Facing the Culture of Silence in Medicine

March 2, 2018

Tales from the Bedside 6 min read

By Ofole Mgbako, MD

We are at a crossroads. The recent movement of courageous Americans, mostly women, sharing their stories and facing down their abusers, has forced the reexamination of a culture of silence that drives rape, sexual assault, and sexual harassment into the shadows.  For too long, this violence has continued unchecked due to hierarchies of power that exist within nearly every sector of our society – from Hollywood to the restaurant industry, from tech to business, from our university system to the military. It is time for the violence to end.

Physicians are not immune to this moment. We too face this violence in our personal lives and in the lives of our loved ones, in the care of our patients, and in our workplace.

As practitioners, we are aware that our patients experience these indignities every day. The National Intimate Partner and Sexual Violence Survey in 2010 found that one-third of women reported being victims of rape, beating or stalking, or a combination of assaults [1]. This same survey found that women who had experienced such violence were more likely to report chronic conditions like asthma, diabetes or irritable bowel syndrome, as well as psychiatric co-morbidities [1]. These numbers are even more pronounced among the LGBTQ community. Compared to 35% of heterosexual women, 61% of bisexual women and 44% of lesbians have experienced rape, physical violence or stalking [1]. Furthermore, about 60% of transgender people of color report being sexually assaulted in their lifetime [2]. These numbers reveal a crisis of violence that disproportionately affects women and the LGBTQ community, and undoubtedly play a role in the health and well-being of our patients.

Physicians must reconsider the scope of this crisis starting with our training. Medical schools often offer only a limited, brief introduction to domestic violence screening. The World Health Organization (WHO) has had guidelines for intimate partner violence (IPV) screening in place since the 1990s [3]. The Institute of Medicine, as well as the US Preventive Services Task Force (USPSTF), recommend IPV screening for all adolescents and adults [4, 5]. Evidence has shown that these screening tools are effective in identification. A 2014 meta-analysis examined the effectiveness of comprehensive and limited screening tools versus usual care to increase identification of IPV, referrals to support agencies, and adverse outcomes [6]. The study showed that screening increased identification of IPV substantially, however did not provide evidence of increased referrals to support service or actual reduction in IPV. And surveys have shown that internists are not commonly screening patients [7]. Innovative, systems-level programs that incorporate non-physician advocates, mandatory training, standardized policies and procedures and collaboration with local support organizations may possibly increase the rate of this basic screening methodology [8, 9]. However, physicians need better and more robust training beyond domestic and intimate partner violence screening that confronts the pervasiveness and long term sequelae of sexual trauma. 

In my clinic at the Manhattan Veterans Affairs Hospital as a second-year resident, I treated a young woman who experienced military sexual trauma. She presented every few months with abdominal pain and bloating, and after an extensive negative workup, she finally disclosed to me that she had crippling anxiety from facing his abuser in the civilian setting every day at her workplace. She could not afford to quit his job, and she loved his job. So she spent every day avoiding this former superior, worried about a hallway encounter, or even worse, another assault. It took us two years to arrive at this conversation. I did not feel prepared to help her because of my medical training, but rather due to my previous role as part of the sexual assault prevention and response team during my undergraduate years.

Giving medical trainees tools to create safe environments in the clinical setting, and using proven communication strategies and sensitive approaches to uncovering histories of sexual trauma, is vital for our patients. Furthermore, we must teach medical students and residents that there is an inherent power differential in the doctor-patient relationship, and we are at risk of exposing our patients to further trauma given the intimacy a medical evaluation often requires. Physicians need to go beyond a list of screening questions and develop a comprehensive toolkit. We must teach our learners to embrace the complexity and nuance of “trauma-informed care” [10].  

Beyond the care of our patients, how we deal with sexual harassment in our workplace is equally important. Medicine is a field marked by power and hierarchy. A 2016 JAMA study found that 30% of successful female doctors reported being sexually harassed compared with 4% of male doctors [11]. Of this group of women, nearly all experienced a sexist remark, while about half reported unwanted sexual advances. Of those, 60% reported a negative impact on their confidence and 50% reported a negative impact on their career development. A study in Ann Intern Med in 2000 found that even 50% of female medical school faculty reported some form of sexual harassment [12].

These experiences happen with both colleagues and patients. A recent NEJM editorial by Dr. Jagsi pointed to “challenging institutional cultures” that force our female colleagues often to suffer in silence, either due to fear of retaliation or other barriers to disclosure [13]. It is unclear, particularly for residents and medical students, when they should report superiors who are disrespectful, or if and when they should remove themselves from the care of patients who make advances or make them feel uncomfortable. We must find ways to lower the barriers to reporting and processing these seemingly commonplace indignities.

There are multiple strategies to consider in addressing the institutional culture of medicine. First, to be sure, large strides have been made in terms of gender diversity in medicine, yet the number of women in positions of leadership still lags far behind. More female and LGBTQ leaders in medicine would undoubtedly help bring this conversation more to the forefront. Second, required gender bias training and LGBTQ disparities education for providers helps to increase awareness of just how much the experience of patients and providers differ by gender and sexual orientation. Furthermore, making reporting systems more robust with powerful ombudsmen or ambassadors who can assist in working through potential barriers to reporting would also be effective. Lastly, medical trainees and superiors must promote a culture of allyship. Male physicians must be more outspoken in advocating for safer spaces for their female colleagues. Straight physicians must be unmoving in advocating for their LGBTQ colleagues. White physicians must advocate for their colleagues of color, and vice versa, and so on. 

We have potentially reached a breaking point. As physicians, we need to advocate better for our patients, and shine a light on the unique experiences of trauma faced by women and the LGBTQ community. We must provide medical students with more robust training on “trauma-informed care.” And we need to create safer workplaces, continually reexamining organizational reporting policies. We also must ensure that attendings and faculty are equipped to stand up for and check in with their trainees. If we are no longer willing to accept that sexual violence is simply a part of our human experience, we will finally begin to heal.

Dr. Ofole Mgbako is Senior Chief resident, Internal Medicine Residency Program at NYU Langone Health

Image courtesy of Wikimedia Commons

References

  1. Black, M.C., Basile, K.C., Breiding, M.J., Smith, S.G., Walters, M.L., Merrick, M.T.,. Chen, J., & Stevens, M.R. (2011). The National Intimate Partner and Sexual. Violence Survey(NISVS): 2010 Summary Report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.  https://www.cdc.gov/violenceprevention/pdf/nisvs_report2010-a.pdf
  2. James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality USTS-Full-Report-Dec17.pdf (transequality.org)
  3. World Health Organization. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. WHO, 2013.
  4. Nelson HD, Bougatsos C, Blazina I. Screening women for intimate partner violence: a systematic review to update the 2004 Preventive Services Task Force recommendation. Ann Intern Med2012;156:1-13;W11-3. https://www.ncbi.nlm.nih.gov/pubmed/22565034
  5. Institute of Medicine (IOM). Clinical preventive services for women: Closing the gaps. Washington, DC: The National Academies Press, 2011.
  6. O’Doherty LJ, Taft A, Hegarty K, Ramsay J, Davidson LL, Feder G. Screening women for intimate partner violence in healthcare settings: abridged Cochrane systematic review and meta-analysis. 2014 May 12;348:g2913. doi: 10.1136/bmj.g2913.
  7. Rodriguez MA1, Bauer HM, McLoughlin E, Grumbach K. Screening and intervention for intimate partner abuse: practices and attitudes of primary care physicians. 1999 Aug 4;282(5):468-74.
  8. Kevin Hamberger, PhD, Karin Rhodes, MD, MS, and Jeremy Brown, MD. Screening and Intervention for Intimate Partner Violence in Healthcare Settings: Creating Sustainable System-Level Programs. J Womens Health (Larchmt). 2015 Jan 1; 24(1): 86–91. doi:  10.1089/jwh.2014.4861
  9. Ambuel B, Hamberger LK, Guse CE, Melzer-Lange M, Phelan MB, Kistner A. Healthcare can change from within: Sustained improvement in the healthcare response to intimate partner violence. J Fam Viol 2013;28:833-847.
  10. Cuevas K, Balbo J, Duval K, Beverly E. Neurobiology of Sexual Assault and Osteopathic Considerations for Trauma-Informed Care and Practice. The Journal of the American Osteopathic Association, February 2018, Vol. 118, e2-e10. doi:10.7556/jaoa.2018.018.  https://www.ncbi.nlm.nih.gov/pubmed/29227505
  11. Jagsi R, Griffith K, Jones R. Sexual Harrassment and Discrimination Experiences of Academic Medical Faculty. 2016;315(19):2120-2121. doi:10.1001/jama.2016.2188.
  12. Carr PL, Ash AS, Friedman RH, Szalacha L, Barnett RC, Palepu A, Moskowitz MM. Faculty perceptions of gender discrimination and sexual harassment in academic medicine. Ann Intern Med. 2000 Jun 6;132(11):889-96.
  13. Jagsi R. Sexual Harassment in Medicine – #MeToo. N Engl J Med 2018; 378:209-211.DOI: 10.1056/NEJMp1715962