Medicine, with its hierarchical institutional structure and male-dominated history, is ripe for abuse. But despite the strides being made in other industries in the wake of the #MeToo movement, medicine seems to be lagging behind.

I discussed this issue with physician and researcher Dr. Reshma Jagsi of the University of Michigan.  A transcript of our interview appears below the video.

Dr. Perry Wilson: The #MeToo movement has affected industries from Hollywood to Washington D.C. and has led to a cultural shift in the way we talk about misogyny and sexual harassment in the workplace. To talk about this, I'm joined by Dr. Reshma Jagsi, a radiation oncologist professor at the University of Michigan and Director of the Center for Bioethics and Social Sciences in Madison. Dr. Jagsi, thanks for joining me on Doc 2 Doc.

Dr. Reshma Jagsi: Thanks for having me.

Dr. Wilson: First of all, you're a radiation oncologist. You've published extensively on advances in breast oncology and breast radiation, clinical practice standards and outcomes. That's your career, but you've been outspoken about this issue, that in some sense, pervades medicine. Tell me about how you got here.

Dr. Jagsi: I have been interested in understanding why women are underrepresented in senior leadership positions in academic medicine for quite some time. As you know, women are now over 50% of the medical school class for the first time just this year, but have been pretty close to 50% for quite some time, and we haven't been able to explain why only 16% of department chairs or 16% of medical school deans are women. I've been interested in understanding what challenges and barriers might explain these differences so we can target those and share equity.

Dr. Wilson: In 2016, you conducted a survey study which looked at, really, some of the most promising, young, academic physicians in the country. These are individuals who received career development awards from the NIH, the sort of best and brightest, and asked about their experiences. These were men and women, and the results were pretty disturbing. Can you give us a rundown?

Dr. Jagsi: Absolutely. Of these individuals who were a mean age of 43, so these are generation X K awardees. They got their K08s and their K23s, which are for clinician researchers, between 2006 and 2009. It's a relatively homogenous, recent set of superstars in academic medicine, and what we found was that 30% of the women reported that they had been sexually harassed by a superior or colleague in their careers. Only 4% of the male respondents had had that experience.

Dr. Wilson: That's a number, again, we're talking about sort of the ivory tower, right? This is the best of academic medicine. When those results came out, how did people respond to you? Were people surprised?

Dr. Jagsi: I think people were very surprised. If you look at the timing of this publication, it was before we really had the outpouring of media attention with disclosures from politicians, from celebrities, and then from individuals in various other high-profile positions in business. This was right before that, and these findings were not only unexpected to me, but to almost everyone who seemed to read them and contact me.

            What was very surprising to me was the outpouring of responses that I received from women I'd never met who felt compelled to reach out and thank me for bringing attention to this issue, to say in their own words what their own experiences had meant to them in their own careers. Of course, I had dry survey data, but now I had these incredibly compelling stories from the vivid, rich, lived experiences of women in medicine explaining why they'd had such difficulty ever talking about this, ever reporting this, their concerns about being marginalized or stigmatized or facing retaliation.

Dr. Wilson: You write about some of their experiences in your perspective piece which appeared in The New England Journal of Medicine in January of this year, in January of 2018. The individual stories are disturbing in their own right, but one of the things that struck me about what you wrote is that all these women had spoken with you, had reached out to you, and not a single one had reported what had happened to them, which is almost jaw-dropping. How did that strike you and what do you think is going on here?

Dr. Jagsi: It actually struck me as very understandable because these women wrote to say, in part, that they felt guilty that they hadn't stopped the perpetrator because they knew that this individual was probably targeting others. They explained what the tremendous barriers were that they faced. These included the fact that if they reported, they, themselves, would come under scrutiny, suddenly their professional accomplishments might be discounted, they would be branded a troublemaker or a victim, and they had devoted their whole lives. I mean, we know what it takes to become a physician. They had devoted their whole lives to their careers, and they didn't feel that they were able to take the risks that reporting involved. It was really compelling to me to hear their stories and to really understand what a challenge we, as a society, face in trying to address this issue when women, themselves, can't come forward and report without fear of retaliation or marginalization.

Dr. Wilson: One thing I found very insightful about your perspective piece was you speak about these reporters calling you to talk about sexual harassment after your research paper came out, and you mention that your administrative assistant was taking these calls, and you felt the need to clarify to her that the reporters were calling you because of your research study and not because you had a specific instance of sexual harassment to discuss with them. Can you take us into your mindset what's going on there?

Dr. Jagsi: Yeah, I received a call. It was actually over the Thanksgiving holiday week, and I was out of town and my administrative assistant was out of town. It was actually a covering administrative assistant who took the call. My own admin assistant knows very well that I get calls from reporters who are asking about these kinds of issues because I write about them, but the colleague who was filling in for her didn't. I know her well. She sent me a lovely email and said something in the email along the lines of, "I'm so sorry. It sounds like you've had an experience with sexual harassment and this reporter is doing a story on sexual harassment and asked me to contact you. I thought that since it was from this prestigious news outlet I should contact you since you're on vacation. Again, I'm so sorry."

            I thought about this and the first instinct I had was, "Oh, my goodness. I have to reassure her that it's not about me. It's not about my own experiences." I mean my first thought was I didn't want her to think that one of my colleagues in my department because we do work in a relatively small department. I didn't want her to think ill of my very wonderful, upstanding, male colleagues. But when I thought about it further, it wasn't just that, right? It was this idea that I didn't want to be labeled a victim, right? I want to be a strong woman, one who's judged on the basis of my professional accomplishments, one who's seen as a future leader of academic medicine. It suddenly recalled for me the comments that were made to me by the women who had emailed me, who said exactly that, "I don't want to speak out about this because it will come to be something that identifies me, and I've worked so hard to be identified by my professional accomplishments. I don't want my mentors or my colleagues to think of sexual harassment when they think of me." That really resonated with me.

Dr. Wilson: Absolutely, and it does with me as well. Of course, it is sort of a terrible thing and makes you wonder because women in medicine are, in many ways, fighting an uphill battle. There's been a lot of institutional misogyny and sexism that I do hope is eroding over time, but is still present and there's still biases there. You still walk into a patient's room and get called nurse. I'm married to a female physician, so I hear these stories all the time and I'm acutely aware of the different ways that people approach my wife and approach me. How do we begin to change the culture where reporting something like this is considered a public service, which is what it really is, right? This is laudable. How do we begin to make that change?

Dr. Jagsi: I think it's an excellent question and I think it's not one that can be answered exclusively by scholars or by leaders or by individuals who've had these experiences. I think we all have to come together in this conversation, and I think that is the tremendous value of the #metoo movement is that for the first time as a society we seem to be coming together in a conscious deliberation over how we transform our culture to make these behaviors unacceptable and to make reporting of them something that doesn't then further victimize the victim.

Dr. Wilson: What can men do to help?

Dr. Jagsi: That's an excellent question, and it's actually one that I've been getting more and more often. After the JAMA research paper, I got a lot of emails from women. After The New England Journal perspective, I got a lot of emails from men. I still got emails from women and I still got emails from men the first time, but this time I noticed that I was getting a number of emails from men who were really troubled by these findings saying, "I can't believe… I'm a good, decent human being, I think, and I'm questioning what it is that I might have done that might have made another woman, one of my female colleagues feel uncomfortable, and I don't think I've done anything like that. I've tried to question whether I've stood by silently," and some of them have actually talked about times that they did stand by silently or times that they did intervene to help in such situations. [00:10:02] But all of them concluded by wondering what they could do to do more. I was heartened that many of these were leaders in the field, and I think that having open discussions, as I'm seeing occur all over the country, institutions, academic medical institutions and hospitals deciding that they're going to host panel discussions, symposia. Many of these hospitals and institutions have offices formally charged with ensuring that this kind of behavior doesn't occur. But they also recognize that there are obstacles to accessing those resources, and so increasing the accessibility, beginning the conversation. Those are the first steps towards true culture change, I think.

Dr. Wilson: One of the things that struck me about some of these cases is that they come to light oftentimes quite dramatically, and then when you talk to people who are associated with the perpetrator, colleagues with the perpetrator, you get the sense that there was maybe not direct knowledge of anything going wrong, but this sense, this feeling, rumors, innuendo that may have persisted for years before the truth came to light. When a victim is not willing to come forward for all the reasons we've discussed, what responsibility do we, as colleagues, have to address these issues when they don't necessarily rise to the standard of hard evidence? What should we do?

Dr. Jagsi: I think this is a real challenge because, of course, we are all very concerned about the potential damage to the reputation of someone who doesn't deserve that. We're concerned about false accusations. We're concerned about ensuring due process under law, and we're very eager to protect the rights of the accused and very legitimately so. This is a real challenge. I think one thing that can potentially work in this area is the fact that civility and respect are expected as part of professionalism. One could create a forum, an anonymous reporting forum, perhaps, where concerns about the degree of civility and respect that have been exhibited by members of our community are anonymously reported, and then evaluated and fed back to individuals saying, "There have been concerns raised about whether your professional conduct adheres to the standards of civility and respect that we expect," and it puts them on notice that they're being watched. I just wonder if even that level of intervention might be enough to cause someone to think twice before they act in that way again. Perhaps, it's not enough, and certainly for the most agreed trespasses, it probably isn't, but it might be a step in the right direction when a victim isn't willing or able to come forward.

Dr. Wilson: When these issues come to light, when it is clear that harassment or worse has taken place, we know who the perpetrator is. The reputation of the institution all of a sudden becomes on the line, and it seems that the response to that perpetrator is key in fostering a more egalitarian workplace culture. I am not sure that institutions always live up to that necessary response, and I'm curious what you think should happen to these perpetrators when it is clear, when we know when they've done.

Dr. Jagsi: I think that I agree with your inclination that institutions don't always live up to their responsibility in this regard. I think I have heard of many a case now. I think we all have of situations in which perpetrators have been passed on from one academic institution to the next so that it becomes someone else's problem rather than going to the extra steps of establishing proof and then more publicly censuring that individual. When we think about punishment in criminal cases, we think about both retribution and we think about preventing future bad acts, and we think about rehabilitation. I think that we need to turn to our colleagues who have thought about this in the context of criminal justice to get more insights in how we best shape behavior and establish our expectations as a society that this type of behavior is absolutely intolerable.

Dr. Wilson: Dr. Jagsi, I get the sense that you're hopeful for the future. I am as well. It's really been an amazing change, even over the past few months, as we've started to address this. I hope it leaks into medicine. Medicine often lags behind society in many ways, but thank you very much for putting it out there for all of us, and I hope you continue to not only do the excellent work you're doing in this area, but your excellent research in radiation oncology as well. Thanks for joining me.