would be centrally stored, enabling pattern recognition of where sexual misconduct behaviours are prevalent, which would alert the need for interventions in terms of education, training and review of policies.
Reform from Health Care Regulators
Currently, the threshold for investigating complaints of sexual misconduct submitted to regulators is too high. A vast majority of cases are dropped at the triage stage of the complaint, meaning that when survivors are brave enough to relive the trauma by raising a complaint, it is often dropped with little to no explanation. This can lead to repercussions for the survivor, such as feelings of helplessness and feeling as though they are not being believed or that their experience does not matter.
Health care regulators need to realise that they have a responsibility to staff safety as well as patient safety, and that should start with them increasing the number of complaints that they investigate. This would also warrant the need of improved support for survivors during the investigation and tribunal processes, with transparency around the tribunal process and psychological support from advocates with specific training relating to sexual misconduct.
Improved Communication
Trusts, GP practices, health care regulators and the police need to improve their communication links in cases of sexual harassment and assault. At present, if a survivor wants to pursue a criminal complaint, they need to report to the police; however, this information is not automatically shared with the NHS Trust involved, nor the regulator of the perpetrator. In a similar fashion, if the survivor reports to the regulator, this information is not shared with other organisations.
These links of communication need to be strengthened as there is a propensity for organisations to pass the buck when it comes to investigating issues, with regulators often refusing to investigate criminal issues (sexual harassment and assault), or stating that complaints do not reach their threshold for investigation and should be dealt with locally. In not communicating these issues, they are adding another burden onto the survivor, making the process of obtaining justice more complicated, forcing them to relive and retell their trauma more times than would be necessary if organisations communicated effectively.
These recommendations are not exhaustive, and as some interventions are introduced, the evidence base of what will be beneficial for survivors will increase, along with further recommendations. There is little information presently about what works best for survivors of interprofessional sexual misconduct within the health care setting. The conversation about the prevalence of sexual misconduct occurring in this space has only opened up over the past few years, so there are a lot more questions than answers about how pervasive sexual harassment actually is.
Surviving in Scrubs will continue to ask the questions about what can and should be done in order to advocate for survivors and protect potential survivors from experiencing sexual misconduct at work. However, it is the responsibility of every individual who works within health care, or within an organisation that supports health care, to strive towards a culture free from this misconduct. Changes must occur across all levels of health care: GP surgeries, community services, hospitals, universities and health care education providers, integrated care boards, NHS England, Wales, Scotland and Northern Ireland, health care colleges and representative bodies, health care regulators with support from the professional standards authority, and the Department for Health and Social Care.
Surviving in Scrubs will continue to speak truth to power, ensuring the voices of survivors are heard. However, ultimately it is these organisations that need to change as they have a responsibility to protect the safety of their staff members, even when it is from other workers.
Next Steps: Leading from Within
When asked to explore the ‘what now/what next’ question, in the context of gender-based violence, it is hard not to be struck, nearly immediately, with moral injury. It feels a little like, if we are having the conversation now, it’s already too late. The harms have already happened, are still happening. Plus it feels so … big. So unwieldy. Having someone ask how to change hundreds of years of patriarchy, hierarchy, power and silence is like having someone ask to just … tweak gravity. But that is kind of the point. The reality is, sure, the best time to change the world we inhabit was hundreds of years ago. But the next best time to change things is today.
So when asked how to change culture and what next, it feels like there are three very distinct questions there – how do we get rid of the normalisation of toxic behaviours and beliefs, how do we excavate the entrenched attitudes of the status quo and then, once we have a dug big ol’ cultural void, what do we fill it with? It’s all well and good to cry ‘burn it down’, but you need a plan about what to build on the ashes.
Most organisations or systems we exist in have survived thanks to certain tacit assumptions. They are a source of strength, a source of reassurance, a cultural blanket to wrap oneself in when things are uncertain. However, the truth is that many of these assumptions do not quite align with the values that might performatively or rhetorically be spoken about. Therefore, when thinking about culture change, many need to overcome the cognitive dissonance between what they espouse and what really happens. This places people and their (albeit anthropomorphised) organisations in a state of anxiety. ‘We must change. We must change now. Oh no. We haven’t changed yet and we don’t even know how. Or what. Or …’. This anxiety state tends to lead to a variant on the grief cycle: fear, anger, denial, more denial, a tons more denial, scapegoating, and then often some more fear and denial.
Instead, we have to lean into our culture. It’s not all bad. In fact, culture gives us strength, it gives us the ability to highlight the bits within our culture that need highlighting for change. It also gives a reassuring sense to those experiencing a fear of, or sense of, loss; we aren’t changing everything, just some bits. Just the bad, toxic, harmful bits.
So what’s next? Next we change the pieces of our culture that need change. We grow, we learn, we make mistakes and then we grow some more. We bring people along with us, as we identify those things that need changing and what we want them to change into. Whether its anonymous reporting systems, ways of declaring relationships in the workplace, websites where people can share their stories, changes in legislation or educational pieces helping people recognise issues, be a bystander or an ally, how to actively listen or any other of the myriad of ways of changing the status quo, the first step is the hardest. Accepting that there is a ‘what’s next?’ and starting to build it. Together.
Medical Education (Louise Stone and Fiona Moir, medical educators)
Throughout this book, we have touched on multiple interventions, many of which begin in medical school. Medical educators have multiple roles, and some of the tasks they perform that are relevant to sexual harassment prevention and management are summarised in Table 34.3.
In chapter 6, we discussed how different axes of power can operate when supervisors take multiple roles, and how these roles can be leveraged to facilitate grooming. We also outlined the importance of the hidden curriculum, and the limitations of competencies as a basis for professionalism training and assessment. We discussed the role of medical migration, and how learners living with multiple layers of disprivilege, including international medical graduates, are at higher risk of sexual harm.
Chapter 6 makes a case for reflective practice. The curriculum is becoming more and more overcrowded with content, leaving less space for students and doctors in training to make sense of their own professional identity formation and workplace experience. Medical students and doctors in training do not have time, or perhaps even the language, to consider who they are becoming as doctors, and when they experience discomfort, unease or trauma, they may not have ways of discussing their own feelings. Without time for facilitated reflection, students and doctors in training are left without models and methods of making sense of complex experiences, and this contributes to silence and shame. Reflection also allows space to consider the culture into which they train, and challenge cultural norms, including inequity, injustice, competitive behaviour, disrespect and misconduct.
In chapter 14 we discussed the importance of professionalism in the curriculum, and the challenge of teaching and assessing it throughout medical training. In this section, we wanted to reflect on the challenge of integrating three aspects of professionalism into the curriculum: teamwork, wellbeing, and trauma and its management.
Wellbeing Curriculum
Medical students and doctors in training are more likely to cope with challenging interactions if they are well. (Reference Byrnes, Ganapathy, Lam, Mogensen and Hu1) Unprofessional behaviour can be a marker of distress within training, noting that student perceptions about what is ‘unprofessional’ can differ markedly from that of faculty. (Reference Reddy, Farnan, Yoon, Leo, Upadhyay, Humphrey and Arora2) Medical training is arduous, and even high performing students with a history of impressive resilience can struggle with the workload and stresses of medicine. However, many strategies used to promote wellbeing in medical students and doctors in training are informal, including voluntary self-care activities, non-specific support mechanisms and the provision of designated pastoral care staff. While these strategies are important, they don’t require students to think critically about wellbeing for themselves or for their patients. This means some students and doctors in training will avoid the curriculum altogether, feeling these strategies are trivial, performative offerings that are not relevant to their situation or their learning.
In New Zealand, medical schools now include curricular content aiming to improve student wellbeing (Reference Moir, Usher, Wilson, Molodynski, Farrell and Bhugra3) with Auckland medical school initiating a longitudinal ‘Health and Wellbeing Curriculum’ in 2013. (Reference Yielder and Moir4; Reference Curtis, Jones, Tipene-Leach, Walker, Loring, Paine and Reid5) The curriculum is based on a framework known as ‘SAFE-DRS’ (Self-care skills, Accessing help, Focused attention, Emotional intelligence, Doctor as patient) and includes assessment, a reflective portfolio and observation by clinicians of how students are managing their stress on the wards. (Reference Yielder and Moir4) The students are encouraged to consider how these principles can be applied to themselves as well as their patients. The inclusion of patients as a focus for wellbeing improves outcomes for both (Reference Moir, Patten, Yielder, Sohn, Maser and Frank6; Reference Frank, Breyan and Elon7) and, frankly, helps to overcome the resistance some students still have to ‘soft skills’ development.
Self-care is an important skill for patients to learn, so they are able to manage their own illnesses more effectively and independently. The World Health Organization has a curriculum of self-care tools, which can provide a basis for learning in this area. (8) Giving students the language of empowerment and agency is important if they are to be able to retain their voices and their agency.
Training includes other challenging topics like diagnostic uncertainty, suicide prevention, and death and dying. Medical training is full of discomforts. Some are quite visceral (like disgust with certain smells, and fainting in the operating theatre) and others are relational, like the dislike or anger that may arise during patient interactions. Learning to name and manage these feelings, and use them as information, are critical parts of becoming a good doctor. Students will also experience ethical discomforts, which are hard to tolerate. By using reflective groups, the medical schools increase students’ ability for self-reflection (Reference Gold, Bentzley, Franciscus, Forte and De Golia9) but also acclimatise the students to talking about feelings and perceptions, in a safe environment. Reflective groups can enable students to talk honestly about their observations and experiences of clinical practice and workplace culture, including negative role modelling and disruptive clinician behaviours. (Reference Villafranca, Hamlin, Enns and Jacobsohn10; Reference Noort, Reader and Gillespie11) These moderated groups can break down silencing, enabling students to normalise conversations about difficult professional conduct in their workplace. It also trains and supports students to speak up for colleagues. (Reference Moir12)
Managing Moral Distress
Moral distress results from ‘physicians inability to act in accord with their individual and professional ethical values, due to institutional and societal constraints’. (Reference Moir13) Many students come into medicine with altruistic aspirations, but the workload and the contrast between their expectations, the values they are taught and the reality of the clinical workplace can be profoundly unsettling. (Reference Gaufberg, Batalden, Sands and Bell14; Reference Warmington and McColl15) Moral distress is associated with a sense of shame, guilt, low self-worth and poor mental health, as well as unhelpful coping mechanisms like overuse of drugs and alcohol. (Reference Dzeng and Wachter13) Managing the inevitable moral distress of working in a workplace under considerable pressure and recognising the early signs of burnout are important skills for students and doctors in training. Students who witness unprofessional behaviour can feel alienated from medical culture, especially if they live with intersectional disprivilege. (Reference Bynum, Varpio, Lagoo and Teunissen16; Reference Romanski, Bartz, Pelletier and Johnson17) In this context it is easy for students to feel they are not valued, and lose trust in their organisations and profession. (Reference Wallace, Lemaire and Ghali18) These students are less likely to report unprofessional conduct, because they do not trust the culture in which they work and the people to whom they must report.
There are two obvious ‘antidotes’ to moral distress and burnout. The first is creating authentic and meaningful roles for students, appropriate to their stage of training and professional development. (Reference Curry19; Reference Grumbach, Lucey and Johnston20) Meaningful work is essential to maintaining wellbeing, but it also helps students use their voices and their opinions. (Reference Helmich, Derksen, Prevoo, Laan, Bolhuis and Koopmans21; Reference Warmington, Johansen and Wilson22) Silent students are vulnerable, and less able to manage or report professional misconduct. The second is reflective practice, which can include reflective writing, (Reference Yielder and Moir4; Reference Wilson and Ayers23) small group discussions about student experiences, and individual or group mentoring. (Reference Uygur, Stuart, De Paor, Wallace, Duffy and O’Shea24) Reflective activities can enable students to discuss the many physical, emotional and ethical discomforts that doctors must learn to manage. To be effective, these groups should be facilitated by an expert who is not involved in grading or assessment, because the dual roles can mean students may not feel the environment is safe. (Reference Reddy, Farnan, Yoon, Leo, Upadhyay, Humphrey and Arora2) Reflective groups can strengthen the bonds between students, improving empathy and shared agency. (Reference Neff25) In the event of misconduct towards them, it may mitigate against isolation, stigma and shame, through having peer allies who can encourage reporting to supportive staff. (Reference Reddy, Farnan, Yoon, Leo, Upadhyay, Humphrey and Arora2) It can also protect against the attrition of empathy that is often seen in early training.
The Trauma Curriculum
Trauma-informed care has become an expectation of clinical practice in many jurisdictions. In medical education, we are only beginning to consider what this means. Many students and doctors in training come to medicine with vulnerabilities and past experiences that will inevitably raise discomforts during training, and even the most robust student will have experiences during training and practice that they will find traumatic. (Reference King, Steenson and Mulholland26–Reference Finkelstein and Mathers28) After all, it is not ‘normal’ or within most students’ experience to dissect a human body, or to cause pain or discomfort to others, even if these activities are authorised within the profession.
If there is one thing medical educators can bring to training, it is the ability to make the implicit, explicit. Medicine is a science, a craft and an art, and there are different skills in teaching these different aspects of the job at hand. While science is familiar, and is generally tackled easily, kinaesthetic skills are taught well by some educators, including interdisciplinary educators like nurses and physiotherapists. However, teaching the art of medicine, including professionalism, is a difficult task. It involves ‘outing’ the feelings and discomforts of others, and modelling appropriate management.
The two disciplines that have a lot of experience in this space are general practice and psychiatry. General practice has a long and proud history of teaching difficult areas of practice, including tolerating uncertainty, managing challenging interpersonal interactions and maintaining appropriate boundaries. Psychiatry has a long tradition of supervision, and good educators in this space have a range of theoretical frameworks to draw on when discussing difficult concepts like trauma. For this reason, these two disciplines are key to the teaching of trauma.
It is our view that students and doctors in training learn best when they see their learning is situated in practice. (Reference Cho, Yu, Lee and Jung29; Reference Shinkaruk, Carr, Lockyer and Hecker30) While some students accept that self-care is part of their role as doctors, others do not, perhaps due to their personal developmental trajectory. Medical educators are well aware of the theory of proximal development: the idea that to teach effectively, concepts must not be already mastered (because the student will disengage) or out of reach (because students will not be able to grasp the idea, and will become demoralised). Ideally, teaching builds on concepts already mastered and ‘stretches’ the student into areas they have not yet understood. (Reference Groot, Jonker, Rinia, Ten Cate and Hoff31; Reference Gillespie, Conn and Dornan32) Teaching skills around wellbeing, trauma and teamwork is best attempted starting with their roles in patient care, and then extending them into self-care, so the student or doctor in training can begin to incorporate personal application when ready.
Like wellbeing, students need a model and language to begin to conceptualise what is happening to them and to their patients when trauma is experienced or re-experienced. There are many ways to undertake this teaching, but one approach to trauma-informed medical education uses the framework detailed in Table 34.4. (Reference McClinton and Laurencin33) It is useful, because it holds individuals and the institution responsible for modelling and managing a trauma-informed approach to curriculum, pedagogy and clinical exposure. It is our belief that students and doctors in training will again be more able to communicate their personal trauma if the language and concepts are normalised in teaching and practice.
| Principle | Practice |
|---|---|
| Realise | Explore systemic bias as a concept and an impediment to just, fair and safe care in the training curriculum. |
| Recognise | Encourage learners to consider bias, discrimination and harms in clinical practice, and to discuss how these may be mitigated. In doing so, students should reflect on their own inherent biases. |
| Respond | Discuss and model how bias, discrimination and trauma activation can be managed to improve patient safety. |
| Resist | Use ‘universal precautions’ to resist unnecessary harms from re-traumatisation. This includes using trauma-informed language, reducing unnecessary requirements to retell stories (patients and learners) and unnecessary exposure to traumatic material in teaching and learning. |
The Teamwork Curriculum
Finally, teamwork needs a similar approach, with the teaching of models of professional interaction and teaching and practice of language around appropriate and inappropriate behaviour in clinical teams. There are many models available to teach, but one useful model has been provided by Belbin. (Reference Belbin34) Belbin asserts that people take different roles in a team, partly due to their inherent characteristics, and partly due to team requirements. Team membership is not static, but fluid, and this can be a reason why a previously functional team becomes dysfunctional. The model taught is less important than the discussions that are facilitated, again in reflective learning spaces. Learners who do not have a language or a model to understand and describe interpersonal dysfunction are left without an ability to understand or respond to toxicity in the team, and again, may withdraw and become disengaged.
Conclusion
In this chapter, we have explored the importance of curriculum around three areas which have previously been taught predominantly in the hidden curriculum: wellbeing, trauma and the interpersonal challenges of teamwork. The hidden curriculum is problematic, because it is unconscious, and may not give students a framework for understanding and responding to difficulties in training. In our view, it is inappropriate, and somewhat cruel, to expect students and doctors in training to learn these difficult skills through simple immersion. Many learners will not ‘pick it up as you go along’, which has implications for them as well as for their present and future patients. In our view, reflective practice, which has been a long-standing tool in the medical educator’s toolkit, should be cemented into the learning experience.
Medical students and doctors in training cannot make sense of the complex world of medicine if they do not have the language, concepts and opportunities to speak. If they have no space to discuss their discomforts and concerns, why would we expect them to have the ability to report sexual misconduct as witnesses or targets?
In this chapter, we have seen authors at different ages, stages and contexts discuss their approaches to sexual harassment in medicine. The chapter raises several important principles:
Lived experience, and the capacity to reflect on personal and witnessed lived experience is critical.
The most vulnerable people in the system should not bear the burden of managing change. Sexual safety is a complex, multi-faceted problem that needs leadership at all levels.
Medical training can be brutal, and this brutality can make it difficult for learners at all levels to have the space and capacity to recognise and respond to misconduct.
Professional identity formation should be discussed, examined and addressed overtly, and not hidden in an experiential curriculum.
Reflection is an important tool that is often displaced by other forms of learning, due to the over-crowded curriculum. This removes critical skill acquisition that is necessary for learners to be safe practitioners in the future.
Organisational oversight is essential to keep students and doctors in training safe. The responsibility for managing sexual harassment should not rest on the shoulders of the most vulnerable doctors in the system.
Medical training is complex and has multiple intersecting curriculums and pedagogy. It is important to keep the art of medicine within the stated curriculum, and not delegate important aspects of learning, like professional identity formation, to the hidden curriculum. Expecting doctors in training to extract learning from experience in this complex area of professional identity formation is unfair, and may mean the most vulnerable are unable to acquire critical skills necessary for their safety and the safety of others.
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