Sexual abuse of doctors by doctors: professionalism, complexity and the potential for healing

Sexual abuse in the medical profession is a complex, multifaceted problem that needs evidence-based solutions

Contemporary attitudes to sexual abuse are changing. The Royal Commission into Institutional Responses to Child Sexual Abuse, the response of the Australian Defence Force to allegations of sexual abuse in the military and the work of the Australian Human Rights Commission around sexual harassment in the workplace all indicate a shift in community values. They also represent a shift in our understanding of the nature and scope of professionalism. As each respected institution has its professional failures exposed, it becomes obvious that no group is immune. Existing codes of professional conduct have not protected colleagues or clients from toxic behaviour.

Sexual abuse in medicine

The recent discussions in the mainstream and social media have sparked national and international attention, on both the allegations of entrenched sexual harassment, misogyny and exploitation within the surgical profession, and the institutional response to these claims. Essentially, the medical profession has claimed that existing policies protect junior doctors by encouraging victims to report inappropriate behaviour. However, this perspective fails to recognise the profound power imbalance that exists between senior and junior staff. Given the personal and professional cost of whistleblowing,1 it is understandable that victims choose to remain silent.

There is little written about the sexual abuse of qualified doctors in the workplace, but there is extensive literature detailing pervasive bullying and harassment of medical students. The literature is complicated by inconsistent definitions, with inappropriate behaviour occurring on a continuum. Sexual harassment covers a broader range of unwanted behaviours than sexual assault or sexual violence. A recent systematic review and meta-analysis of harassment and discrimination suggests that 59.4% of medical trainees had experienced harassment or discrimination during their training.2 Consultants were the most commonly cited offenders. The authors concluded that the average prevalence of sexual harassment was 33%.2 Other studies report a higher incidence among women.3,4

The impact of this abuse is profound. In a 1990s study, 69% of those abused reported that the abuse was of “major importance and very upsetting”.5 Half (49.6%) of the students indicated that the most serious episode of abuse affected them adversely for a month or more, and 16.2% said that it would “always affect them”.5 There is strong evidence that sexual harassment has a negative impact on students’ emotional and physical wellbeing and on their professional behaviour.6–8

One study found that female medical students learn to manage patients who behave inappropriately, but struggle to manage the unprofessional behaviour of supervisors.9 They described feelings of guilt and were resigned to the fact that these events would affect their personal and professional identity.9 It also seems that doctors and nurses have different expectations. While nurses tend to challenge abusive behaviour, medical students tend to acquiesce.10

Disturbingly, remedial efforts by institutions to prevent sexual harassment appear ineffective. On completion of a 10-year program to prevent medical student mistreatment in a United States hospital, the problem persisted with little change in prevalence.11 The authors concluded that the “hidden curriculum” may be more powerful than professionalism training.11

Changing our professional culture for the future

It seems unlikely that sexual harassment ceases at graduation, so it is interesting that little is written about abuse within the medical profession. Without published literature, there can be little clinical or academic conversation about the management of the victims of abuse, and no evidence-based organisational response to the culture that enables or tolerates this behaviour. However, some levers for change already exist.

There is much to learn from the way professional expectations, policies and processes have shifted to manage other unwanted professional behaviours, such as medical errors. It has been necessary to tackle the tendency to deny errors, to cover up the evidence, and to avoid frank and open discussion.12 This shift has been difficult and has required a corresponding shift in cultural norms. It has involved research at all levels, including cognitive studies of clinical reasoning and organisational research into institutional behaviour.

Preventing and managing sexual harassment and sexual assault will require a similar breadth of research and policy change. At the organisation level, the Australian Medical Council accreditation framework requires all Colleges to meet Standard 7.4 on the management of bullying and harassment. The 2014 survey of doctors in training by the Australian Medical Association (AMA) found that 30% of participants felt their College had clear and accessible policies on bullying and harassment, and only 12% felt that their College responded in a timely manner to such complaints.13 In light of the AMA’s findings and recent events, it appears that this standard and assessment against it need urgent review.14 Similarly, National Safety and Quality Health Service Standards could strengthen their emphasis on the safety and security of staff.15

To understand and modify professional culture, however, we also need to explore the experience of individuals in the context of hierarchical medical teams, and follow the impact of abuse over time. Specifically, further work should critically examine the cultural frameworks that enable abuse and promote the silence of victims, and should explore the way doctors seek help and support.

To help promote healing, we need to produce and adopt an empirically derived framework for developing therapeutic guidelines that explicitly redress the personal and professional impact of sexual harassment and sexual assault in the medical profession.

Qualitative research into the experience of young doctors who experience abuse in the workplace would be the first step in understanding these complex behaviours, and would be the first study of its type internationally. Collaborative research is necessary to expose, question and correct toxic cultural practices, and to create safe working environments for all doctors in the future.

Sexual harassment and sexual assault are illegal, deeply traumatic and profoundly unprofessional. However, given the ongoing harassment of medical students internationally, it is likely that this abuse is an entrenched part of medical culture. The cause is not simple, but we must heal ourselves. It is high time the profession critically examined this problem from multiple perspectives and provided a multifaceted, committed and evidence-based approach to changing this toxic culture.

Not so innocent bystanders

It’s time for all of us to accept responsibility

“The standard you walk past is the standard you are prepared to accept.” With this wake-up call in June 2013, Lieutenant General David Morrison challenged all those serving in the Australian Army to take responsibility for the culture and reputation of the army and the environment in which they work.1 He made this call in response to an emerging scandal of sexual abuse and harassment in the army. At the 2015 Australian Medical Association national conference in May, James Lawler, President of the Australian Medical Students’ Association, named bullying, harassment, sexual harassment and their mental health as the biggest problems affecting medical students.2 He explained that he could not tell his peers to take a stand against the perpetrators because “the hierarchy is too high and too strong”. Quoting David Morrison, he called on those present to help change the culture of medicine.

Discrimination, bullying and sexual harassment are illegal and breach both published and implicit codes of ethics and professional standards in medicine.3 Yet they are prevalent in medicine and health care, not only in Australia, but in many other countries and cultures and in other professions, notably law.4 Both men and women perpetrate this behaviour, but the most common pattern is a male perpetrator and female victim. The behaviour affects the individuals involved and the organisations they work in, reducing individual and team morale and performance and, in health care, ultimately diminishing patient safety.5

Most incidents are not reported. Reasons for this include lack of confidence in complaint processes, fear of adverse consequences, reluctance to be viewed as a victim and cultural minimisation of the problem.6

Hierarchies lend themselves to misuse of power. Our profession remains hierarchical, and the further one advances up the hierarchy in many parts of the profession, the greater the imbalance between the sexes. This is particularly so in surgery, where only 10% of fellows are female, and few women hold office.7

In this issue of the Journal, Walton points to the profound power imbalance that exists for junior medical staff8 and Mathews draws attention to the system of patronage where trainees depend on powerful senior colleagues for advancement.3 These articles go some way towards explaining why victims cannot be expected to solve the problem or even to take primary responsibility for identifying and naming it.

What can the rest of us, the bystanders, do?

How can peers and colleagues not notice inappropriate behaviour going on around us? Or do we notice but feel disinclined to become involved or reluctant to act? And how do we respond if a student or trainee comes to us for help and support? Or if we are part of a formal complaints mechanism?

Those who are perpetrators, whether their behaviour is deliberate or unconscious, need to know that their peers do not accept and will not tolerate it. The behaviour needs to be recognised and condemned as and where it occurs.

The lack of confidence in complaint processes and fear of reprisals is a sad reflection of the hidden curriculum in medicine, the cultural norms and expectations that run counter to the explicit curriculum of professionalism.

The way forward

“Good medical practice”, the code of conduct issued by the Medical Board of Australia outlines the professional values on which all doctors are expected to base their practice.9 These values include integrity, truthfulness, dependability, compassion and self-awareness. Bullying, discrimination and sexual harassment are incompatible with these qualities.

Problems of discrimination, bullying and harassment are not new, but they are increasingly at odds with the standards expected in the 21st Century. Other institutions are facing up to the darker aspects of their history and culture, bringing them into the light of day and committing to eliminating abuse and exploitation. It is time for all of us to accept responsibility for the culture and reputation of our profession and work to create environments in which respect is the dominant quality of relationships with our colleagues, trainees and patients.

It is not appropriate to dismiss inappropriate care

Personalised care does not justify use of therapies that have been shown to lack benefit

Will you be disbelieving, dismissive, disheartened or alert to the dangers after reading the study in this issue of the MJA that identified potentially inappropriate care in Australian hospitals?1 Using routine hospital admissions data, Duckett and colleagues found that five procedures not supported by clinical evidence happen more than 100 times a week and there is great variation in hospital-specific rates of procedures that should not be done routinely.

Disbelieving

Confirmation that inappropriate care continues to occur challenges to the core the optimal, ethical and patient-centred medical care that medical professionals strive to provide.2 To disbelieve the findings would be human,3 as “evidence contrary to our personal beliefs tends to be dismissed as unreliable, erroneous or unrepresentative”.4

To counter the discomfort these findings provoke, we may rationalise, arguing that the appropriateness of care is quintessentially where the art and science of medicine merge, where balancing the logic of evidence with the personal values of each individual patient leads to variation in care. However, personalised care does not justify inappropriate care.

Or we may argue that this is to be expected when there is a vacuum of evidence about what is appropriate (eg, the established and widespread practice of off-label use of medications5), or that today’s radical ideas may become standard practice in another era.6,7 However, neither of these are valid counterarguments to Duckett et al’s findings.1

Instead of disbelieving, we should consider how we respond to consumers who will react to the results of the study with incredulity — and perhaps even outrage — that a contemporary health care system continues to deliver therapies with clinical research evidence showing they are of no benefit to patients. Patients should be receiving care that is appropriate and, ideally, based on evidence of benefit. Robust research evidence from testing the merits of a therapy and demonstrating a lack of benefit identifies inappropriate care. This is different to a lack of research evidence of benefit.

Dismissive

Those who would be dismissive will point to the inherent limitations in the study; for example, reaching conclusions about health care interventions with the use of a secondary analysis of hospital discharge data instead of clinical registries.8 The use of cross-sectional data, describing clinical practice from 5 years ago, provides no insight into temporal trends and whether these inappropriate procedures have tapered and are now eradicated. Further, a very small number of interventions were examined; and the highest volume of inappropriate care, also referred to as “do not do” treatments, involved hyperbaric oxygen therapy. This highly specialised therapy is only available in a small proportion of health services in Australia and accounted for 79% (4659/5888) of all procedures included. The remaining do-not-do interventions affected a very small but important number of patients.

Disheartened

The true believers who sought a revolution to improve patient safety and quality of health care will be disheartened. Unexplained variation in care was first reported over 5 decades ago9,10 and there was a flurry of activity throughout the world11 to improve the quality of health care, which generated considerable momentum from the evidence of patient harm.12

Duckett and colleagues’ study reminds us that we still do not have answers about how to ensure a high quality of care, that the impacts of most interventions to improve care remain incompletely understood, and the potential for inadvertent adverse consequences is ever present.

Alert to the dangers ahead

Inappropriate care is a “wicked problem”13 — difficult to resolve and requiring a fundamental change across the health care system. The danger ahead is we become mired in negative emotions. Now is the time to be interested, somewhat trusting and encouraged. Be interested in understanding and contributing to solving a complex problem, and put to use the natural inquisitiveness and skills of inquiry required in any consultation to make a diagnosis. Be somewhat trusting of the data, given there is substantial other robust empirical evidence showing inappropriate use of common procedures (coronary angiography, carotid endarterectomy, caesarean section) in health care.14 Be encouraged that this important aspect of quality health care continues to receive attention.

These findings call for action and we should all be interested in the outcome. However, we need to be only somewhat trusting of the recommendations for addressing inappropriate care through pay for performance, the use of rewards or sanctions as these may be premature, are conventional and provide at best a partial solution.

What should happen next?

Instead of dismissing, we should consider that for any inappropriate care to occur, complicit action on a large scale is required. To deliver a do-not-do procedure a medical practitioner must first be credentialled, have a defined scope of practice and operate within their clinical team alongside support services and the governance structures of an organisation. Start counting how many people are involved. Therefore, the question we should be asking is: how is it possible for inappropriate care to occur? And what systems-level agreements perpetuate this situation?

Instead of feeling disheartened we should embrace this opportunity to address appropriateness of care, which is integral to all six domains of quality.15 Our approach to this situation will be far more sophisticated because of the collective experiences and lessons on how to improve practice from the past 25 years.

Instead of merely feeling alert to the dangers ahead, we must be engaged and encouraging in our efforts to seek out the underlying factors and new solutions. This requires a change in thinking16 and incorporating the science of performance measurement with the science of human factors (a branch of applied science that draws on psychology, engineering, computing science, education, ergonomics and anthropology to improve patient care).

Prudent policy makers, medical practitioners and patients expect community resources to focus on efficacious and effective provision of health care. The ideas and concepts presented by Duckett et al1 are worthy of heated debate and concerted action to explore what we must do to eradicate inappropriate care.

Sexual harassment in the medical profession: legal and ethical responsibilities

Sexual harassment in medicine became a national concern after a senior surgeon warned that trainees who complain about these incidents are not well supported, and advised trainees that the safest action to protect their careers was to comply with unwanted requests.1 The surgeon referred to the case of Dr Caroline Tan, who was found by a tribunal to have been sexually harassed by a neurosurgeon who was involved with her surgical training. While Dr Tan successfully sued for sexual harassment,2 she reportedly faced substantial career detriment after pursuing her rights.1

While the prevalence of sexual harassment in Australian medicine is unknown, reports suggest it is an entrenched problem for both trainees3 and specialists.4,5 This is consistent with surveys in Australia, the United Kingdom, the United States, Sweden and Canada that have found between a quarter and three-quarters of women experienced sexual harassment in training or practice.6–9

Sexual harassment is an umbrella term covering a range of behaviour, from everyday exchanges communicating derogatory messages (“micro-aggressions”), through to direct acts of physical sexual assault.10

As we will show, some forms of harassment also constitute criminal sexual assault. Sexual harassment can adversely affect women’s safety and wellbeing, choice of specialty11 and career progression. The vast majority of incidents are unreported due to: lack of confidence that reporting would help; fear of adverse consequences; reluctance to be viewed as a victim; complicity of senior staff; and cultural minimisation of the problem.12 Men also experience harassment, but women are more frequently targeted.6,7

While sexual harassment occurs across professions, women in medicine are at particular risk because of male dominance of senior positions13 and the “patronage” system of training, whereby trainees depend on a small group of powerful senior colleagues for entry into training, assessment, job opportunities and career progression.

In this article, we review four dimensions of legal responsibilities owed by individuals and employers across Australia, and analyse professional standards and ethical frameworks. There are compelling legal, reputational and economic reasons for medical schools, hospitals, colleges and other organisations to create cultural change to reduce sexual harassment. These interests are further supported by an ethical and professional duty to promote gender equality and equal opportunity.

Four legal dimensions of sexual harassment

Criminal law

Criminal laws in every Australian jurisdiction make it an offence to commit sexual assault and more serious acts such as rape. Other criminal offences include indecent exposure, obscene communications and stalking.

Sexual assault is defined as an “unlawful and indecent assault” punishable by maximum prison terms of 5–21 years (Box 1). An assault is “indecent” if it has a sexual connotation and is “contrary to the ordinary standards of morality of respectable people within the community”.14 The acts found by the civil tribunal to have been committed without consent in Tan v Xenos2 (paragraphs 15–16 and 532–546) included embracing the complainant, kissing her on the lips, touching her breast, pinning her against a desk, and asking for oral sex. Such acts would constitute sexual assault if proved beyond reasonable doubt in a criminal prosecution.

Criminal laws in every state and territory set clear principles. Importantly, consent must be “freely and voluntarily given” for any sexual act to be lawful (Box 1). Consent is invalid if obtained by threat or intimidation, or by abuse of a position of authority (Box 1). Mere lack of physical resistance does not prove consent (Box 1). Therefore, sexual acts committed without any agreement will be criminal; as will sexual acts where a medical practitioner obtained “agreement” through threats, intimidation or reliance on a position of authority.

Anti-discrimination law

Legislation in all jurisdictions prohibits discrimination in the workplace. This legislation imposes two duties: individuals must not sexually harass a colleague; and employers must provide work environments free of sexual harassment.

The legislation prohibits unwelcome conduct of a sexual nature in circumstances where a reasonable person would have anticipated the other person would be offended, humiliated or intimidated (Box 2). Prohibited conduct includes inappropriate comments, sexual propositions, indecent exposure and sexual assault. Circumstances relevant in determining whether the other person would be offended, humiliated or intimidated include each person’s sex and age, and the relationship between the individuals. The concept of “unwelcome conduct”, with the element of offence, humiliation or intimidation, distinguishes unlawful harassment from lawful interactions between consenting adults. Therefore, even forms of harassment which are apparently more minor are serious and cannot be dismissed as trivial or justified as banter.

Sexual harassment under anti-discrimination legislation has consequences for individual offenders and employers. Individuals may face civil proceedings and be ordered to pay damages (Box 2). Employers are vicariously liable for an individual’s acts unless reasonable steps were taken to prevent them (Box 2). It is insufficient for an employer to merely respond after a complaint. Proactive steps include making policies, educating staff, establishing grievance procedures and monitoring workplace environments.

Where sexual harassment is proved, damages are awarded to approximate the hurt caused to the victim. In Tan v Xenos, the award was $100 000.2

Tort law

Tort law gives individuals a further range of rights enforceable in civil law, separate from their rights in anti-discrimination law and the state’s capacity to bring criminal proceedings. Some of these rights can be pursued in civil lawsuits against individuals and employers for sexual harassment. For example, an individual may be liable for battery for intentionally causing harmful or offensive physical interference with another’s body. An individual may also be liable for breach of duty, enabling a victim to sue for compensation when further losses have crystallised, such as the nature and extent of psychological injury, and the victim’s economic loss.15

Employers have a positive obligation to provide a safe workplace for employees, including an environment free of sexual harassment.16 In the branch of tort law known as negligence, employers owe employees a duty of care to prevent damage being suffered. An employer will be liable for breaching its duty of care to a harassed employee if the employer knows, or ought to know, of an employee’s propensity to harass other employees, does not take reasonable steps to prevent further offending, and the individual offender subsequently causes damage to the harassed employee.

Contract law

Employment contracts contain an implied duty requiring the employer not to engage in conduct likely to damage the relationship of trust between employer and employee.17 Connected with this is an implied term to provide a safe work environment free of sexual harassment.17 These terms may support an action for breach of contract against the employer where an employee experiences sexual harassment by another employee.

Where a person resigns because sexual harassment makes the workplace intolerable, a court or the Fair Work Commission may find the person has been subject to “constructive” dismissal. That is, workplace conditions gave the employee no reasonable alternative but to resign. Such indirect forced dismissal warrants compensation from the employer for lost remuneration. Finally, if an employee complains about harassment and resigns because of subsequent pressure or victimisation, this may constitute an additional contractual breach and a separate breach of anti-discrimination legislation (Box 2).

Professional standards

Professional codes of conduct establish clear professional and ethical responsibilities to treat colleagues with fairness and respect. These responsibilities are established for all doctors in the code of conduct of the Medical Board of Australia (Box 3).18 Other codes reinforce these profession-wide duties. The code of ethics of the Australian Medical Association urges doctors to recognise that their conduct may affect the profession’s reputation, and encourages reports of colleagues’ unprofessional conduct (clause 2.1).19

Many professional colleges address harassment in their codes of conduct. For example, the Royal Australasian College of Surgeons’ code of conduct requires surgeons to “eradicate bullying or harassment from the workplace” (clause 4.1.6).20 This code states that surgeons, by virtue of their position, should be role models for those they supervise and teach (clause 10) and are prohibited from seeking intimate relationships with trainees under their supervision (clause 10.1). Sexual harassment is prohibited by other colleges’ codes of conduct, including those of the Royal Australasian College of Physicians21 and the Australian and New Zealand College of Anaesthetists.22

Serious breaches of standards may result in notifications to the Medical Board. Under the Health Practitioner Regulation National Law, which has been enacted in every Australian state and territory, practitioners and employers must notify cases where a practitioner engages in “sexual misconduct in the practice of the profession”. Although this usually arises when practitioners breach boundaries with patients, sexual assault of colleagues has been reported to the Australian Health Practitioner Regulation Agency under these provisions or the voluntary notification provisions for unprofessional conduct.

In serious cases, tribunals can suspend or deregister practitioners for misconduct, including for repeated instances of unprofessional conduct or conduct inconsistent with being a fit and proper person to hold registration.

Conclusion

Sexual harassment is illegal and unethical. Prohibitions in Australian laws and codes of conduct are clear. Practitioners face serious consequences for committing sexual harassment, and employers can be liable for failing to take preventive action.

Nonetheless, sexual harassment of women in medicine remains a serious concern in training and clinical settings, but complaints are rare. This suggests that the problem requires cultural change rather than legal reform. A potent alloy of gender inequality, normalisation of inappropriate conduct, professional monopolies and powerful hierarchies combine to create a culture that shields offenders and silences victims.

We suggest that culture change requires a five-pronged approach. First, we need a clearer understanding of the nature and scope of the problem, its effects and potential impacts on clinical care. Many acknowledge the gravity of the problem, but others contend that concerns are infrequent and historical. The establishment of the new Royal Australasian College of Surgeons Advisory Group, which will review policies, establish a reporting framework for harassment and explore problems of gender balance, is a welcome development.

Second, we need to educate students, practitioners, employers and boards about their responsibilities. Improved knowledge can influence attitudinal and behavioural change: the goal is for doctors to cease the sexual harassment of students and colleagues. In designing educational programs, Australia may benefit from the experience of Canadian colleges, which have provided sexual harassment training for 2 decades.23 Other helpful tools may include the Victorian Equal Opportunity and Human Rights Commission’s recommendations for reform of the legal profession, directed partly at preventing sexual harassment.24

Third, health practitioners should have access to a sound complaint mechanism. However, this alone is insufficient and does not mean that victims are responsible for resolving the problem. Victims should not simply be ordered to “speak up”, as this ignores factors that impede disclosure, and leaves undisturbed the power imbalances, gender discrimination and tolerance of inappropriate conduct which foster the problem.

Fourth, we should recognise and support individuals and employers who promote respectful work environments. It takes courage for victims and bystanders to speak up about sexual harassment. Employers who set new standards of conduct demonstrate leadership and integrity. An environment that unequivocally supports women and rejects harassment can powerfully influence the behaviour of perpetrators, the careers and wellbeing of women, and the “hidden curriculum”25 communicated to students and trainees.

Finally, the medical profession can nurture wider efforts to promote women’s rights through its status in society and its broad interaction with the population. By modelling a commitment to gender equality and women’s rights to safety and dignity in the workplace, the medical profession can embody what should be core aspirations in contemporary Australia.

1
Sexual harassment as a criminal offence in Australian states and territories

The offence of sexual assault or indecent assault exists in each state and territory, with substantial penalties: Crimes Act 1900 (ACT) s 60 (7 years); Crimes Act 1900 (NSW) s 61L (5 years); Criminal Code (NT) s 188(2)(k) (5 years); Criminal Code 1899 (Qld) s 352 (10 years); Criminal Law Consolidation Act 1935 (SA) s 56 (8 years); Criminal Code Act 1924 (Tas) s 127 (21 years: s 389); Crimes Act 1958 (Vic) s 39 (10 years); Criminal Code Act Compilation Act 1913 (WA) s 323 (5 years).
Consent only exists if freely given and will not be present if obtained by threat, force or abuse of position: ACT s 67; NSW s 61HA; NT s 187(a); Qld s 348; SA s 46; Tas s 2A; Vic s 36; WA s 319.
Consent is not shown simply by lack of physical resistance: ACT s 67(2); NT s 192A(a); Vic 37AAA(e); WA s 319(2)(b).

2
Sexual harassment as discrimination in Australian states and territories

Sexual harassment can be constituted by a single act. It is generally defined as unwelcome sexual conduct in relation to the other person, committed in circumstances where a reasonable person would have anticipated the other person would be offended, humiliated or intimidated: Discrimination Act 1991 (ACT) s 58(1); Anti-Discrimination Act 1977 (NSW) s 22A ; Anti-Discrimination Act 1992 (NT) s 22; Anti-Discrimination Act 1991 (Qld) s 119; Equal Opportunity Act 1984 (SA) s 87(9); Anti-Discrimination Act 1998 (Tas) s 17(3); Equal Opportunity Act 2010 (Vic) s 92; Equal Opportunity Act 1984 (WA) s 24(3-4).
Sexual harassment is prohibited, with substantial penalties for the individual offender: ACT s 58; NSW s 22B; NT s 22(2); Qld s 119; SA s 87(1); Tas s 17(2); Vic s 93; WA s 24(1).
Substantial penalties can also be imposed on an employer, who will be vicariously liable unless appropriate preventive steps were taken: ACT s 121A; NSW s 53; NT s 105; Qld s 133(2); SA s 91; Tas s 104; Vic ss 109-110; WA s 161.

3 Sexual harassment as a breach of good medical practice

Under Good medical practice: a code of conduct for doctors in Australia,18 “good medical practice” includes:

Communicating professionally, respectfully and courteously with colleagues (clause 4.2)
Understanding the nature and consequences of harassment, and seeking to eliminate such behaviour in the workplace (clause 4.4)
Acting as a positive role model and supporting students and practitioners (clause 4.4)

[Correspondence] Surgical palliative care in resource-limited settings

To relieve suffering in people is a universal aim of all medical and surgical specialties, yet a chasm exists between palliative and surgical disciplines. Every year about 40 million people need palliative services worldwide, but only 10% receive them.1 The need for palliative care is disproportionate to the density of health-care providers: 80% of those in need are in low-income and middle-income countries (LMICs) where the health-care workforce is limited.1,2 In such areas, the surgical workforce might feel obligated to focus on patients with curable conditions rather than those with terminal conditions because it might seem too late to help the latter.

[Comment] Reducing unintended pregnancy through provider training

Access to family planning services allows women and families to plan pregnancies and achieve desired family size. These factors are crucial to health, wellbeing, and economic advancement. However, unintended (mistimed or unwanted) pregnancy remains a major public health challenge, accounting for nearly half of all pregnancies in the USA,1 and 85 million worldwide each year.2 Even where modern contraceptive methods are available, unintended pregnancy occurs through inconsistent or incorrect use. Unintended pregnancy has important health consequences, and its reduction is a component of the United Nations Millennium Development Goals to lower maternal mortality.

Sexual equality, discrimination and harassment in medicine: it’s time to act

More enlightened teaching would go a long way towards solving these problems

Among entrants to Australian medical schools, women slightly outnumber men. Of a total of 14 384 domestic medical students enrolled in medicine in 2014, (51.3%) were women.1 By the time these women complete their training, significant gender imbalances will emerge in their fields of practice, with palliative medicine and sexual health being the only specialties with more women than men.

Redressing sexual inequalities in medicine will require more than increasing the numbers of women in male-dominated specialties; the changing roles of the sexes in society, learning styles, hospital-based training and the professional identities of women in a largely masculine medical hierarchy are all deeply relevant.

A 2015 United States study of women’s perceptions of discrimination during surgical training and practice found that most observed or experienced gender-based discrimination during medical school (87%), residency (88%) and practice (91%).2 These results suggest that bullying and discrimination are rife, and complaint mechanisms inadequate. Studies of women in North America show they experience greater levels of abuse than men, and that the high prevalence of harassment and discrimination has not diminished over time.3–5 A 2014 systematic review and meta-analysis of harassment and discrimination in medical training showed that verbal harassment was the most common type of abuse and that physical abuse was the least common.3 Abuse (verbal, physical, sexual, harassment, sex discrimination) affects performance and leads to stress and discomfort,4–6 which in turn affects how supervisors and teachers view particular students. Women in all stages of medical training have been subjected to harassment and discrimination — beginning as early as medical school. No area is untouched.

Medical school

Medical students, eager to assume a professional identity, absorb the medical culture. Many argue that this is necessary for success, but enculturation can lead students to believing that progression in medicine requires them to accept the status quo.5 Students quickly learn that conformity and complacency are crucial components of learning and professional advancement;7 complaining is not an option. An Australian study pointed out that a reluctance to report bad behaviour might relate to the legalistic framework for managing complaints, particularly immediate notification of the complaint to the perpetrator and identification and subsequent vilification of the whistleblower.8

In 2007, American medical students observed that unprofessional medical educators, who were protected by an established hierarchy of academic authority, did more to harm students’ virtue, confidence and ethics than was acknowledged.9 They said that students struggle to understand the disconnection between the explicit professional values they are taught and the implicit values of the hidden curriculum.9 A 2012 US longitudinal study of third-year female medical students showed that gender would play a substantial role in their future careers, and that inappropriate gendered behaviour was inevitable in medical training generally.3

Trainees

Clinical training in hospitals involves working in a hierarchical team structure headed by a consultant, with the least experienced intern at the bottom. This crucial phase — a time when the dynamics of hierarchy and interpersonal relationships enhance or impair learning — can influence career choices.4 Good supervisors can have positive influences on career choices; conversely, bad ones can quickly diminish aspirations. A 2005 US study of 4308 respondents (medical students, surgical residents, fellows and fully trained surgeons; 76% male) showed that men and women had similar reasons for choosing surgery, but for women, a significant factor was their positive clerkship (training) experience and availability of female role models.10 Women were less likely to agree that their surgical training experiences were comparable to those of their male peers.10 A 2012 Australian study of doctors’ preferences for choice of specialty reported that life balance and capacity to provide continuity of care with opportunities for academic or procedural work were highly influential.11 This study did not break down its findings for men and women, but 61.5% of respondents were women. The study concluded that doctors prefer fewer hours of work, control of their working hours, low level on-call responsibilities, academic opportunities and significant procedural work.11

Surgery

In March this year, the Royal Australasian College of Surgeons established an Expert Advisory Panel to examine its culture after complaints of bullying and harassment of female surgical trainees reached the media. Surgery is popular among medical students, but their enthusiasm diminishes significantly for both sexes, particularly for women, by the time they need to decide on a specialty. Reasons include the heavy workload and a desire to have children.12 Once they become surgeons, women are more positive about their career choice than female medical students contemplating such a career.13 A 2014 literature review on gender-based differences in surgical training found that the lack of role models and gender awareness were responsible for the low numbers of women training in surgery. Women were unlikely to meet a female surgical role model during their training, and were more likely to experience gender-based discrimination during their surgical rotation (P < 0.05), leaving them with a perception that surgery was incompatible with a rewarding family life, happy marriage, or having children.12

Only 10% of surgeons in Australia (539/5507) are female. The Box shows a breakdown of Australian medical practitioners by specialty and sex. Less than 3% of female doctors are surgeons and less than 1% of all doctors are female surgeons. Among surgical specialties, women are most highly represented in paediatric surgery (29%) and least highly represented in orthopaedic surgery (3%) (Appendix).

Role strain, harassment, career penalties associated with maternity leave, and gender-based pay differentials are common challenges faced by women in many workplaces. However, in medicine generally, and in surgery in particular, there is an additional constraint. The main difference from medical school learning is that service provision is a significant component of the learning contract between the trainee and the employer. While trainees are required to focus on both learning and providing a service, the hospital is focused on patient care. A Canadian study describes sexual stereotyping that classifies females as being concerned about the welfare of others and being motivated by stronger needs for nurturance, in contrast with males who are classified as striving to master, dominate and control the self and the environment.14 In hospitals, these attributes may lead women to prioritise patient safety ahead of their own learning needs.

US studies show that, while female medical students perform equally well on objective assessments, they consistently report less confidence in their abilities, and experience significantly more anxiety about their performance.15 When making the transition to the workplace, female doctors, who are often more cautious, will worry about their inexperience, while many male doctors (with the same experience) will emphasise their skills and present as being ready for the clinical challenge. A supervisor responsible for patient care is likely to select the more confident trainee because of their work schedule and their assumptions (founded or unfounded) about trainees’ competence. Hesitating and underconfident women miss out on opportunities because of their fear of not being good enough. This is particularly the case in procedural medicine.

All of this means that women gain experience at a slower rate than men; at the same time, the culture of “can do” prejudices them against specialties such as surgery. Surgery, with its roots in the male apprenticeship model, may underappreciate female learning styles, which can lead supervisors to think female trainees lack commitment or are not cut out for the job, leading to women being belittled, excluded and bypassed on the basis of incorrect assumptions about skills and knowledge. A Finnish study found that male medical students were exposed to and performed surgical procedures significantly more often than female students.16 This is where women may be at a disadvantage — their learning approaches and styles may not be as suited to the opportunistic supervision learning method used in hospitals that requires an assertive personality and a “can do” attitude that are not necessarily the best for patient care, but are best for progress in specialty training.

What can we do?

We need to heed the prevailing belief held by students that the medical culture is resolute. Governance structures for complaints about the behaviour of teachers should be transparent and accessible to medical students. Token attention to grievance processes without removing teachers who behave badly reinforces the belief that nothing can or should change. Targeted education is required, with accountable and transparent processes in place to ensure that zero tolerance of harassment and bullying is the norm.

Surgery is one area where the experience of women is well documented and consistently found wanting. If the surgical culture were reformed to accommodate gender differences in training, it may become a template for other areas of medicine. Recent research shows there is a generational shift among both men and women in relation to the balance between personal and professional lives, with participants saying that their priorities are radically different from those of their senior colleagues.17 Given the increasing role played by women in medicine, it is time to reflect on the models underpinning specialty training and to look to methods shown to enhance learning for both sexes. Nurturing female surgeons to become clinical supervisors and encouraging female surgeons to teach and be involved in mentoring programs would help.

College policies and guidelines about harassment and discrimination alone will not change the culture — these must be accompanied by swift and strong action by college representatives when instances are brought to their attention. That men and women have inherently different characteristics and learning styles is now well established; the next step is to explicitly acknowledge these differences in the design of medical education. A failure to do this will maintain the status quo and perpetuate discrimination against women in medical training. Allowing a supervisor who is known to be sexist or discriminatory to teach brings into question the sincerity of a college in dealing with bad behaviour. Colleges need to have zero tolerance for harassment and discrimination.

Acknowledging the powerful influence of supervisors on learning outcomes for trainees is crucial. In addition to excellent knowledge in their disciplines, clinical supervisors need to have knowledge and skills in the areas of teaching methods, different learning styles, ethics, patient safety and sexual stereotyping. Being a senior doctor is not a qualification for teaching in itself, and the assumption that it is exposes medical education to the risk of nothing changing. Clinical supervisors need to be accredited. Accredited supervisors can reinforce the potential of all trainees rather than acting as a de-facto barrier to women’s entry into male-dominated specialties.

Medical practitioners registered in Australia at 28 February 2015 by specialty, and proportions by sex

Specialty	Total number	Proportion	Female	Male

Addiction medicine	165	24%	76%
Anaesthesia	4 579	28%	72%
Dermatology	504	44%	56%
Emergency medicine	1 649	32%	68%
General practice	23 759	40%	60%
Intensive care medicine	808	16%	84%
Medical administration	329	32%	68%
Obstetrics and gynaecology	1 834	40%	60%
Occupational and environmental medicine	301	17%	83%
Ophthalmology	951	20%	80%
Paediatrics and child health	2 408	46%	54%
Pain medicine	251	22%	78%
Palliative medicine	293	55%	45%
Pathology	1 985	39%	61%
Physician	9 325	27%	73%
Psychiatry	3 385	38%	62%
Public health medicine	432	39%	61%
Radiation oncology	361	40%	60%
Radiology	2 255	24%	76%
Rehabilitation medicine	468	42%	58%
Sexual health medicine	116	55%	45%
Sport and exercise medicine	119	22%	78%
Surgery	5 507	10%	90%
Total	61 784	33%	67%

Source: Australian Health Practitioner Regulation Agency’s Public Register of Medical Practitioners.

Worrying trends in MBS review

There are mounting concerns about the direction of the Federal Government’s far-reaching overhaul of the Medicare Benefits Schedule amid indications up to 100 review groups will be established to examine specialist items.

The AMA has cautiously welcomed the MBS review, led by Sydney University Medical School Dean Professor Bruce Robinson, and has undertaken to help organise and coordinate the input of clinicians.

But AMA President Brian Owler has convened a meeting of medical profession leaders for the later this month to discuss worrying aspects of the Government’s approach to the review, including excluding specialist colleges and societies from direct involvement, opaque processes for the selection of review members that raised the risk of influence by individual vested interests, and a lack of transparency regarding the work of review groups and their decision-making.

Professor Owler warned the Government that it risks jeopardising the medical profession’s support for the process if it turns out to be just a cost-cutting exercise that lacks transparency and excludes clinical input.

“Doctors are not afraid of change and reform. We will willingly participate in reform where it is in the best interests of our patients,” he told the National Press Club last month.

He said the MBS, which list treatments and procedures for which the Government will provide a Medicare rebate, was due for an update because of improvements in medical technology and innovations by doctors to provide better and more effective treatments.

“However, our support is predicated on this review not being aimed at cutting the funding to health,” Professor Owler said. “We agree with not paying for procedures that don’t work for certain indications, but we also need to ensure that we don’t deprive people of important services.”

He voiced concern that the Government might use the review mostly to remove items from the MBS, rather than ensuring the schedule was up-to-date and reflected advances in care and medical practice.

“The MBS review cannot be a cost-cutting exercise,” he said. “If there are clearly savings that are identified and the evidence is there that supports those savings, then fine. But we also need to make sure that we have the ability to introduce new items onto the MBS. This cannot be about just taking items off.”

The AMA President said there were a lot of procedures and services currently not covered by the MBS that should be included, and lamented that currently the process for getting new items on the schedule was lengthy and costly.

He said an important aspect of the review was the opportunity to add new items and make the MBS “modern”.

“What we need to do as part of this review is ensure that we can actually add new things on and make sure that we do actually come up with a modern MBS,” the AMA President said. “If we get the sense that this is a cost-cutting exercise, then AMA support and, I suspect, the support of the whole medical profession, will be jeopardised.”

The MBS review meeting by convened by the AMA later this month will be addressed by Professor Robinson.

In his letter to college and society leaders inviting them to the meeting, Professor Owler detailed a number of issues regarding the Government’s approach to the review, including that:

it had not articulated a strategic vision for the health system to guide the review’s outcomes;
that it had not been given specific and quantifiable aims;
that specialist colleges and societies were excluded from direct involvement;
that the criteria to be used to select review members was unclear; and
there was a lack of transparency around individual reviews as they progress, and the decisions that will come from them.

“Any review of this nature must bring the profession along with it,” the AMA President wrote in his letter. “In the absence of a Government process that facilitates that, it is very important for the medical profession to be collaborative and coordinated.”

Adrian Rollins

IT investment key to health savings

Penny-pinching governments should invest in information technology to improve health quality while cutting waste and reducing inefficiency, AMA President Professor Brian Owler has said.

As the Federal Government pushes ahead with an overhaul of the much-maligned Personally Controlled Electronic Health Records (PCEHR) system, Professor Owler said policymakers and health system administrators needed to invest in the use of information technologies in providing health services.

He said doctors and hospitals had embraced IT in their everyday practice, but there was not the unifying structure to integrate these systems to ensure patients received seamless, well-coordinated and cost-effective care.

“Doctors have embraced IT in practices, particularly our GPs,” the AMA President said. “The problem is that all of these systems have been built up as silos, rather than allowing people to communicate and talk to each other. What we need to do is develop the ability to link that IT with the hospital.”

The previous Labor Government’s much-vaunted PCEHR was intended to provide part of that link, giving patients and their doctors access to their medical records, wherever and whenever they were needed.

But its adoption has fallen far short of expectations amid concerns from the AMA and others that the ability of patients to edit their record had fatally compromised its usefulness as a clinical tool.

An Abbott Government-commissioned review called for an overhaul of the system to make it opt out and to curb the extent to which it could be altered by patients.

The AMA President said that, over time, the PCEHR had morphed into a “sort of grandiose plan” as people pushed for more and more features, and in the end it outgrew any usefulness.

“What we need to do with the PCEHR is scale it back, allow it to be the vehicle that allows us to do what we need to do – provide the clinical information between doctors, allow that doctor-to-doctor communication, so that we can actually know what people are saying to each other. That’s the sort of direction the PCEHR needs to go down.”

Professor Owler lamented that $1 billion had so far been wasted on the scheme, but said that should not deter governments from investing in IT for the health system.

He said the ability to quickly and seamlessly share information would not only improve the efficiency of the health system, but also reduce unwanted clinical variation, delivering improved health outcomes for patients and reducing costs through more effective treatment.

The AMA President said that on a trip to the United States last year, he had seen first-hand how hospitals in Chicago and Washington DC equipped with advanced IT systems were able to use sophisticated techniques like predictive analytics to improve the quality and efficiency of the care they provided.

“They can actually predict for a patient with certain characteristics, what should be done to prevent that patient from developing a disease, or they can predict if that patient is likely to get into trouble within the next few months. And so they’re more pro-active about trying to intervene,” he told the National Press Club.

“That’s the sort of direction, that’s the…smarter way, that we need to be heading.

“Unless we have that sort of infrastructure that is being developed that reduces the waste, that reduces unwanted clinical variation, then we are always going to continue to struggle.”

Professor Owler said there was “no reason” similar systems could not be used in Australia.

“There’s no reason why, in a country of 24 million people, we can’t do this. There are regions in the United States where they have systems that cover a population that’s larger than that,” he said. “So, there’s no reason why this cannot be done. It just needs some resolve, and it needs to focus on what we need to do to make the system work.”

Adrian Rollins

Plan for future, no more piecemeal cuts: Owler

The foundations of the nation’s health system are being undermined by a dangerous period of policy drift characterised by piecemeal approaches to major challenges, AMA President Professor Brian Owler has warned.

In a major televised speech, Professor Owler bemoaned a lack of vision and resolve among the nation’s political leaders on health, and called for the formulation of an overarching National Health Strategy.

He said that too often, the slogan that health care should be about the ‘right care, right place, by the right person’, had become little more than code for cost shifting and responsibility ducking.

“A long-term, bipartisan National Health Strategy may be difficult to achieve, but allowing our health care system to meander risks its future, and allows its foundations to be undermined piece by piece,” the AMA President said. “A National Health Strategy should guide our health policy, our decisions, and any future reform of the health care system.”

Professor Owler’s call received strong backing from the Australian Health Care Reform Alliance, a coalition of peak health groups, which said the AMA President’s speech was “a wake-up call” on the need for national health strategy and greater focus on preventive and primary care.

“Apart from a focus on funding cuts with little evidence of their value and long-term impacts, the Government has not articulated its values and intentions to tackle the variety of urgent issues reducing the effectiveness and fairness of our health systems,” AHCRA Chair Tony McBride said. “Saving money by randomly cutting services, such as funds for…public hospitals and…for NGOs appears to be the extent of the Government’s vision for health.”

The outlook for health has for years been clouded by unresolved Commonwealth-State tensions and disagreements over funding and lines of responsibility.

Professor Owler said a national leaders’ retreat held last month to consider the division of health responsibilities and funding as part of reform of the Federation was a welcome first step, but talks limited to rearranging tasks or raising a little more revenue by themselves were not enough.

He called for a thoroughgoing reassessment and change in the way health is considered by governments.

“Health should not be an annoyance – a concerning budget line to be dealt with,” he said. “Health is an essential ingredient to any economy.

“We need to see health care expenditure not as a waste, but as an investment.”

The AMA President held up the Federal Government’s approach to Indigenous wellbeing as an example of the muddled and ineffective policymaking that can arise in the absence of an overarching strategy.

The Commonwealth has instituted a crackdown on truancy among Aboriginal children and carrot-and-stick measures to boost Indigenous employment.

But Professor Owler said that, by neglecting health, the Government’s strategy would achieve only limited success in closing the gap.

“The lack of focus on health is one of the reasons why I struggle to understand the Government’s Indigenous advancement strategy,” he said. “Making kids go to school, encouraging young people to get a job, and making a safer society are all noble objectives. But health must underpin these strategies, particularly when it comes to Closing the Gap.”

The AMA President said a more honest and incisive assessment of the health system was needed to identify and take advantage of opportunities to achieve better and more cost-efficient care.

He said that, contrary to the claim of politicians, health spending was not out of control, though he acknowledged that scarce health dollars could be used to greater effect.

Rather than trying to hold down health spending by rationing access to care and other punitive measures, Professor Owler said a smarter approach was to drive dollars further by improving health system integration, particularly through the use of information technologies.

In addition, he said, governments should invest in general practice to help care for patients with complex and chronic conditions and to upgrade preventive health initiatives.

“Investment in general practice is essential if we are going to keep people well and in the community,” the AMA President said.

“Seven per cent of hospital admissions may be avoidable with timely and effective provision of non-hospital or primary health care.

“Our family doctors are the cornerstone of chronic disease management. They need to be supported to do this work with investment, funding, and resources.”

Mr McBride said that the Government should search for efficiencies before resorting to rhetoric and fearmongering about “unsustainable” health expenditure: “This means being smarter about what services we fund, not just cutting them.”

Adrian Rollins