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Blurred lines

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You’re working a night shift in the emergency department. One of your first patients of the night is a young male who has presented with hallucinations. You take him into a consult room and begin your history and proceed to a physical examination. While auscultating his heart he stares intently at your face the entire time and towards the end says ‘you’re very beautiful’.

An elderly man in an outpatient clinic waiting for the bathroom to become free stands next to you and your female colleague and proceeds to talk about your clothes, to call you young pretty girls and repeatedly interrupt your conversation to ask you what you’re doing for the rest of the day.

A patient you’re seeing in a follow up appointment is upset and talking about how he can’t find a job. He talks about how ‘they don’t hire people like me these days, they want’ – he points at you looks you up and down and says ‘I mean that as a compliment’.

Workplace bullying and sexual assault are widely recognised in the medical profession as a serious issue for junior medical staff and in particular females in the profession.

“Sexual harassment is associated with unwelcome conduct of a sexual nature by which a reasonable person would be offended, humiliated or intimidated”, including but not limited to “leering or sexual comments about a person’s body”, “sexually explicit jokes” or “intrusive questions or suggestive remarks.” (NSW Health, 2016)[1]

The documentation and policy implementation surrounding sexual harassment centres mostly around interactions between work colleagues. But what about misconduct that occurs from a patient towards a doctor or other medical professional?

It is not uncommon for doctors and nurses to have to deal with an aggressive or disgruntled patient. We have methods to deal with these situations and are aware of the ways to protect each other and ensure safety of everyone dealing with them. We can use verbal de-escalation, we can bring extra team members in for support, we can call a code black and at the extreme we can use medications. However, there is a large gap in the teaching, or even talking, about the ways in which we can handle contempt towards us from patients. How do we approach a patient who is ‘simply’ making inappropriate remarks, who is invading your space or making you feel just uncomfortable?

‘Often the work environment offers few supports for women doctors and they are subject to more incivility, bullying or harassment at work. Women can experience inappropriate sexual comments and behaviour, which may not be overt or intentional, but which are still demeaning.’ (RACP, 2013)[4]

Every time I am asked my age, whether I am married, told I’m young or pretty I wonder how often this affects male colleagues. Why should this be a daily part of my job, when for half of my profession it’s not? Maybe I should have a thicker skin but also, I know I’m not alone in feeling uncomfortable with some male patients in an isolated consult room and also that many of my colleagues have had worse examples of blurred patient boundaries than those relayed above. I’ve heard of peers who after making a call to a patient on their personal phone were stalked for weeks following. And while I have heard of many examples towards doctors, I cannot ignore the fact that nurses have these experiences tenfold.

The effects of these experiences can’t be underestimated. And although much of the data, like the policies, focus on colleague interactions, the damaging effects of workplace sexual harassment are undeniable. Sexual harassment in the workplace has been shown to be associated with long-term psychological distress [5]. In addition, early career workplace sexual harassment has been linked with long-term depressive symptoms which in turn have effects on career trajectory [6].

So, while there are clear avenues to report sexual harassment committed by someone you work with, how should you go about reporting sexual harassment from someone you care for? I wonder if I was to approach my senior or supervisor about feeling uncomfortable due to comments a patient was making, even if the patient hadn’t touched or made ‘obvious’ advances towards me, how they would handle the situation. I recall one example where on a small medical team the female registrar and myself made up the team when no consultant was rounding. We had a young male patient admitted with sciatica who on every review, was wearing only his underwear while sitting on top of the bed covers with arms stretched above his head, and I can only imagine what would be said if a female patient was doing the same thing to an all-male team. But who could we tell or talk to about this? What could we say to the patient (and could we say something to the patient)?

There are also situations when comments are made when you’re not on your own or only with female team members. Recently I entered a bedside space with my consultant and another team’s male registrar was taking a history from the patient. The patient stopped talking, loudly said hello and moved about in his chair.

He said to the registrar ‘Sorry I get excited when I see ponytails.’ It was not assault but it was demeaning. In these instances, as a female doctor you’re seen not as a professional but you are reduced to a ‘ponytail’ – an object. If your first interaction with a patient is one where you’re objectified or told you’re pretty or asked a question about your personal life – you immediately feel guarded with that patient, you’re worried about what they will say next and you don’t want your professional kindness towards them misinterpreted.

There are many challenges for women in medicine and sexual harassment, although less explicit, it is very real and very challenging. So, what can be done?

Is this a system problem, a societal issue or is it something that needs attention in early training years? The teaching and research is widening about protective factors for JMO mental health and institutions are becoming more committed to implementing these. The knowledge surrounding doctor-patient dynamics and sexual harassment are not so widely scrutinised but clearly this is an issue that needs attention. Some argue that workplace sexual harassment should be treated as a public health issue [2], and I would argue that regardless of the source of the sexual harassment there needs to be processes to deal with it. There needs to be some way to approach these behaviours rather than it just being something you debrief about with other female colleagues about some disturbing interaction you just had or asking your consultant to always be with you to review a particular patient so you have ‘back up’.

Some measures could include teaching on how to approach these kind of patient interactions in the way you would an aggressive patient, including how work peers who witness the incident can step in and support their colleague. Others might include in-hospital signage stipulating to patients that there is no tolerance for aggression OR sexual harassment. A message needs to be sent that our institutions are changing, along with many other issues in medicine, we are changing the culture in which we practice.

Please note names and personal information have been removed or changed to protect the author’s privacy.

This blog has been republished with the permission of onthewards and can be read at its original location at blurred linesonthewards is a free open access medical education website and not for profit organisation that aims to improve the availability of resources for medical students and junior doctors.

References

1. NSW Health Prevention and Management of Unacceptable Workplace Behaviours in NSW Health – JMO Module. 2016. [Accessed 30 October 2018]

2. Workplace sexual harassment is a public health issue and should be treated as such 2018. [Accessed on 17 November 2018]

3. Sexual harassment in the medical workplace. Australian Medical Association – Position statement (2015).  [Accessed on 17 November 2018]

4. Health of Doctors. The Royal Australasian College of Physicians – Position statement (May 2013). [Accessed on 17 November 2018]

5. Neilsen, M & Einarsen, S. (2012). Prospective relationships between workplace sexual harassment and psychological distress. Occupational Medicine, 62, 3, 226-228.  [Accessed on 17 November 2018]

6. Houle, J., Staff, J., Mortimer, J., Uggen, C., Blackstone, A. (2011). The impact of sexual harassment on depressive symptoms during the early occupational career. Society and Mental Health, July 1:1 (2): 89-105. [Accessed on 17 November 2018]

 

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