SGO Ethics Series: Ending the Mistreatment of Junior Gynecologic Oncologists | David Shalowitz, MD, MSHP
David Shalowitz, MD, MSHP
The afternoon after a patient’s intraoperative cardiac arrest, the chief of gynecologic oncology asked the operating fellow “how it felt to kill [his] patient.” Later that week, after a disagreement about a transfusion threshold, the same oncologist asked the fellow why he “tries to hurt his patients.”
The future of our profession is threatened by the bullying, harassment, and abuse of junior gynecologic oncologists. To those who believe that mistreatment is rare: a systematic review of academic bullying in medicine including 68 studies with 82,349 respondents found that abuse and punishment of victims through overwork, isolation, blocked career advancement and threats to academic standing are common.1 Sixty-seven percent of gynecologists have experienced workplace discrimination,2 and 64% of gynecologic oncologists have experienced sexual harassment or gender discrimination.3
To those who believe that mistreatment of junior clinicians has no important consequences: abuse of clinicians by other clinicians is associated with depression, substance abuse, self-perceived loss of clinical ability, termination of employment, and hospitalization for coronary and cerebrovascular disease.1 Disrespectful behavior by senior clinicians is strongly associated with junior clinicians’ burnout and suicide.4–6 No more data are needed to establish the prevalence and urgency of this threat.
And to those who believe that mistreatment should be dealt with through existing reporting infrastructure: only 15% of gynecologic oncologists who experienced sexual harassment or gender discrimination reported mistreatment due to fear of inaction or reprisal, and their concerns are well-founded: 64% of those reporting mistreatment were dissatisfied with their institution’s response.3 This is not surprising: human resources departments exist to protect their parent institutions, not to advocate for individual employees who have been mistreated. Furthermore, institutional leadership may be conflicted between advocacy for mistreated junior clinicians and support of senior clinicians into whom the institution has invested substantially and stands to lose substantially if misconduct is acknowledged.
After reporting being inappropriately touched in the operating room to her section chief, a gynecologic oncologist has her block time decreased and changed weekly. She notices that she is now being assigned to outreach clinics more than her partners. When she objects that her schedule now makes it disproportionately difficult for her to meet productivity targets and the irregularity adversely affects her family life, she is told that she needs to be more flexible and that her home issues are for her to figure out. She considers changing institutions but worries that her chief will portray her as “difficult” to potential employers.
We cannot ignore the effect that the “small world” of gynecologic oncology has on our colleagues’ likelihood to report abuse. Raising concerns about mistreatment by gynecologic oncology faculty or staff may adversely affect completion of training, ability to care for patients, or opportunities for professional advancement. Anonymity is often impossible, transfer to another training program may not be feasible, and physicians seeking jobs outside of a toxic environment may need references from their abusers. Fear of retribution is powerful: even if a gynecologic oncologist decides to leave an institution because of mistreatment, the prospect of negative references and leverage of the “whisper network” to ensure that the victim is blamed for their departure may be sufficient motivation to remain in an abusive environment. Those oncologists who survive their mistreatment – perhaps literally – may normalize the behavior they experience and inflict similar damage on gynecologic oncology’s next generation.
A department chair is overheard at a national meeting confessing to a colleague that although a senior gynecologic oncologist is known to behave inappropriately towards OR staff and trainees, he hopes that she retires soon so that he can avoid publicly addressing her behavior, as it would not be “a good look” for the cancer center.
How can we protect and support early career gynecologic oncologists from abuse? A fundamental change is needed to our profession’s approach to the mistreatment of its junior colleagues. Sexual misconduct, assault, and suicide of patients are considered “never events” by the Agency for Healthcare Research and Quality (AHRQ) on par with wrong-site surgery, and substantial resources are routinely mobilized to ensure that these events do not occur. Moreover, the Joint Commission mandates root cause analysis after every sentinel event.7 Our colleagues deserve equal investment in protection against mistreatment and support whenever it occurs.
Junior and senior clinicians within all gynecologic oncology practices should conduct an honest assessment of internal processes – and people – who may directly contribute to or enable mistreatment. It is an abdication of leadership responsibility to “wait out” abusive clinicians; proactive measures are needed for culture change, and we owe it to our colleagues and their patients not to enable malignant behavior to transfer institutions along with clinicians.
Mistreated trainees should be encouraged to consider reporting a complaint with the Accreditation Council for Graduate Medical Education (ACGME), as complaints trigger an independent investigation, and motivate institutions to address mistreatment of trainees through the potential for reduced educational funding and diminished academic prestige. Mistreatment of junior gynecologic oncologists threatens our profession, and therefore also merits attention from professional organizations, including the SGO. While investigation and adjudication of individual incidents should be managed by the clinical practices and institutions in which they occur, advocacy for junior clinicians should come in part from SGO, as local institutions may not be as able or inclined to support victims of mistreatment. A diverse panel of advocates, working under the auspices of SGO to provide confidential support, mentorship, and to decrease mistreatment of junior gynecologic oncologists, would go far to combat the quiet perpetuation of abuse.
Importantly, most gynecologic oncologists are compassionate doctors and committed mentors. However, most of us also have either been mistreated by fellow clinicians or know someone who has. Let’s remember that hurt doctors hurt other doctors. Overwork, burnout, and isolation experienced by prior generations during training may be normalized, even considered beneficial, and serve as justification for continued abuse of younger gynecologic oncologists. Let’s end the cycle now. Gynecologic oncology needs to heal itself: we owe it to our colleagues, ourselves, and our patients.
The author would like to acknowledge colleagues who contributed to this piece but wished to remain anonymous due to the potential for retribution.
References
1. Averbuch T, Eliya Y, Van Spall HGC. Systematic review of academic bullying in medical settings: dynamics and consequences. BMJ Open. 2021;11(7). doi:10.1136/BMJOPEN-2020-043256
2. Brown J, Drury L, Raub K, et al. Workplace Harassment and Discrimination in Gynecology: Results of the AAGL Member Survey. J Minim Invasive Gynecol. 2019;26(5):838-846. doi:10.1016/J.JMIG.2019.03.004
3. Stasenko M, Tarney C, Seier K, Casablanca Y, Brown CL. Sexual harassment and gender discrimination in gynecologic oncology. Gynecol Oncol. 2020;159(2):317-321. doi:10.1016/J.YGYNO.2020.08.014
4. Hu YY, Ellis RJ, Hewitt DB, et al. Discrimination, Abuse, Harassment, and Burnout in Surgical Residency Training. N Engl J Med. 2019;381(18):1741-1752. doi:10.1056/NEJMSA1903759
5. What I’ve Learned from 1,710 Doctor Suicides – Pamela Wible MD. Accessed July 9, 2023. https://www.idealmedicalcare.org/ive-learned-547-doctor-suicides/
6. Bullying junior medical staff is one way to harm patients | Aeon Essays. Accessed July 9, 2023. https://aeon.co/essays/bullying-junior-medical-staff-is-one-way-to-harm-patients
7. Never Events | PSNet. Accessed July 9, 2023. https://psnet.ahrq.gov/primer/never-events
David Shalowitz, MD, MSHP, is gynecologic oncologist and director of health equity & community outreach at West Michigan Cancer Center.