American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Moving the Mark on Harassment in Surgical Training

The standard you walk past is the standard you accept.”
—Lieutenant General David Morrison

Over the past 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 impact patient care and outcomes. Fortunately, the surgical community’s commitment to combatting the patterns of injustice endemic to our culture has recently gathered increasing momentum.

Surgical colleges around the world are paying increased attention to their role in setting and upholding standards of conduct expected from their Fellows and trainees. A watershed moment occurred in 2015 after Dr. Gabrielle McMullin, a vascular surgeon, described a pervasive culture of sexism within the profession of surgery in Australia.1 She claimed that sexual harassment of trainees was widespread and that the current 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 females and international medical graduates most at risk.2 Later that year, RACS president David Watters issued a formal apology for the destructive behaviors that had become pervasive in the College’s training scheme and launched the Operate with Respect program to address some of these issues.3 Mandatory courses for Fellows and trainees challenge common biases and assumptions in surgical culture and provide practical skills and strategies to respond appropriately to unacceptable behavior.4

Dr. SinclairRecognizing the international relevance and importance of this topic, the American College of Surgeons (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, 2019, meeting in Chicago, IL. The statement can be found online. As the RAS-ACS liaisons to these committees, we had the opportunity to contribute to the drafting and revision of this important policy.

While there are still blatant examples of bullying and harassment in surgical training, the ubiquitous agreement on the significance topic has led to escalating efforts to eliminate the most egregious examples. It is unacceptable for attending surgeons to throw instruments at residents in the operating room; residency programs cannot expect that female residents delay pregnancy. While not yet consistently acted upon, it is universally accepted that there must be zero tolerance for discrimination based on gender, race, or religion. In the hierarchical world of surgery, however, the every-day indiscretions we experience as trainees—inappropriate comments, differential treatment of team members, pressure to work over hours, or punishment for failure to meet unrealistic expectations— are much easier to forgive or overlook. 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.

As trainees, we have both the responsibility and the 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, current trainees are acutely aware of the value of workplace diversity, the importance of inclusion, and the challenge of managing implicit bias—our own and others.

Dr. DareIt is essential that cultural change be embraced and modeled from the very top. The ACS’ publication of this 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 on 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 complicity has been especially problematic in surgery. Most students and residents can readily recall circumstances in which we have been witness to examples of bullying, harassment, or discrimination, even if we have not ourselves 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. While it may be difficult or uncomfortable at times, find a way to articulate when conduct is outside the standard you 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 to be 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, we can each contribute in our own way to fostering fair, respectful, and inclusive training and working environments, and to ensuring our surgical culture reflects the best—not the worst—of our profession.

References

  1. Sexual harassment rife in medical profession, warns surgeon. ABC News. March 7, 2015. Available at: http://www.abc.net.au/am/content/2015/s4193059.htm. Accessed September 17, 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 Dec;85(12):905-909.
  3. RACS apologises for discrimination, bullying and sexual harassment. Available at: https://www.youtube.com/watch?v=lm_YLicg9Sw. Accessed September 17, 2019.
  4. Coopes A. Operate with respect: How Australia is confronting sexual harassment of trainees. BMJ. 2016 Sep 1;354:i4210.

Tiffany Joy Sinclair, MD
Stanford University, Palo Alto, CA
Liaison, ACS Women in Surgery Committee

Anna Dare, MBChB, PhD, PGY-5 
University of Toronto, ON, Canada
Liaison, ACS Committee on Diversity Issues

College Approves Statement on Social Media

The ACS Committee on Ethics recently authored the Statement on Guidelines for the Ethical Use of Social Media by Surgeons.

Read the statement