Addressing Sexual Harassment and Gender Bias: Mandatory Modules Are Not Enough

Sexual harassment (SH) and gender bias (GB) continue to be problems in academic medicine. Our department of family medicine (FM) found that SH and GB were frequently experienced by most women, yet most were hesitant to report or respond. ¹ Respondents cited fear as a barrier on a continuum of interpersonal-level fear of reporting, from being seen as someone who “takes the fun out” of work, to “losing opportunities for career advancement.” ¹ Respondents’ experience of SH and GB is associated with lasting psychological effects that mainly spared the men in our department. ² These findings are consistent with those reported in other disciplines.

Organizations have responded to SH and GB with mandatory trainings and policies intended to mitigate both. The literature on trainings about SH and GB is based on workplace and college campus interventions and not guided by any theoretical model. ³ There is no long-term data on whether participation in these trainings changes culture or behavior. ⁴

The National Academy of Science, Engineering and Medicine (NASEM) Report, The Sexual Harassment of Women, states “…the cumulative result of sexual harassment in academic sciences, engineering, and medicine is significant damage to research integrity and a costly loss of talent in these fields.” ⁵ The authors encourage structural interventions to improve transparency and accountability, cultivate respect and civility, diffuse the power structure, and reduce isolation.

Based on encouraging results from the diversity training literature, the NASEM monograph recommends that trainings occur in-person, be tailored to group needs, include active participation, and change knowledge and behaviors rather than only attitudes. We believe it is also critical to include the role of bystanders (encouraging upstanders who actively respond despite potential personal or professional risks), ⁶ and to address the context.

We explored the lived experiences of our faculty and learners through focus groups. ^{1, 2} We then presented our findings to faculty and triangulated data with faculty feedback and discussion of the data. Based on these results, we developed trainings to reinforce the department’s stance against harassment and discrimination, to develop shared behavioral expectations and to educate all members of our department about policies and procedures.

We used an annual resident and faculty retreat to practice skills in addressing SH and GB from patients. We started with a patient focus, believing these scenarios were psychologically safer than experiences with colleagues/faculty, and then moved to experiences with colleagues. Faculty trained in Theater of the Oppressed (TO), or Forum Theater techniques ^{7, 8} led this workshop. The facilitators established an atmosphere of emotional safety to collaboratively develop and practice responses.

During two regularly-scheduled faculty meetings, we assigned small groups to examine case scenarios of SH and GB drawn from our data, asking teams to develop responses. Then the groups came together to discuss strategies and recommendations. This exercise focused on building skills, while acknowledging a range of individual responses, the importance of recognizing shared values and developing a community of proactive bystanders. See Table 1 for demographics and Table 2 for workshop and case details.

We conducted a χ² test to determine how well the survey sample generalized to the members of the department across the roles (eg, physician, nurse practitioner, and resident). Results indicated that the proportions of respondents by role were not statistically significantly different (P=.259).

We surveyed all residents and faculty (n=100) using a 16-item retrospective pre/postsurvey (See Appendix Table A).⁹ We included “recognizing” as a separate category acknowledging that additional challenges may prevent responding or reporting even when the behavior is recognized. We surveyed all faculty and residents because our ultimate goal was to change the culture and experience of the department. The survey occurred in the following academic year and included respondents who had not attended trainings and interns who had not been present in the department at the time of the trainings.

Fifty respondents completed the survey, including 26 faculty (behavioral health, nurse practitioner, and physician faculty) and 24 trainees (family medicine physician- and nurse practitioner residents). Most (56%) of the respondents attended at least one training.

All differences between perceived pre/post confidence and skills were statistically significant (P<.05). The largest changes were in recognizing GB and confidence in reporting both SH and GB Table 3.

Respondents reported frequently using skills learned in the 6-month posttraining period, with 55% recognizing GB during this interval. Many reported responding in the moment as a target (22%) or a bystander (30%). Eleven percent of respondents reported GB to a departmental leader and 5% reported GB to an institutional leader. Similarly, 17% recognized SH during the 6-month time period, 7% reported to a departmental leader and 2% reported to an institutional leader.

In academic medicine, a one-time series of trainings is unlikely to yield long-term change, as faculty and residents turn over. Mandatory online training modules may increase short-term knowledge and fulfill regulatory obligations, but are unlikely to reduce the frequency of GB and SH. ³ Our results must be considered in light of the goal to transform institutional culture and improve the behavior of all members with regard to SH and GB.

We surveyed all faculty and residents, regardless of training attendance. We observed increased confidence in each domain surveyed although statistical significance was reached only among attendees. This may indicate that informal conversations outside the trainings changed behavior. We believe community awareness of the ongoing conversation in the department is itself an intervention and departmental prioritization of this work helps to decrease fear of retaliation. We assessed changes once, approximately 6 months after the last training. Additional research is needed to determine whether similar interventions result in longer-term change.

Some department members who may have benefited from attending voluntary training did not participate, highlighting a challenge for all institutions. Mandatory education conflicts with the main tenets of adult learning ¹⁰ and Self-Determination Theory, in which autonomy is a key driver of an individual’s motivation to make a behavioral change. ¹¹ We suggest that those who require corrective action be managed and mandated through the relevant institutional process. Additionally, we did not ask if confidence in this behavior is at different levels when the behavior involves a colleague, personal behavior, or a patient.

A retrospective, pre/postdesign eliminates a problem with traditional pretests in that participants may not be aware of what they do not know. This design can introduce bias as individuals resist reporting lower or unchanged skills. Further, a person’s reported knowledge prior to the training may not be accurate, as internal standards or values may have changed through participation in the training. ¹²

Ongoing trainings represent a challenge within academic medicine given competing priorities for educational time. Our department is committed to at least annual workshops for all faculty and learners that are in-person, tailored to group needs, include active participation, and build skills. To further reinforce individual accountability, we now require specific discussion of diversity, equity, and inclusion contributions in all faculty annual reviews. Culture and behavior change take time and resources; understanding the lived experiences of the group allowed us to create valid, tailored trainings.

This work occurred within one FM department at one large academic medical center. We recommend that other departments and institutions adopt similar processes. When all faculty and trainees are aware of institutional expectations and confident speaking about their concerns, we will be closer to the culture we all deserve.