You might call him a monster — a man, given power, authority, and access to women’s bodies, who abuses his position to almost unbelievable ends. He’s Larry Nassar, the USA Gymnastics doctor who molested more than 100 young athletes during so-called clinical care. Or Robert Hadden, the Columbia University obstetrician at the center of a class-action lawsuit alleging he digitally penetrated, fondled, even licked women on his exam table for more than 20 years.
But monsters are fiction. Perhaps a more apt metaphor for cases like these would be a virus — something that festers, and something that spreads.
“The minute we have an individual case that’s so egregious, the first question should obviously be, ‘Well what was the system that grew them?’” says Esther Choo, MD, MPH, Associate Professor, Emergency Medicine, Oregon Health & Science University (OHSU). “They had a rich petri dish. They had to have a milieu that was nutritious to them.” That’s why she and a group of 50 of her colleagues and peers have come together to form Time’s Up Healthcare, the organization’s next industry-specific offshoot. The healthcare field, they say, is friendly to viruses like these.
“These problems are so egregious that it basically becomes one monster,” Dr. Choo says. “I mean, licking patients during ob/gyn exams? If I had to make up a story I wouldn’t make it that bad.” Of course she didn’t have to make it up. In her years of research into gender discrimination in medicine, women have brought their monsters to her. Once, while preparing to give a talk about workplace violence in emergency medicine, she took an informal poll of her colleagues. “I got all these emails where people were like, ‘Well somebody swung a knife at me, but they missed. Does that count?’ Or ‘someone said they want to rape me, does that count?’ The questions were so revealing. What kind of environment did we create where you’re wondering if that was violence,” she asks.
Dr. Choo’s peers in the eight-person steering committee driving Time’s Up Healthcare compared the environments in our hospitals, medical centers, and academic-research institutions to a locker room and a firehouse, a charged-up scene where lives hang in the balance and testosterone is king.
Photo: “Our fundamental proposition is that women are different than men, and if you bring more of us into healthcare in safe, respectable, and equitable workplaces, the workplace gets better and healthcare gets better," Dr. Choo says. "We take what is supposed to be a ‘weakness’ for women, and turn it on its head: Communal is good. Communal is how we sustain the energy for this.”
“I knew when I became a physician that I was entering a boys club of a certain kind, in the sense that all the levers of power for the most part were controlled by men,” says Jane van Dis, MD, Ob/Gyn, Ob Hospitalist, and one of the steering committee members of Time’s Up Healthcare. As a woman in her early career, she says she felt lucky to have been let in. “You want to adapt to the culture and climate, and you want to succeed. That means you’re going to ignore the pat on the butt, the hand on the leg, and the comments — so many comments — about one's breasts and sex life, one’s fertility plans, and loss of virginity. It’s like the locker room, but it’s the halls of medicine.” Operating rooms, she says, are the most scatological places of all.
Being hazed in an emergency room during her medical training is what alerted Jessi Gold, MD, MS, who is now an Assistant Professor of Psychiatry at Washington University in St Louis, to the toxic work environment in medicine. She was a student, looking on as doctors worked to save a patient who had been shot. A supervisor yelled for her to jump in — to grab the man’s heart in her hand and attempt to massage it back to rhythm, which takes expertise and experience she did not yet have. She tried, though, afraid to look scared or incapable, squeezing and squeezing to save the man’s life. A room full of men watched, in on the joke that the patient was already dead.
Dr. Gold (pictured second from the left, above) heard similar stories from friends: one had something thrown at her in an operating room, several were ignored or insulted by patients who expected to see a male doctor instead. At the same time, she began seeing Drs. Choo and van Dis in esteemed medical journals (and on Twitter), agitating about gender harassment and discrimination. And then, she saw the Golden Globes. “I thought, well, if it happens in their industry, and they’re uniting with farmworkers and all these other industries… I thought it was weird that these conversations were happening in parallel but not joined.” So, she joined them. She sent a tweet to Time’s Up saying, hey, there are some women doctors I think you need to talk to. And the rest is soon to be history, as Time’s Up Healthcare officially launches on March 1, 2019.
Photo: “I knew that my mother was sexually harassed in her workplace, and I had no reason to think it would be better for my daughter,” says Dr. Jane van Dis. Together with Dr. Esther Choo, she founded Equity Quotient, a consultancy looking at gender discrimination in medicine. The goal was for executives to hire them, “with the idea of looking at their culture, in terms of where that institution’s secrets lie. What we found is they are not actually interested in doing that.”
“Time’s Up is [about] everyone coming together in a vocal and visible way and saying this isn’t something we’re okay with anymore. We shouldn’t ever have been okay with it, but this isn’t something we’re going to keep doing,” says Dr. Gold, who is now a steering committee member. And while Time’s Up is for furthering safe, equitable workplaces for everybody, its wide reach should not be misconstrued as a lack of focus. Since it launched in January 2018, the organization has been making targeted attacks on fields that are particularly harrowing for women — entertainment, advertising, venture capital.
For healthcare, this means connecting women who work in isolated situations, from a home health aid to a pharmaceutical rep to a nurse or doctor in a small private practice, to the larger movement and industry. It means educating the leaders in their field about what has been occuring right under their noses. It means presenting solutions, including long-term culture shifts (changes in hiring, retention, and promotion practices, for example). It means impacting policy, for which they've tapped steering committee member Laura Stadum, a lawyer and Director of the Affirmative Action and Equal Opportunity Department at OHSU. There are immediate solutions, too, like providing financial support for women to take legal action.
That’s where the Time’s Up Legal Defense Fund comes in. To date, it has received 4,094 requests for help in cases of workplace harassment or discrimination; it has more than 800 attorneys available to take those cases, and millions of dollars in donations to defray the cost. Just over 10 percent of the claims (where an industry is disclosed) represent people who work in entertainment, the industry in which Time’s Up made its splashy debut. Women in medicine are in a close second, with 8 percent.
A growing body of research explains why. As many as 30 percent of female physicians report being sexually harassed on the job; 33 percent of nurses have experienced physical violence and bullying — a quarter have been sexually harassed. Meanwhile, 50 percent of female med students will experience harassment before they even graduate. In 2018, the National Academies of Sciences, Engineering, and Medicine released a comprehensive report into the climates of harassment across STEM fields. It found working in academic medicine to be the worst.
Reshma Jagsi, MD, Professor and Director of the Center for Bioethics and Social Sciences in Medicine at the University of Michigan, is something of a legend for her research on sexual harassment in healthcare. She says there have been dozens of studies — “dozens, plural” — tracing the effects of workplace harassment to everything from anxiety to depression, and performance of the individual being harassed and of their larger team. “Absenteeism, tardiness, withdrawal from the workplace. Really unfortunate and costly outcomes that we would want to prevent,” she says.
Photo: “After I came out as trans, a lot of people came to me and shared their stories: individuals who had been discriminated against, bullied, harassed,” says steering committee member Michaela West, MD, Ph.D., Adjunct Professor of Surgery, University of Minnesota. "I’m in a position at this point in my career that I don’t have anything to lose. I can be speaking out, and giving those individuals a voice."
Individual emotional trauma isn’t the only side effect — though that would be enough of a reason to say it is time for a change. This is also creating a feedback loop where many women simply cannot get ahead. As Dr. Jagsi explains, sexual harassment is more common when women are in the minority, not just in numbers but in terms of their access to power and authority. Just as the entire Hollywood machine seems to have been erected in such a way as to keep men like Harvey Weinstein as the centers of power — and force down or out anyone who dared cross him — reports like this illuminate that our very hospitals, doctor’s offices, and academic health institutions function in much the same way.
Consider the films that haven’t been made because of a brain drain that happens when women are overlooked, actively shut out, or fleeing the profession for self-preservation. Now consider we’re also missing out on advances in our own healthcare.
This may seem odd to anyone who is met by a (female) receptionist at their doctor’s office, has their vitals checked by a (female) nurse, and is even cared for by a female physician. Yes, 80 percent of the medical workforce is made up of women, according to Bureau of Labor statistics — but only 11 percent of the industry’s executive seats are. Exactly zero women serve as CEO of a Fortune 500 healthcare company (though if you include health and life insurance corporations, there are three).
“When a lot of people think of diversity and equity, they think about recruitment only,” says Rhonda Graves Acholonu, MD, a pediatrician and the Co-director for the Leadership, Engagement, and Diversity Program at the Children’s Hospital at Montefiore, and a steering committee member of Time’s Up Healthcare. “They think about the boxes to check and they don’t think about retention. They don’t think about the climate those people are working in.”
Photo: “A lot of people say their work environment is free from harassment, and they have great policies in place, but the exact opposite is true for the people of color or for the women, and no one’s addressing it,” says steering committee member Tiffany A. Love, Ph.D., a nurse practitioner and Regional Chief Nursing Officer at Coastal Healthcare Alliance.
As Sharonne N. Hayes, MD, cardiologist, founder of the Women’s Heart Clinic, and Medical Director for the Office of Diversity and Inclusion at Mayo Clinic in Rochester, MN, explains, “There’s a little bit of magical thinking going on, or ‘it doesn’t happen in my backyard.’” She references subtle discrimination like “mommy tracking” (excluding women who do or may have children from prestigious roles, or hitting them with pay cuts for taking maternity leave, which is common in private practices where doctors’ pay is tied to the hours they bill), or even disproportionately appointing women to CEO positions when an organization is in crisis. Working to change these entrenched inequities — even to explain them — has felt like “screaming into a hurricane,” Dr. Hayes says. There are a lot of good people in medicine who want the best for everybody, but “leaders gotta lead. If you expect the victims to be continually fixing things and explaining it to people, we will not get where we need to go.”
And inclusion can't just be paid lip service in a med school's brochure. This is an industry where representation really matters: Studies have shown that patients experience better health outcomes when treated by a diverse medical team (specifically when the race or gender of their doctor mirrors their own). Not only that, but anyone’s at risk of receiving subpar care when their doctors, nurses and support staff are working in stressful or abusive conditions. Something as simple as making sure patients have privacy can add to the caregivers’ stress.
“There are always rooms where the doors lock. There are always opportunities to corner somebody in a space. Every clinic has rooms you can be pushed into or barricaded,” explains steering committee member Dara Kass, MD, Assistant Professor of Emergency Medicine, Columbia University and the CEO of FeminEM, an organization for women in emergency medicine. Patients can pose a risk to staff, but these windowless rooms give anyone the opportunity to attack.
Janie Harvey Garner, RN, who founded an online community for nurses, says sexual assault and harassment is so commonplace it’s the “dirty little secret” of nursing. “The threat of sexual violence causes nurses to leave the bedside to avoid being treated like prey by those who never have to answer for their behavior." She says half will quit within two years on the job, which means half of the workforce is always new, and inexperienced.
Photo: “The whole Time’s Up movement started with women in Hollywood using their influence and voice to advocate for people who didn’t have the same thing, and that’s what we’re doing in healthcare,” says Dr. Dara Kass. We get to stand up, and with, and for the women that are working at an hourly rate, that are vulnerable to get fired, that don’t feel that they can speak out.”
That the workplace seems set up to harm its female employees can feel like a trap, and the only way through is out. “If you can’t solve the problem, you feel like you have no voice and no advocate, then you leave,” Dr. Dara Kass says. “I was watching women leave jobs they had trained so hard for, for so long — in all fairness at the cost of debt and their twenties — and I didn’t want them to leave. I thought there was a better way.” She and other founding members of Time’s Up Healthcare echoed that the better way is speaking out, which they feel safe and obligated to do now as leaders in the field.
When Time’s Up launched, it did so with star power — it had Natalie Portman, it had all those celebrities wearing black at the Golden Globes — and it’s fair to say the pop-culture moment brought public attention to the cause. In the case of Time’s Up Healthcare, the industry itself is its superpower. Healthcare represents one-sixth of the American economy and 13 percent of the country’s workforce. The problem of harassment and inequity is everywhere in medicine, and so everyone in medicine should be galvanized to fix it.
After a case of sexual harassment at the Yale School of Medicine five years ago, which the university responded to in part by moving the accused from one prestigious position to another, more than 1,000 students, faculty, and alumni signed a letter demanding he be removed. “People were saying ‘we should be better than this,” says Lynn Fiellin, Associate Professor of Medicine at the Yale Child Center and the Yale School of Medicine, and a founding member of Time’s Up Healthcare. Now, Yale is a signatory of Time’s Up Healthcare, meaning it will state publicly that it’s dedicated to establishing a safe, equitable workplace. Others include the Mayo Clinic, which has 65,000 employees across the country, and medical schools at Brown, Drexel, and the University of Wisconsin.
Time’s Up Healthcare is also tapping into partner organizations that have been fighting versions of this battle for decades. The American Medical Women’s Association (AMWA), for example. The American Nurses’ Association, long at work on pay equity and safety, and the Service Employees International Union (SEIU), which looks out for workers like hospital janitorial staff and home health aids.
Photo: “At the end of the day, we all went into this to take care of patients,” says Dr. Acholonu. “I went into this to impact future generations, and if I’m in an environment that’s not equitable, that’s not safe, then how can I take the best care of my patients? That’s what Time’s Up Healthcare will do: Bring awareness to this and acknowledge it is impacting our patients.”
As for the Time’s Up Healthcare’s founding group, they are all volunteer. “Women are asked to fix, for free, what men impose in their paid time,” Dr. Choo says. But the movement hopes to one day hire a formal staff, with the help of sponsors. The scrubs brand Figs, which outfitted the women in this article, is on board. As of 10 a.m. on February 28, any of its scrub tops can be upgraded with a Time’s Up Healthcare logo, with proceeds benefiting the Legal Defense Fund (they cost $48, and are, by all reports, extremely comfy); Figs is also making Time’s Up compression socks, a must for people who work on their feet.
Part of the thinking behind the merch is that it provides an element of safety, either by acting like a secret self-empowerment boost (a scrub sleeve can be easily covered by a white lab coat). Uncovered, they’re a visible sign that the wearer is armed with the mighty force of a community that says, yes, Time’s Up. At the very least, they could begin a conversation, and that’s as good a starting point as any.
“I’m a firm believer in ‘name it to tame it,’” says Dr. Acholonu. “If you don’t name the problem, you’re not even going to try to fix it. Is it hard to change individual behavior? Absolutely. But there’s no way you’re going to change it if you don’t acknowledge it. So let’s start there.”