Being Brave

“But one thing is certain:

If we merge mercy with might,

and might with right,

then love becomes our legacy

and change our children’s birthright...

For there is always light,

if only we’re brave enough to see it”1

This month’s issue begins with a qualitative study conducted by a team of researchers from the University of Rochester’s Department of Family Medicine. This team, led by Holly Russell, MD, MS, explored barriers and facilitators to reporting and responding to gender discrimination and sexual harassment within their own department.2 This was brave, and inspiring, and—as it was done extremely well—also lays out an educational roadmap for those moved to replicate this important work. The women editors of Family Medicine collaborated on this editorial, after recognizing the strength of shared narrative highlighted by this study. The italicized quotes that follow are reflections from this team.

The article starts by describing the pervasiveness of gender discrimination and sexual harassment in medicine, citing studies that reveal most women clinician-researchers and almost all women residents have experienced gender discrimination during their careers, with one-third experiencing sexual harassment.3,4 Discrimination must be ubiquitous to support such statistics, however the frequency uncovered by this work surprised even some members of Dr Russell’s research team and department. This is understandable, as it is easiest to believe that “almost all” means everyone else, rather than the more logical truth that it includes us all. But as this research team demonstrated, and what our society is discovering, is that being brave enough to see also suggests one is responsible to challenge the darkness when revealed.

“Reading this paper I feel weary—soul weary. I have lived most of these comments, as have other women in my generation. Often I told myself ‘This is just the way it is. Things will change.’ As a senior, a leader, it is my job to support our residents and faculty, so part of me feels like a failure too. Could I have done more?”

People are discriminated against in many ways. Dr Russell and her team focused on patient and workplace discrimination, but inequities exist throughout our systems and institutions. Gender pay is not equal and payment systems are designed to reward problem-focused and procedural visits, disincentivizing the longer, more comprehensive visits often expected of women physicians.5,6 In academic medicine, women and people who identify as minorities are less likely to achieve promotion, hold leadership positions, have high-impact first or last authorship positions on publications, or be on editorial teams,7-13 a longstanding inequity once again demonstrated by a second article in this issue, led by Tilden Keller, MHA.14 Advancement and leadership practices that reinforce existing structures will always risk disenfranchising those who don’t already belong, and structural discrimination impacts career trajectories. Recognizing how inequity might have hindered another’s career requires humility, and needs each of us to acknowledge that an individual’s story may represent truth, especially when that story has a different cadence than our own.

Once we admit that unseen15 discrimination and harassment exists in our own worlds, and restrains our own people, we must also question the assumption that we know where it is. People who experience harassment formally report at extraordinarily low numbers, with those with intersecting marginalities more likely to be harassed and less likely to report.16 Despite expressed intention of protection, reporting is associated with both perceived and actual risk. Asking regularly and often, utilizing validated climate surveys,17 offering focus groups and exit interviews, and allowing for anonymous reporting are all strategies that can lead to better understanding.16 And true to the Hawthorne Effect,18 when we invest time to research we also impart importance to the inquiry.

“As her friend and confidante, I saw him differently, but pretended otherwise. Was it for her sake, or his, or mine? I still don’t know. He was quietly moved to another clinic, only to return to the faculty roster after a few years. We wonder: did he learn his lesson? Or is he doing it again?”

It is a daunting task to change the world. But that call becomes manageable, and even urgent, when we consider changing our own hallways, offices, or programs. In those spaces we have power, and can promote a culture that recognizes, accepts, and celebrates differences.19 And if we are able to create enough spaces in which everyone can feel respected, we will eventually forge a legacy of support. Waiting for discrimination to disappear, or for it to age out, is not a strategy but instead a form of complacency, often fueled by indifference.20 And similar to relying on reporting structures, for those who profess to be trying,21 patience is quite simply not enough. Those affected by discrimination lack trust in the system’s response—a legitimate reaction when a system has not been responsive.

Instead, the National Academy of Sciences has published guidelines to help organizations transform their culture around discrimination and harassment. This report outlines several strategies that promote respect while confronting discrimination and harassment on individual, relational, and institutional levels. Such strategies include bias reduction and bystander training, the voicing of clear antiharassment policies, and progressive discipline that corresponds to severity and frequency of misconduct that can be used to correct behavior before it escalates.16 Starting the conversation in this way defines behavioral expectations, sets the ground rules for a group of people, and provides tools for those who are interested in being part of the solution.

“On the first day we were told we were lucky, because 30% of our class was female. And we were told not to waste that seat.”

The students and residents who will carry our profession into the next generation deserve to inherit a culture that values each and every one of us. The only way this will happen is if we dismantle the constructs that intrinsically support certain individuals while devaluing others, and then create kind and inclusively-empowering structures as replacements.

The most potent predictor of discrimination is the degree to which those within the organization perceive that it is tolerated.16 This is both a sobering and an empowering truth. Understanding the culture around discrimination and harassment within our organizations, and doing the work it takes to change that legacy on behalf of all marginalized and vulnerable populations, will benefit us all.16 We need to shine the light on our institutions and understand how our people—all of our people—are being treated, for to face that truth is to take our first step toward change.22 It is time to be brave.