Moving the mark on harassment in surgical training

Editor’s note: The following column was published in the September issue of the American College of Surgeons (ACS) Resident and Associate Society e-newsletter. The Bulletin is republishing it to reach the full ACS membership.

Over the last few years, the topics of harassment, bullying, and discrimination have come to the forefront of discussion in medicine and society at large. Surgical culture, in particular, has been guilty of perpetuating behaviors that are punitive and promote inequality, negative work environments, and job dissatisfaction. More importantly, such behaviors negatively affect patient care and outcomes. Fortunately, the surgical community’s commitment to combating the patterns of injustice endemic to our culture has recently gathered increasing momentum.

A worldwide issue

Surgical societies around the world are paying increased attention to their role in setting and upholding standards of conduct expected of their active and resident members. A watershed moment occurred in 2015 after Gabrielle McMullin, MCH, FRCSEng, FRACS, vascular surgeon director, South Sydney Vascular Centre, Australia, described a pervasive culture of sexism within the profession of surgery in her country.¹ Professor McMullin claimed that sexual harassment of trainees was widespread and that the system offered little protection for the victims and impunity for the perpetrators.

An independent expert advisory group was commissioned by the Royal Australasian College of Surgeons (RACS), the official body that represents surgeons in Australia and New Zealand, to evaluate the extent of the problem. A national survey conducted as part of the investigation revealed that half of all trainees reported having experienced bullying, discrimination, or harassment, with women and international medical graduates most at risk.² Later that year, Prof. David Watters, FRACS, FRCSEd, OBE, then-president of the RACS, issued a formal apology for the destructive behaviors that had become pervasive in the RACS training system and launched Operate with Respect to address some of these issues.³ Mandatory courses for RACS fellows and trainees challenge common biases and assumptions in surgical culture, and provide practical skills and strategies to respond appropriately to unacceptable behavior.⁴

ACS issues statement

Recognizing the international relevance and importance of this topic, the ACS Women in Surgery Committee, with input from the ACS Committee on Diversity, recently developed an updated Statement on Harassment, Bullying, and Discrimination. The ACS Board of Regents approved the statement at its June 7−8 meeting in Chicago, IL.⁵ As the Resident and Associate Society of the ACS liaisons to these committees, the authors had the opportunity to contribute to draft and revise this important policy.

Although blatant examples of bullying and harassment can still be found in surgical training, the ubiquitous agreement on the significance of this topic has led to escalating efforts to eliminate the most egregious examples of this behavior. It is unacceptable for attending surgeons to throw instruments at residents in the operating room, for example, and residency programs cannot expect that women residents delay pregnancy. Though not yet consistently acted upon, it is generally accepted that the residency program must have zero tolerance for discrimination based on gender, race, or religion.

In the hierarchical world of surgery, however, some individuals find the everyday indiscretions trainees experience much easier to forgive or overlook. Examples include inappropriate comments, differential treatment of team members, pressure to work longer hours, or punishment for failure to meet unrealistic expectations. The profound imbalance of power between faculty, trainees, and students allows for continuation of negative, yet frequently accepted, behaviors. Implicit—and sometimes explicit—bias at all levels of physician and patient interaction remains a significant contributing factor.

What can you do?

As trainees, we have both the responsibility and opportunity to promote a more positive, respectful, and equitable learning environment to benefit our own education, our daily working environment and that of our colleagues and, most importantly, the care of our patients. As a result of generational and educational differences, today’s trainees are acutely aware of the value of workplace diversity, the importance of inclusion, and the challenge of managing implicit bias—our own and that of others.

It is essential that cultural change is embraced and modeled from the very top. The ACS’ issuance of a disruptive behavior-related statement is a testament to the overall commitment of our leaders and our wider community to end bullying, harassment, and discrimination in surgery. For true change to be realized, however, such commitments must extend beyond high-level discussions and statements into our workplaces and our daily working lives. Education of trainees and trainers, nonpunitive reporting structures, and an enforced policy of zero tolerance within institutions and departments will encourage changes in attitude, culture, and behavior. Training in implicit bias will be a crucial measure in preparing physicians to combat these problems in their own daily work environment.

Bystanders are complicit in enabling bullying, harassment, and discrimination in the workplace, and this passivity has been especially problematic in surgery. Most students and residents can readily recall circumstances in which we have witnessed examples of bullying, harassment, or discrimination, even if we ourselves have not been the target.

As trainees, it can be challenging to call out what is wrong or stand up for what is right in the moment within the evident hierarchy of surgical culture. This behavior must change, and it is incumbent on leadership at all levels to promote a culture where it is safe to speak up. It may be difficult or uncomfortable at times, but trainees must find a way to articulate when conduct is outside the standard they expect. It can be especially important to demonstrate these attitudes and behaviors in front of junior team members, who often look to senior trainees to set the tone. The standard we walk past is the standard we accept. For too long as a profession, we have silently witnessed and walked past behavior we know is wrong.

We hope that the College’s statement will inspire you to model and maintain a new standard of professionalism at work—to lead by example at your institution or participate in national efforts to promote a standard of inclusion and equity in surgery. As future leaders in surgery, residents and fellows can contribute in our own way to fostering fair, respectful, and inclusive training and working environments, and ensuring our surgical culture reflects the best—not the worst—aspects of our profession.

References

1. Matthews A. Sexual harassment rife in medical profession, warns surgeon. ABC News. March 7, 2015. Available at: www.abc.net.au/am/content/2015/s4193059.htm. Accessed September 25, 2019.
2. Crebbin W, Campbell G, Hillis DA, Watters DA. Prevalence of bullying, discrimination and sexual harassment in surgery in Australasia. ANZ J Surg. 2015;85(12):905-909.
3. Royal Australasian College of Surgeons. RACS Apologises for Discrimination, Bullying and Sexual Harassment, YouTube video, 3:43, posted by RACSurgeons, September 9, 2015. Available at: www.youtube.com/watch?v=lm_YLicg9Sw. Accessed September 25, 2019.
4. Coopes A. Operate with respect: How Australia is confronting sexual harassment of trainees. BMJ. 2016;354(8071):i4210.
5. American College of Surgeons. Statement on Harassment, Bullying, and Discrimination. Bull Am Coll Surg. 2019;104(9):47-48. Available at: http://bulletin.facs.org/2019/09/statement-on-harassment-bullying-and-discrimination/. Accessed October 16, 2019.