Operate with respect: how Australia is confronting sexual harassment of traineesBMJ 2016; 354 doi: http://dx.doi.org/10.1136/bmj.i4210 (Published 01 September 2016) Cite this as: BMJ 2016;354:i4210
- Amy Coopes, freelance journalist, Sydney, Australia
It has been a year since Gabrielle McMullin’s claims of rampant sexual harassment of trainees rocked Australia’s college of surgeons and triggered an unprecedented drive for cultural change across the medical profession.
McMullin, a vascular surgeon, stunned physicians and the public with a frank interview given on International Women’s Day in which she described an entrenched culture of sexism within the surgical profession and impunity for perpetrators of harassment and abuse.1
Relating the story of a neurosurgical trainee2 who was unable to find work in the public system after taking legal action against a senior surgeon for propositioning her for sex, McMullin made headlines by claiming that the trainee would have been better off agreeing to have sex.
The remarks sparked a firestorm in the press, unleashing a wave3 4 of similar stories that thrust the Royal Australasian College of Surgeons (RACS), which represents surgeons in Australia and New Zealand, and medicine more broadly into the spotlight.
“The reason it was such a huge story is that it is such a huge problem,” said McMullin.
Endemic bullying and discrimination
The college appointed an expert advisory group to examine the scope of the problem and find solutions.5 A comprehensive internal inquiry was launched, inviting surgeons, trainees, and international medical graduates to participate in an anonymous survey, online forum, and face-to-face interviews.
More than 3500 people came forward to share their experiences,6 which were published in September 2015. They detailed a culture of endemic bullying, discrimination, and sexual harassment where power imbalances meant junior staff were afraid to speak out.
Female trainees reported expectations of sexual favours in return for tutelage, being propositioned for sex or subject to repeated physical advances, and fielding sexual innuendo, gender slights, and comments on their appearance during surgery. Just 11% of RACS members are women.7
“I participated in the survey. It took ages and I felt a bit fragile afterwards,” said neurosurgical trainee Ruth Mitchell, who described the process for some as “digging deep into the abyss.”
She said, “I’ve heard a lot of awful things from trainees, and the advisory group report allowed others to see the extent and depth of the problem, which I found really helpful.”
Ultimately, half of all fellows, trainees, and international medical graduates reported having experienced bullying (39%), discrimination (18%), or harassment (19%).8 More than 200 respondents, some 7% of those surveyed, said they had been subject to sexual harassment, with half reporting more than one incident and 75% of cases perpetrated by surgical consultants.9
According to the report, a culture of fear and reprisal meant victims felt unable to speak out, and this was compounded by distrust in the process for handling complaints.
RACS president, David Watters, apologised unreservedly after the findings were released, acknowledging that too many surgeons had been silent bystanders as well as perpetrators.10
David Hillis, the college’s chief executive, said it had been a difficult but necessary process for the college.
“It needs to be frankly stated that our behaviours were not meeting the standards we had set for ourselves and, importantly, that the community believes we must maintain,” said Hillis.
“Lip service was being provided to the required standards, but the difficult task of ensuring the standards were maintained was not being undertaken.”
A hierarchical, authoritarian environment with poor diversity and little support for victims or whistleblowers had allowed a toxic culture to take hold, and Hillis said the problem started at undergraduate level, where “teaching by humiliation” was the default.11
These problems do not seem to be confined to surgical medicine. A majority of Australian medical students—74% according to one recent study12—have experienced shaming during teaching, and harassment and discrimination has been shown to be widespread in medical training globally.13
Carmel Tebbutt is chief executive of the Medical Deans of Australia and New Zealand (MDANZ), which represents the two countries’ 20 medical schools.
She said MDANZ was working closely with the college of surgeons and other groups to ensure a “safe environment for all those involved in the teaching, learning, and practice of medicine.
“Medical deans believe all students have the right to learn medicine in an environment free from bullying, harassment, and discrimination,” she said.
Mitchell said surgery was far from alone. As chair of the college trainees’ association, she sits on the Australian Medical Association’s Council of Doctors in Training and said she was “convinced it’s a profession-wide problem.”
Several other colleges subsequently commissioned internal surveys, and Mitchell said the “same picture emerges with regard to bullying, discrimination, and sexual harassment.”
The Australian Medical Association, representing the country’s doctors and medical students, described cultural change as a matter for the “whole profession to confront and resolve.”14
Previous studies have shown that at least 25% of Australian doctors experience persistent bullying and harassment,7 and a large mental health survey of the medical workforce conducted in 2013 showed serious problems.15 One in five medical students and one in 10 doctors reported having suicidal thoughts in the past year, and bullying (4.5%) and racism (1.7%) were among the stressors.
Many who came forward to the RACS inquiry spoke of the crushing toll their experiences had had on their psychological wellbeing, including thoughts of suicide.16
“There are far too many stories about attempted or completed suicide in the junior doctor space, and this is only the tip of the iceberg of the extent of poor mental health outcomes from a toxic environment,” said Mitchell.
Mitchell was recently named the Australian Medical Association’s inaugural Doctor in Training of the Year for her work mentoring and advocating for young doctors.17 She was commended for “maintaining the respect of her senior colleagues” while doing so—“a fine balance to strike.”
“If we really want change to happen we have to keep everyone at the table,” she explained.
“We want to avoid more senior members of the tribe feeling like they are dinosaurs to be phased out or replaced. They are our elders, and we need them. But sometimes we need them to be better elders than they are right now.”
In July, it unveiled a mandatory new training module on discrimination, bullying, and sexual harassment20 for its 7000 members and an updated code of conduct explicitly identifying these behaviours as breaches.21
The previous code,22 which was last revised in 2011, stated that a surgeon should “seek to eradicate bullying or harassment from the workplace” but described this conduct and discrimination as a breach only in the context of teaching or mentoring—not when interacting with colleagues more broadly. Sexual harassment was not specifically mentioned.
The college has signed memorandums with major hospital groups and health agencies to improve resolution of disputes and training of doctors with teaching responsibilities. It has also rolled out an anonymous complaints process and free confidential counselling for staff.
Hillis said the success of the programme would not be known for some years, with cultural change across two countries and multiple levels of government in more than 350 hospitals a “daunting challenge.”
Mitchell commended the actions of a “few courageous people in the right place at the right time” for lifting the “cone of silence” on a toxic culture that had prevailed for far too long.
“There is a long way to go, but for the first time in my career I feel hopeful and optimistic about my profession because I see people taking serious action and making changes,” she said.
McMullin would like to see the college go even further, calling for black boxes to be installed in operating theatres to record what is said and done when the gloves are on. Until then, she said, it will be “business as usual for a small group of individuals.”
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.