Sexual misconduct in the workplace

By: Kate Hanneman, MD, and Anastasia L. Hryhorczuk, MD

Sexual misconduct is a nonlegal term that encompasses a wide range of behaviors that may make a workplace or educational institution unsafe for its members. Several institutions have specific definitions of sexual misconduct. The University of Iowa outlines sexual misconduct as “… encompassing any unwelcome behavior of a sexual nature that is committed without consent or by force, intimidation, coercion, or manipulation” (1).

Yale University describes sexual misconduct as “… a range of behaviors including sexual assault, sexual harassment, intimate partner violence, stalking, voyeurism, and any other conduct of a sexual nature that is nonconsensual, or has the purpose or effect of threatening, intimidating, or coercing a person” (2). Both men and women can commit or be victims of sexual misconduct.

Recent media attention surrounding sexual misconduct has brought this issue into sharp public view. Media companies, the entertainment industry, and political institutions have grappled with reports of long-standing sexual misconduct within their midst as more women and men begin to report inappropriate behaviors. Although hospitals and physician groups have not received the same public attention, it is important for radiologists to reflect on these issues and consider the ways that our leadership in hospitals and departments can create a positive environment for the entire staff, without allowing sexual misconduct to damage our peers, relationships, and institutions. The following scenarios explore sexual misconduct in the radiology workplace.

Scenario one

Dr Summers is a 3rd-year female radiology resident interested in pursuing thoracic radiology. Her program director, Dr Snow, is a nationally recognized thoracic radiologist who has many valuable national connections. He is a married father of two young children whose photos he proudly displays in his office. He invites Dr Summers to meet with him at dinner to discuss her career aspirations and a potential research project of national importance in the field.

When Dr Summers arrives at an upscale Italian restaurant, the evening is social, and there is no discussion of research. While helping Dr Summers put on her coat, Dr Snow’s hand lingers on her lower back, which Dr Summers finds uncomfortable but ultimately dismisses. In the following weeks, Dr Snow calls and texts Dr Summers several times on her cell phone, telling her that he “thoroughly enjoyed the dinner and would like to meet with her again to discuss her career.”

Dr Summers asks Dr Snow to stop contacting her on her cell phone. He texts her back and notes that “it is going to be hard for him or the rest of his division to work with her in the future” if she’s not willing to spend the time meeting after hours to work on research. He states that he finds “her vivacious personality difficult to get out of his head” and is “disappointed” that she is not interested in spending time outside of work to pursue their “shared academic interests.” He persists in sending her e-mail, some with direct links to scientific articles he has written.

Dr Summers is uncertain how to proceed, and she searches for general information on sexual misconduct and harassment in medicine.

Which statement is true regarding sexual harassment in the medical workplace?
A) Sexual harassment is extremely rare during medical training.
This is incorrect. Try another answer.
B) Through the process of medical training, women may be conditioned to accept inappropriate gendered behavior as an inescapable part of being a physician.

Unlike sexual misconduct, which is a broad term, sexual harassment in the United States has been defined by the U.S. Equal Employment Opportunity Commission (EEOC) as a specific type of sex discrimination in the workplace. The EEOC asserts that “unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature constitute sexual harassment when this conduct explicitly or implicitly affects an individual’s employment, unreasonably interferes with an individual’s work performance, or creates an intimidating, hostile, or offensive work environment” (3).

The EEOC continues by stressing that (a) harassers and victims may be of any gender, (b) anyone affected by offensive conduct can be a victim, and (c) unlawful sexual harassment can occur in the absence of economic injury or job loss (3).

Sexual harassment is prevalent within the medical workplace, often targeting those who are most vulnerable in the medical hierarchy. The pattern of harassment can begin in medical school. The 2016 Association of American Medical Colleges (AAMC) survey reports that almost 13% of students had been called offensive names or witnessed sexist remarks, and approximately 4% of students had experienced unwanted sexual advances (4).

In a 2014 meta-analysis exploring harassment and discrimination in medical training, investigators discovered that approximately one-third of medical students and residents reported sexual harassment in training, and just over half of trainees experienced gender-based discrimination (5). Therefore, answer A is incorrect.

In the findings from a recent survey, investigators assessed the prevalence of sexual harassment and reported patterns among radiologists (6). Approximately 10% of radiologists directly experienced sexual harassment, while 30% of radiologists witnessed sexual harassment in the workplace. When radiologist responses were separated by gender, approximately 25% of women and 5% of men stated that they had been sexually harassed, and approximately 40% of women and 25% of men had witnessed sexual harassment. Therefore, answer C is incorrect.

With regard to patterns of reporting among radiologists, only 30% of victims said that they would likely report sexual harassment, with women and U.S. medical graduates less likely to report sexual harassment than men and foreign medical school graduates. Therefore, answer D is incorrect.

Although 25% of women in radiology acknowledged experiencing sexual harassment, it is possible that the actual number of women exposed to inappropriate behavior in the radiology workplace is much higher. The findings from a longitudinal study of women in medical school demonstrated that over the course of clinical clerkships, women experienced a variety of unprofessional and uncomfortable experiences with patients, peers, and supervisors. By the end of their core clerkships, women in the cohort “concluded … that gender would play a substantial role in their future careers, but had accepted the inevitability of inappropriate gendered behavior in their medical training” (7). This developed tolerance of inappropriate behavior in medicine may lead some to ignore or “brush off” actions that would deemed unacceptable in other professional environments. Therefore, answer B is correct.
C) Women in radiology experience and witness sexual harassment less frequently than men.
This is incorrect. Try another answer.
D) Among women radiologists, it is common that incidents of sexual harassment are formally reported to workplace supervisors.
This is incorrect. Try another answer.

Scenario two

Based on her research, Dr Summers determines that she has experienced sexual harassment. She reports this to her institutional GME office and department chair. After an internal investigation, Dr Snow is removed as the program director and ultimately resigns from his position to pursue a job in a teleradiology practice.

A few months later, Dr Summers is on an ultrasound rotation, being supervised by Dr Spring. Dr Spring is a new attending who has just finished her fellowship in body imaging. The sonographer, Ms Rainey, enters with a case from the emergency department, stating, “I think you need to come in and look at this. The patient is a little strange, but he seems to have something going on in his right lower quadrant. I might be seeing an abnormal appendix.”

Dr Summers, Dr Spring, and Ms Rainey enter the room to scan the 35-year-old male patient. Together, they determine that he does not have acute appendicitis. As Dr Spring begins conveying the results to the patient, she notices that he has exposed himself and is masturbating. Dr Spring, Dr Summers, and Ms Rainey quickly exit the room.

“What should we do now?” wonders Dr Spring.

Whom should the physicians and sonographer contact?
A) The attending physician in the emergency department, to inform him or her of the events that occurred during the examination.
This is incorrect. Try another answer.
B) Security.
This is incorrect. Try another answer.
C) Their supervisors.
This is incorrect. Try another answer.
D) All of the above.

No recent studies have explored the extent of patient sexual misconduct toward doctors in the medical setting. An older survey of female Canadian family physicians found that approximately 30% of physicians encountered “suggestive exposure of body parts,” and 20% were forced to contend with uncomfortable “brushing, touching, or grabbing” (9). A recent survey of physical therapists illustrates that sexual misconduct by patients in medical settings continues to be surprisingly common (10). Almost 20% of physical therapists, over the course of their career, reported a patient exposing his or her genitals or breasts, and almost 7% have witnessed a patient masturbating during physical therapy sessions. Addressing these behaviors is complex, because patients may have urgent medical needs that still require attention, or they may be cognitively impaired and unable to assess their actions.

In the current situation, Dr Spring, Dr Summers, and Ms Rainey have little information about the patient. They certainly need to contact the attending physician in the emergency department to inform him or her of the situation because others in the emergency department may also be at risk for (or may have already experienced) sexual misconduct by this patient. The presence of one or more security personnel may stop further undesirable behavior while the patient’s medical evaluation is completed and can provide support if the radiologists or sonographer choose to pursue formal charges for indecent exposure. Finally, departmental supervisors need to be made aware of the event so that they can provide employee assistance and consider policies for future situations. Therefore, answer D (all of the above) is the correct answer.

It is important to understand that the EEOC has taken the position that, as sites of employment, hospitals have a legal obligation to protect employees from sexual harassment by third parties such as patients and visitors. In 2013, a suit brought by the EEOC resulted in Southwest Virginia Community Health System paying $30,000 in damages to an employee who reported repeated sexual harassment by a patient, which was ignored by her supervisors (11). From a systems perspective, failure to respond to sexual harassment or misconduct by patients can have serious repercussions for an organization.

Scenario three

In a scheduled debriefing after this event, Dr Spring, Dr Summers, and Ms Rainey meet with the chair and vice chairs of their department. The department has developed a plan to address inappropriate patient behavior, as well as patient violence, in radiology work spaces.

Dr Weathers, the long-standing department chair, is in his 70s and has never addressed this type of issue in the workplace. However, even with his lack of experience, he appears responsive, engaged, and appropriately concerned throughout the meeting. As the three women are excused at the end of this debriefing, Dr Weathers states, with a wink, “I am so sincerely sorry that this happened to you. But, you know, these kinds of terrible things are a risk we run with so many lovely ladies in our department!” Dr Freeze, the vice chair, looks down in embarrassment.

What should Dr Freeze do?
A) Ignore Dr Weathers—he is an older radiologist who just didn’t know what he should say to the women.
This is incorrect. Try another answer.
B) Explain afterwards to Dr Weathers why his attempts at teasing/humor/flattery could be reasonably viewed by others as being extremely inappropriate.

Those who are near the end of a long career in radiology have lived through major changes in the role of women in medicine. In 1993, the annual RSNA meeting featured a special focus session, “Gender Bias and Sexual Harassment in Radiology: Does it Exist?” A published excerpt from the session declared, “… although the situation for women in radiology may not be the best, it is far from the worst among the medical specialties” (12).

As we look on this today, it is striking how much the discourse surrounding these issues has changed in just over 20 years. In today’s climate, most would acknowledge that sexual harassment, as well as subtler episodes of gender bias, are ubiquitous. One would also imagine that most radiologists aspire for our field to be more than “far from the worst” of medical specialties in welcoming and supporting women!

Dr Weathers appears to have been responsive and proactive when addressing the main administrative issues of this episode. However, his attempt at humor likely fell flat for his intended audience. In bringing the focus back to the appearance of the women in the department, he is creating a microinequity—a term coined by Dr Mary Rowe of the Massachusetts Institute of Technology to describe “inappropriate comments, ‘clever but cheap’ jokes, conscious or perhaps unconscious slights, and other behavior that is ‘small in nature but not trivial in effect’” (12). Clearly, Dr Weathers’ error needs to be corrected.

Dr Freeze, a younger man within the department, has identified why this remark is a problem. He should not ignore it, support it by laughing and nodding, or put the women on the spot to explain to their supervisor why this comment is a small but real way of diminishing the women at their workplace. Answers A, C, and D are incorrect. Instead, Dr Freeze needs to explain to Dr Weathers why he should not make these types of statements, as well as the negative impact of microinequities in the workplace. Ideally, this explanation should be delivered with great sensitivity, forethought, and clarity. In addition, this conversation should be private, in order for Dr Freeze to address the issue in forthright fashion and to show respect to the long-standing chair—including when he is wrong. Therefore, Answer B is correct.
C) Force himself to smile and nod his head—although he might think that Dr Weathers’ joke was inappropriate, if he pretends that it was ok, the women might just think that they are being too sensitive and brush it off.
This is incorrect. Try another answer.
D) Call the women back in to explain to Dr Weathers how his comments made them feel.
This is incorrect. Try another answer.

Scenario four

After the discussion of these comments, Dr Weathers signs the radiology department leadership team up for a class in inclusion and diversity, hosted by the medical school. He learns about microinequities and racial microaggressions, and he realizes that he wants to work to change his language and the department’s structure to be more inclusive.

A few months later, Dr Weathers learns of a disciplinary meeting involving Dr Storm, a urologist who maintains a joint appointment in radiology. The chair of the urology department contacts Dr Weathers and asks him to come to the meeting to support Dr Storm, stating:

“It’s too bad I have to bother you with this. Really, there’s no reason we should even have this committee meeting. Dr Storm is a world-renowned expert in adolescent varicocele, and some boys who get a little twitchy with urology exams mistook his physical exam techniques as ‘inappropriate touching.’ Three of the other urologists in my department who know what a great guy he is have cleared him, so the meeting is just a formality. We just need you to come to sign off on his continued affiliation with radiology. This has been a real mess for us, you know. Can you believe that two families even went to the police? It’s a good thing that the rest of our urology team stands behind Dr Storm and gave statements to the police praising his clinical skills. At least we’ve been able to keep it within the urology group!”

What should Dr Weathers do?
A) Sign off on the affiliation. This is not primarily a radiology issue, and he trusts the expertise of the subspecialists in urology to judge their own colleagues.
This is incorrect. Try another answer.
B) Don’t sign off on the affiliation, but avoid the meeting. It’s best to have the radiology department stay out of this on all fronts, and the urologists can make their own decision.
This is incorrect. Try another answer.
C) Express concern about this situation to the chair of urology, and leave it up to the urologists to decide how to further pursue the complaints.
This is incorrect. Try another answer.
D) Promote these issues to higher leaders in the hospital, and suggest that, at a minimum, external physicians should review Dr Storm’s practice.

A few years ago, this scenario might have sounded preposterous—how could blatant sexual misconduct and the assault of multiple patients by a physician possibly occur in a hospital setting with peer review? Sadly, a number of recent cases have emerged in which physicians, sometimes with years of uninvestigated reports of sexual misconduct, have been identified as serial sexual predators (13–15).

Several of these cases have common features, including patients who were medicated and unable to voice complaints or accurately remember details of an assault, younger patients who were viewed as medically unsophisticated and unable to understand “appropriate care,” and colleagues at home institutions who had long-standing relationships with the perpetrators and continued to clear them of accusations. Such profound violations of trust erode the professionalism of medicine in the eyes of the public, and it is up to all of us, as physicians, to confront any behavior that may be jeopardizing patients.

In the previous scenario, it is unclear whether Dr Storm’s behavior reflects appropriate medical treatment or sexual assault. However, enough red flags exist for Dr Weathers to pause. He should not simply sign off on the affiliation at the request of the urologists; if he is being asked to assume responsibility for this clinician, he needs more information. Therefore, answer A is incorrect.

Similarly, Dr Weathers should not ignore this situation and place all further decisions in the hands of the urology department. Dismissing a situation that is so potentially significant violates his responsibility to the public. Therefore, answer B is incorrect. Although expressing concern to the chair of urology may be an appropriate first step, Dr Weathers cannot assume that he has fulfilled his responsibility to these patients after one discussion with an individual who is so invested in Dr Storm’s reputation and success. Therefore, answer C is incorrect.

It is imperative that Dr Weathers promote these concerns to senior hospital leaders. At a minimum, Dr Storm’s body of work needs to be assessed by external physicians with no relationship to him or the hospital. Although some superiors may be reluctant to pursue further investigations with the urology department, the potential stakes in this situation are so high for patients and the health system that Dr Weathers must persist in escalating these concerns through the hospital hierarchy. Therefore, answer D is correct.