Clinical Ethics in Anesthesiology. A Case-Based Textbook

5. Practice issues

39. The abusive and disruptive physician

Stephen Jackson

A hospital’s busiest surgeon is universally disliked because of his persistent negative demeanor, punctuated by harsh and abusive outbursts that spare no category of healthcare provider, and often upset the efficient functioning of patient care areas. Over the years, this behavior has been tolerated without any effective attempt at correction or control by the medical staff. His list of surgeries has been delayed because the preceding surgeon (who is slow and marginally competent) took 2 hours longer than anticipated. The surgeon berates the OR secretary, technician and circulating nurse. Then as the anesthesiologist is transferring his patient to the recovery department, the surgeon demands that his case get started in short order.

The surgeon has stated in his workup that his patient is having a right inguinal herniorrhaphy – but the patient has related to the admitting nurse that she has left-sided symptoms and was told by the surgeon in his office that she has a left-sided hernia. In the preoperative unit the surgeon marks the right side as the operative site and convinces a somewhat recalcitrant – but otherwise timid – patient to sign an informed consent for a right-sided herniorrhaphy. The preoperative nurse, known herself for harsh verbal attacks against physicians and co-workers, calls the anesthesiologist to warn him of this potential for wrong-site surgery, and rails against the head nurse for assigning her to this surgeon’s patients. In the background the anesthesiologist can hear the surgeon berating her for making the phone call to him.

The behavior described in this scenario is experienced by many physicians during their professional careers. It is termed abusive and disruptive, and adversely impacts the ethical practice of medicine.Abusive behavior signals the treatment of others harshly, cruelly and unremorsefully. Disruptive behavior indicates interference with the integrity and continuity of functions necessary for the provision of quality care. One may encounter nonabusive but disruptive behavior, represented by the slow surgeon in our case. Or, one may encounter abusive but nondisruptive behavior, represented by the preoperative nurse in the case scenario. The focus of this chapter, however, is mean, abusive, and disruptive (MAD) behavior of medical professionals in the workplace.

The importance of respect and civility in assuring good patient care is a foundation of the American Medical Association’s Code of Medical Ethics.1 MAD behavior subverts the ethical obligation of healthcare professionals from consistently placing the interests of the patient foremost, by interfering with the normative processes of collegiality, cooperation, communication, and teamwork. This sabotages the viability of an effective and efficient institutional culture of safety and quality care. Indeed, there is ample evidence of the linkage of MAD behavior to adverse events, medical errors and compromise of patient safety.2

MAD behavior – definition and consequences

MAD behavior encompasses an extreme degree of uncivil and unprofessional demeanor. It violates ethical standards of practice and impedes patient safety and quality improvement. It is a pattern of personality flaws and traits that interferes with a physician’s effective clinical performance and can be directed at any member of the healthcare team, as well as patients and/or their family and friends. Manifestations include, but are not limited to:

(1) Verbal abuse – threats; intimidation; insults; degrading, demeaning, or foul language; or unwarranted yelling, tone or innuendo.

(2) Physical abuse – inappropriate physical contact that is threatening, humiliating or intimidating, or actual physical violence (from finger poking to battery).

(3) Invasion of the space or boundaries of others, physically and/or psychologically.

(4) Visual abuse – threatening or humiliating movements; or inappropriate writings, drawings or photographs, including electronic transmissions.

(5) Harassment or discrimination against any individual on the basis of race, religion, color, ethnicity, national origin, ancestry or culture, socioeconomic status, physical, mental or other medical disability, marital status, gender or sexual orientation.

The MAD physician controls others through intimidation, bullying, belittling, berating, and condescendence. They manifest impulsive and unexpected anger, behave with arrogance, inconsideration and inflexibility, blame others rather than accepting responsibility, and are intolerant of those they deem to be “incompetent.”

MAD behavior’s harmful impact on workplace staff increases the risk for substandard care and adverse patient consequences. It amplifies stress; diminishes productivity; lowers self-esteem and morale; increases absenteeism, turnover, “sick” leave and worker compensation claims; and impedes the hiring of new staff. MAD behavior encourages failures to follow policies and procedures – for example by causing fear, disinclination or disinterest in questioning a MAD physician’s orders no matter how illegible, inappropriate or incorrect they may appear to be. MAD behavior decreases or aborts normative communication regarding patient care and polarizes staff into those who are deemed as “favored” versus “not favored.” The adverse impact on healthcare institutions includes time-consuming, unpleasant, and frustrating medical staff investigations; malpractice claims; and legal suits because of creation of a hostile work environment.

The aberrant personality of the MAD physician

MAD behavior is an Axis II psychiatric classification (which is not a psychiatric diagnosis or illness) characterized by an underlying personality with maladaptive behaviors that deviate markedly from normative expectations. This behavior poses a direct danger to patients as well as an indirect one by disrupting institutional and professional cultures of safety. This personality disorder is one of enduring traits, that is, it is part of the person’s innate character, and not merely a response to environmental factors. Cultural factors, concomitant substance abuse, or a dual psychiatric diagnosis may play a contributing role. But, because they suffer from lack of insight, the MAD physician is impervious to psychotherapy. The only potential treatment is to hold the MAD physician to strict limits of acceptable behavior. Unfortunately, the medical community’s history has been one of impotence, permissiveness, frustration and a collective unwillingness to act decisively to address these antics.

Quelling MAD behavior – a standard for assuring quality of care

The Joint Commission has declared that MAD behavior constitutes a “Sentinel Event Alert” because of the potential to “foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes.”3 Indeed, in the new “Leadership Standard” requirements, they state that

“The hospital [must have] a code of conduct that defines acceptable and disruptive and inappropriate behavior … [and that] … leaders [should] create and implement a process for managing disruptive and inappropriate behaviors.”4

Two of the six core competencies for which The Joint Commission and the Accreditation Council for Graduate Medical Education (ACGME) want every physician to be regularly appraised relate to MAD … that enable [physicians] to establish and maintain professional relationships with patients families, and other members of the healthcare team;” andprofessionalism, especially for “behaviors that reflect a commitment to continuous professional development, ethical practice, and understanding and sensitivity to diversity, and a responsible attitude towards their patients, their profession, and society.”4

Ethics, morals, and professionalism

Moral precepts and dilemmas involve actions that may harm or benefit others. Ethics is the study of society’s moral challenges, precepts and codes – a scholarly effort to analyze rules, customs and beliefs, and how to achieve the moral good. Ethics focuses on the study of intentional human actions that we choose to carry out with sufficient knowledge with respect to their being right or wrong.

In Western literature concerning morality, some philosophers describe the qualities of character that lead to praise or blame. Others reflect on the duties and obligations that bind humans to perform certain actions and to refrain from performing others. Still others consider how the existence of communities is related to the purpose of individuals. These three themes – character, duty and social responsibility – are recurrent topics of ethical reflection, serving as the threads that also bind medicine and morality.

The writings ascribed to the School of Hippocrates describe characteristics of the “good physician.” Physicians should be gentle, pleasant, comforting, discreet, and firm, and these qualities represent true values. A more grave morality involves the injunctions that define the duty of the good physician: to benefit the sick and do them no harm, to keep confidences, to refrain from exploiting patients, and to show concern and caring, even at the cost to one’s own wealth and health. These duties are more profoundly linked to deep moral beliefs than to the admonitions of decorum, and the paradigm of these moral imperatives are embodied in the Hippocratic Oath. Finally, as ethical professionals, physicians must define their place in society, by demonstrating their worthiness of social trust, social authority, and reward.

Becoming a physician involves the acceptance of specific moral responsibilities. Physicians are members of a learned profession defined by its educational breadth, importance in satisfying fundamental human needs, and society’s permission to use their special knowledge, powers, and privileges. In return, societies have expected that physicians will hold as their primary concern the welfare of their patients. The covenant of trust established by physicians with patients serves as the basis for the physician’s privileged contract with society. The special claim of the medical profession lies less in physicians’ knowledge and expertise, and more in their altruistic dedication to something other than self-interest or self-indulgence. The insistence on clinical competence, caring and trustworthiness define the core of medicine’s professional responsibilities, but it is a physician’s unique commitment – his or her promise and dedication to the welfare of those who seek their help – that makes medicine a moral enterprise.

As a structurally stabilizing, morally protective force in our society, professionalism protects vulnerable persons and social values. The ideal of professionalism has succinctly been described as a “set of values, behaviors, and relationships that underpin the trust the public has in doctors.”5 The ACGME includes in its compellation of the essence of professionalism the “adherence to ethical principles.”6Indeed, the expectations of ethical behavior are stated in professional codes such as the American Society of Anesthesiologists’ Guidelines for the Ethical Practice of Anesthesiology,7 which also incorporate the American Medical Association’s Principles of Medical Ethics. The ASA Guidelines speak to an anesthesiologist’s ethical responsibilities to their patients, themselves, their colleagues, their healthcare institutions, and society.

Curbing MAD 'margin-bottom:0cm;margin-bottom:.0001pt;text-align: justify;line-height:normal'>Section I.1 of the ASA’s ethical guidelines addresses an anesthesiologist’s primary ethical responsibility to patients: “The patient–physician relationship involves special obligations for the physician that include placing the patient’s interests foremost, faithfully caring for the patient and being truthful.” Because MAD behavior creates a practice atmosphere in which quality of patient care is threatened, it is not consistent with this primary ethical responsibility.

With respect to ethical responsibilities to colleagues, Section II.1 declares “Anesthesiologists should promote a cooperative and respectful relationship with their colleagues that facilitates quality medical care for patients. This responsibility respects the efforts and duties of other care providers including physicians, medical students, nurses, technicians and assistants.” MAD behavior clearly fails to conform to this ethical duty.

Anesthesiologists also have ethical responsibilities to themselves, as addressed in Section IV.2: “The practice of quality anesthesia requires that anesthesiologists maintain their physical and mental health … [,and] … if in doubt about their health, then anesthesiologists should seek medical evaluation and care,… [and furthermore,]… during this period of evaluation or treatment, anesthesiologists should modify or cease their practice.” A practical problem with MAD behavior is that MAD physicians are largely incapable of acknowledging it, and equally unable to gain meaningful understanding or insight through treatment.

Finally, Section III.2 iterates that anesthesiologists have ethical responsibilities to the health care facilities in which they practice and should “share with all medical staff members the responsibility to observe and report … any potentially negligent practices or conditions which may present a hazard to patients or health care facility personnel.”7 Detection and documentation of a physician’s MAD behavior is the first of the requisite steps to curb this harmful institutional infestation.

Civility and social capital

Relationships with colleagues and staff involve overlapping responsibilities and obligations centering on the care of patients. Our diverse healthcare community is composed of a wide spectrum of personalities, knowledge bases, intelligences, competencies, motivations, backgrounds, cultures, races, ethnicities, religions, and value systems. Given this reality, disagreement, tension, and even conflict are not only anticipated, but welcome when managed civilly, because they can contribute to improving quality of care. Yet, no matter how well honed our coping skills may be, it is extremely challenging to circumvent the distasteful aftermath of unprofessional and uncivil behavior.

Civil, the root word for civilization, connotes an advanced stage of social development.8 “Civil” is generally thought of as being “polite” or “courteous,” each synonym referring to behaving with manners necessary in social situations and interactions. Civil behavior increases social capital, which is the well of interpersonal trust, sense of obligation, strength of norms, and unrestrained information pathways that accrue from robust relationships among members of a community.9 Social capital produces communities of cooperation, fosters communication, enhances achievement of common goals, and facilitates successful realization of complex and dynamic relationships. MAD behavior, on the other hand, weakens social capital and breaks down cooperation, communication, and achievement of common goals – the very essence of a well-functioning medical team.

Managing MAD behavior

Accrediting authorities mandate that every medical staff have bylaws that delineate a credible and effective policy to deal with the MAD physician.3,4 Identification and documentation of MAD behavior is the point of initiation of this process. This presupposes a workplace educated about the endangerment to patient care wrought by such behavior and the ethical responsibility to respond to quell it. Personnel should be urged to bring allegations, concerns or complaints to the attention of medical staff leadership. The entry point for incident reports must be simple, easily accessible, and free of impediments. The complainant must be fully protected, and fear of retaliation and/or retribution dispelled.

Investigation of the incident report is the ethical responsibility of the medical staff. The review and verification of this report must be free of bias or prejudice, yet thorough. It should include interviewing the initiator of the report as well as any other relevant third parties. The medical staff leadership must adhere to its bylaws, policies and procedures. The physician under investigation must be treated with respect and in compliance with due process rights under relevant law. The law protects medical staff review of actions that affect quality of care from discovery.

When appropriate, intervention should incorporate an attempt to resolve the allegations with simple solutions – first pursuing collegial steps without necessarily progressing to disciplinary measures or facilitative rehabilitation. One example is an interview and counseling by the department chair. If that approach is impractical or impossible (there already exists an adverse relationship with the chair, or they are economic competitors), then the medical staff president with at least one other medical staff leader should conduct an interventional meeting. All conversations must be documented.

For a first offense, depending on the tone and responses during the interventional meeting, the MAD physician might simply be warned that the process for the medical staff’s abusive/disruptive policy will be invoked upon another reported incident. However, if warranted by the severity of the initial incident and/or the response of the MAD physician in the first “interventional” meeting, then the full body of the disruptive/abusive policy can and should be enforced immediately. If particularly egregious, then the MAD physician should be placed on summary suspension.

The “repeat offender” would, upon judgment of leadership, have to enter a process of further investigation, counseling and advice. Ultimately, the medical staff bylaws addressing repeated MAD deportment must lead to a referral for evaluation and recommendation for treatment by a psychiatrist with experience in providing a comprehensive “fitness-for-duty” evaluation or its equivalent. The full force of imminent suspension of medical staff privileges – and its attendant report to state and national authorities – may suffice to induce the MAD physician to comply with this mandate. The MAD physician’s options, consequences for failure to comply, and potential sanctions, must be made crystal clear.

A contract for treatment and monitoring in accordance with the recommendations of the evaluator must establish absolute boundaries for acceptable behavior, and clear and meaningful consequences for their violation. The institution’s Well Being Committee or its equivalent can be consulted for advice and assistance. Anger management therapy often is one of the elements included in these recommendations. The goal of therapy and monitoring is behavioral compliance, not psychological insight. Expert legal counsel’s advice at each procedural step is prudent.

Constructive problem solving and avoidance of future incidents can be achieved without a change of attitude, by compelling compliant behavior. However, some MAD physicians may not achieve substantial changes in attitude or behavior, and even may retaliate, escalate MAD behavior or even pursue litigation. Despite this, there should be no laxity in applying the expectations and limits of acceptable demeanor. Recidivism is not unusual and must be handled according to its severity and frequency. Monitoring adherence to behavior contracts is crucial to success: it should include montoring attendance at “therapeutic” sessions (individual or group), reviewing reports from therapists (or psychologist “coaches”), and requiring the physician to meet regularly with medical staff leadership to review compliance with the contract.

Abuse of disruptive/abusive policies

In the US, physicians may participate in business arrangements that hospitals might view as unfair or unwanted competition, such as physician-owned surgery or procedural centers. Professional competition and animosity has, on occasion, created incentives for hospital administrators to use the disruptive/abusive label inappropriately in a ruse to remove such competitors from the medical staff. Physicians should not be labeled as MAD if they violate onerous, overly broad, or sham “codes of conduct” that are created to squelch medical advocacy, target competitors, or otherwise have no nexus to improving patient care.

Key points

• MAD behavior violates ethical standards of practice and impedes patient safety and quality of care.

• MAD behavior is a manifestation of a personality disorder that is characterized by maladaptive behavior and lack of personal insight. It is not amenable to psychotherapy.

• The American Society of Anesthesiologist’s Guidelines for the Ethical Practice of Anesthesiology outlines obligations to patients, colleagues, self and health care institutions that are incompatible with MAD behavior. In fact, it is the ethical obligation of anesthesiologists to work to eradicate MAD behavior from the workplace.

• Investigation of MAD behavior should be thorough, unbiased, and respectful of the accused physician.

• The goal of intervention and monitoring of the MAD physician is behavioral compliance and not psychological insight.

• In order for MAD physicians to continue to practice, they must be strictly be held to exert a sufficient degree of control over their behavior that precludes their adversely impacting the culture of safety.

References

1* American Medical Association. Council on Ethical and Judicial Affairs. (2003). Code of Medical Ethics.

2* Rosenstein, A. and O’Daniel, M. (2006). Impact and implications of disruptive behavior in the perioperative arena. J Am Coll Surg203, 96–105.

3 The Joint Commission on Accreditation of Healthcare Organizations. Sentinel Event Alert. Issue 40, July 9, 2008.

4 The Joint Commission on Accreditation of Healthcare Organizations. Hospital Accreditation Standards. 2009. LD.03.01.01; MS.06.01.03; PC.01.03.05.

5* Wass, V. (2005). Doctors in society. Medical professionalism in a changing world. Clin Med5 (Suppl 1), S5–40.

6* Accreditation Council on Graduate Medical Education. (2006). Outcome Project: Enhancing residency education through outcomes assessment. Available at www.acgme.org.

7* American Society of Anesthesiologists. (2009). Guidelines for the Ethical Practice of Anesthesiology. Available at www.asahq.org.

8* Jackson, S. (2005). Civility and professionalism in anesthesia. In Principes de Reanimation Chirurgicale, 2nd edn. J-L PourriatC Martin, eds. Paris: Arnette, pp. 1420–24.

9* Waisel, D. (2005). Developing social capital in the operating room: the use of population-based techniques. Anesthesiology103, 1305–10.

Further reading

Jackson, S. (1999). The role of stress in anaesthetists’ health and well-being. Acta Anaesthesiol Scand43, 583–602.

40 Sexual harassment, discrimination, and faculty–student intimate relationships in anesthesia practice

Gail A. Van Norman

The author wishes to thank Rosemary Maddi MD for her contributions to the author’s understanding of discrimination and harassment in the anesthesia workplace. Regretfully, due to illness Dr. Maddi was unable to participate personally in the writing of this chapter, which is nevertheless a direct result of her previous writings, teaching, and discussions with the author.

The Case

Dr. Frances K. Conley held a tenured professorship in Neurosurgery at Stanford University. She was the first woman to complete a surgical internship at Stanford in 1966, and the first woman appointed to a tenured professorship at any US medical school in 1986. In 1991 she abruptly resigned when a male colleague with a widely publicized pattern of misogyny, harassment and disrespect of female physicians and staff members was appointed Acting Chair of her department. In a letter to the Los Angeles Times, Dr. Conley described a workplace that was relentlessly hostile and demeaning. She related stories from her own illustrious career: a male colleague who repeatedly suggested in front of colleagues that she “go to bed” with him, professional presentations she had attended in which images of Playboy centerfolds “spiced up” the lectures, and male physicians who groped female colleagues and staff members at will in the operating room. She described finding that “any deviation on my part from the majority view often was prominently announced as being a manifestation of either PMS syndrome or being ‘on the rag.’ She ultimately rescinded her resignation, but not before her office had been rifled, her name had been summarily removed from the university stationery (even before her resignation had taken effect), and her research lab had been dismantled. Only 12 years ago Dr. Conley wrote, “I have acquired a curious inner peace … realizing, in my lifetime, I will not see women obtain the equality that should be theirs.”1

Frances Conley’s story is a sadly familiar one to the more than 80% of female academic physicians who report sexual harassment or discrimination on the job.2 Sexual harassment and discrimination represent only the tip of an iceberg of similar issues in the medical workplace that include discrimination based on race and sexual orientations, and bullying.

Sexual harassment

In the US, sexual harassment is considered sexual discrimination and violates the Civil Rights Act of 1964 – Title VII. Sexual harassment is anti-social and unacceptable behavior defined as unsolicited sexual advances or requests for sexual favors, or any verbal or physical conduct of a sexual nature. Sexual harassment is independent of the gender of the offender or the recipient. It can occur between members of the same or opposite sex, and between workers of any rank. The victim is defined as anyone who is offended by the behavior, not just the person toward whom the behavior is directed. It can take the form of inappropriate jokes or stories, touching, or subtle or overt pressure for sexual activity. Sexual harassment is deemed to exist if the victim’s job performance is adversely affected by the behavior, or if an offensive, hostile, or intimidating work environment results from it.

In the US, federal law recognizes two forms of sexual harassment. The first is “quid pro quo” harassment, in which the offender demands verbal or physical sexual behavior from an employee in return for job benefits or advancement. The second is the creation of “a hostile work environment” in which no quid pro quo exists.3 The law also recognizes retaliation against an employee for resisting or complaining about offensive conduct as unlawful.

In 2005, Great Britain amended the Sex Discrimination Act of 1975 to include sexual harassment, defined as verbal, nonverbal, or physical conduct based on sex that has the effect of violating [her] dignity or creating a hostile, degrading, humiliating, or offensive environment. British courts further recognize that women suing for sexual harassment need not show that a man would have been treated differently in order to prevail. The European Union defines sexual harassment as unwanted conduct of a sexual nature affecting the dignity of women and men at work.4

Sexual discrimination is more commonly directed against women, but male students are not immune from mistreatment. In pediatrics, obstetrics, and gynecology, for example, men report frequent discrimination with regard to mentoring, educational opportunities, and even general support for entering these specialties.5

How is this behavior harmful?

Many ethical principles and values are breached, whether intentionally or not, when sexually charged and discriminatory behavior is tolerated in the workplace. Discrimination flies in the face of social principles that hold that all persons have intrinsic value, and that equals should be treated equally. It also violates principles of justice, beneficence, nonmaleficence, and respect for individual autonomy.

Discrimination creates exclusionary classes of persons – unfairly bestowing benefits on some while harming others – and thus violates the ethical principle of justice. Unfair benefits to a “privileged” group include a greater sense of power and control, lower stress, greater access to educational and promotional opportunities, and by extension, professional and financial advancement, job security, and greater social acceptability. By excluding some individuals, members of the privileged class also proportionally increase the remaining benefits to themselves.

Exclusion from the privileged class assures lower quality education, personal and professional insecurity, higher stress secondary to bullying and harassment, lower rates of promotion and lower rates of pay. In the case of Frances Conley, the “privileged” class was male physicians, and the “excluded” class was women on the healthcare team. But unfair discrimination can just as well be described for any racial, ethnic, financial, or social divisions in which professionally and intellectually comparable persons are treated unequally due to qualities that are unrelated to their ability to perform the job required of them.

Discrimination restricts the individual autonomy of members of the “excluded” class. They do not have the same freedom that the members of the “privileged” class have to choose their associates or their profession – discrimination reduces even their ability to acquire mentors who could advocate for them. The oppressive environment increases stress and limits the individual’s emotional ability to cope with bullying. In extreme cases, some individuals may feel compelled to engage in unwanted sexual acts to secure a benefit or promotion they desperately want or need.

Tolerance of discrimination is harmful to patients as well as to the medical profession as a whole, while conferring few if any benefits. When talented future physicians are excluded from training or practice due to discrimination, advancements for the profession that these individuals might have contributed are never achieved. Physicians as a whole are less able to understand and advocate for their patients when the profession is restricted to a sexually and ethnically narrow group of individuals that is not reflective of the population of patients they serve. Restriction of access to the profession gives everyone in the “privileged” group the short-term gain of a larger share of “benefits,” but at the expense of long-term degradation of physician resources for patient care – the very reason for which the medical profession exists.

It has been shown that trainees who experience or witness sexual harassment or discrimination in the workplace become accepting of it, and more likely to commit abuses themselves in the future.6Thus the harasser of today not only harms today’s trainee, but the trainees of tomorrow as well. Physicians often justify the presence of hostile work elements as “routine” and even a “rite of passage,” implying that mistreatment and abuse of staff and trainees is not merely acceptable, but somehow necessary because it toughens the trainee to a demanding occupation. This further entrenches discriminatory behavior, even while being antithetical to the training of empathetic, compassionate physicians. Furthermore, demeaning any victim who objects to such treatment as “too sensitive” or “not able to play with the boys” violates the values of respect and preservation of dignity of individuals – values that are integral to the ethical practice of medicine.

These harms are not merely theoretical, and certainly are not trivial. In one study,7 more than 80% of women medical students had heard jokes in the workplace demeaning to women, 71% had experienced subtle sexual comments, 62% had heard overtly sexual comments, 22% had received unwanted sexual advances, and 36% had seen printed sexual material such as magazines or “pin-up” images of women in sexual situations in the workplace. Such behaviors were more common on surgical rotations (74%) and rare on anesthesia rotations (2%). However, the specialty of anesthesia was not exempt: one student described an attending anesthesiologist who asked her about “the sexy things” she was wearing under her scrubs and then told her to “lighten up” when she was offended. Another study found that anesthesiology residency was fourth among specialties (following only surgery, internal medicine, and emergency medicine) in frequency of sexual harassment of residents.8

Sexual harassment undermines the victim’s sense of self-confidence and dignity. Female trainees report feelings of confusion (“Did he really mean that?” “Did he touch me by accident?”), self-blaming (“I’m too sensitive”), and fear of reprisals (“They’ll say I’m a ‘bitch,’” “They won’t work with me”).7 The belief that reporting harassment is a sign of weakness, and that a “strong” woman would put up with the behavior and “just go on,” undermines attempts to identify and punish offenders. Society tends to view “victims” in a negative light (as powerless outsiders or angry zealots), and it is often easier for individuals to ignore harassment or blame themselves for the problem than report it. Failing to act to prevent harassment grants legitimacy to the beliefs that such behavior is benign or innocuous. Frances Conley admitted that she may have herself contributed to the problem when she “put up” with such behavior and “shut up” rather than taking action against it.

Research has shown that the perception of being sexually harassed results in increased cynicism, lessened professional commitment, poor self-esteem, depression, and increased risk of posttraumatic stress disorder. Psychological manifestations are seen in 90% of women who experience sexual harassment, although few seek professional help. In one study involving European physicians, suicidal ideation among female physicians was three times more commonplace among those who had experienced degrading or harassing experiences at work.9

Are consensual sexual relationships in the workplace the same as sexual harassment?

A third-year female anesthesia resident falls behind her peers in clinical performance. Although her technical skills are average, she does not appear to be studying, is far below her peers in her objective knowledge, and regularly comes to the operating room poorly prepared. Her faculty advisor warns her that unless her performance improves, she will be put on academic probation, and ultimately graduation from residency is in question. The resident tells her advisor that she is dating a male faculty member, who has assured her she is doing fine and will graduate. Her partner attends faculty evaluation meetings where her performance is reviewed, and participates in performance evaluations of her. Although faculty evaluation meetings are confidential, he has revealed some of their confidential discussions to her.

Ethical boundaries in the medical student–teacher relationship are complex. The participants are adults, and Western culture values freedom of choice for mature individuals. Freedom of association is a basic tenet of democracy and centers of higher learning. Romantic and/or sexual pairing is intensely private, and scrutiny by governments and regulators of such relationships generally is discouraged in both the US and Europe. Regulatory interference in private relationships is therefore usually restricted to those situations in which behavior is perceived to clash with critical social values, or when vulnerable persons may be exploited. Examples include domestic abuse, marital rape, and incest.

Although intimate relationships between teachers and adult students are not illegal, they are problematic, sharing some issues in common with sexual harassment. Such relationships may intentionally or unintentionally exploit unequal power dynamics. They run the risk of creating actual or perceived favoritism, and may cast doubt on the integrity of the faculty member or institution. Overt sexual harassment of either party can also occur. Such relationships are therefore risky for both the student and the teacher, and are at minimum imprudent in most cases.

Faculty–student consensual sexual relationships appear to be common. In one report, up to 17% of psychology students admitted to engaging in “consensual” sexual activity with teachers.10 Most students later reported an impaired sense of well-being, and many took action to avoid certain teachers, even changing specialties or dropping out of training as a consequence of such relationships. Many students who engage in a sexual relationship with a teacher report that they feel coerced to some degree, and such feelings increase over time.11 Importantly, many do not feel free to break off the relationship while the teacher is in a position to supervise or evaluate them.

Deceiving someone – such as promising positive evaluations, or professing emotional commitment where there is none – in order to engage them in a sexual relationship is a form of exploitation. Sexual exploitation is wrong, because it is an example of one person using coercive or manipulative influence over another, thus violating their autonomy. Are consensual faculty student relationships truly “consensual” or are they actually exploitative?

Many professionals argue that faculty–student relationships are never truly consensual if the teacher is in a position to affect the student’s evaluations or future career prospects. Even if the teacher does not intend to coerce or deceive, the student may believe that their evaluations will suffer if they do not participate, or be elevated if they do. The student may be desperate for a particular benefit from a teacher, and therefore believe they are not truly free to refuse a sexual advance. Even if such relationships begin consensually, many students later report fear, regret and disproportionate guilt. Furthermore, studies show that when a student participates in such a relationship they are more likely to commit future sexual misconduct with their own patients and future students.6

Quid pro quo relationships between a teacher and an adult student, even if voluntary, are clearly unethical because they are unjust to other students who actually perform the necessary academic work to receive the academic recognition. Favorable evaluations that are awarded in return for sex corrupt the academic process by disconnecting academic evaluation from academic performance. Furthermore, teachers may be unconsciously unable to assign even “fair” grades to students with whom they are intimately involved, or from whom they have recently severed a sexual relationship.

When a teacher agrees to pursue a “voluntary” sexual relationship with a student, the “rightness” or “wrongness” of that decision depends in part on how accurately they have assessed that the student is behaving in a truly “voluntary” manner. Self-deception may prevent an instructor from being able to truly recognize problems of coercion and academic fairness. Even the perception of unfairness among colleagues and students can cause institutional harm by casting doubt on the objectivity of the academic process. These issues can be difficult to judge from the “inside” of an intimate relationship, and ethical considerations therefore weigh against faculty engaging in such relationships with students as a general rule.

In the 1990s, almost half of US 4-year academic institutions had adopted or were considering adopting policies restricting intimate relationships between faculty and students. In 2003, the University of California instituted a policy that prohibits teachers from dating either students in their classes, or students that they might reasonably expect in the future to be in their classes.12 Many universities now proscribe intimate relationships between faculty members and students so long as the supervisory relationship is intact or has the potential to occur in the future. If an intimate relationship develops between a student and instructor, the teacher has at minimum an ethical obligation to withdraw from any supervisory and evaluation processes involving their partner.

Case resolution

In the case example, the relationship between the student and faculty member presents several serious problems. The student has developed an unrealistic faith in her partner’s reassurances, or she may believe that their sexual relationship “guarantees” her graduation. The student is not learning what she needs to learn to perform her duties well, and may therefore harm future patients. She may even fail to graduate by not attending to her studies, and her peers may discredit her if they believe that she received academic favors in return for sex, regardless of her actual ability to do her job.

The faculty member has broken fidelity with his faculty colleagues to keep confidences, and may be deceiving the resident about his intentions or ability to guarantee her graduation. He is harmed by the negative impact these actions have on how others perceive his professional and personal integrity. The institution is harmed if other trainees believe that such relationships are tolerated and can corrupt the integrity of the academic process. The faculty member should withdraw immediately from any role in his partner’s evaluations, and should observe the confidentiality of faculty meetings. The resident must be informed that her graduation is in jeopardy, and be held to the academic goals that must be met in order to graduate.

Key points

• Sexual discrimination and harassment in the workplace are examples of a broader group of antisocial and unethical behaviors that include discrimination on the basis of race and sexual orientation, and general bullying.

• Sexual harassment is antithetical to the values of medicine which promote respect for autonomy, beneficence, nonmaleficence, justice, respect for others, and promotion of human dignity.

• Physicians have ethical obligations to avoid discriminatory behavior as well as to take measures to banish it from the workplace when it occurs.

• Not all consensual sexual relationships in the workplace are automatically unethical, but all have the potential for harm through exploitation of vulnerable persons and degradation of the educational process. The proven, harmful effects on students, faculty and institutions suggest that such relationships are imprudent and generally should be discouraged.

• When a consensual sexual or romantic relationship develops between a teacher and student, the teacher is ethically obliged to withdraw from any process involving evaluation or promotion/demotion of the student.

References

1* Conley, F. (1998). Walking Out on the Boys. New York: Farrar, Straus and Giroux.

2 Carr, P.L.Ash, A.S.Friedman, R.H.et al. (2000). Faculty perceptions of gender discriminatin and sexual harassment in academic medicine. Ann Intern Med132(11), 889–96.

3 Title VII, Civil Rights Act of 1964.

4 Directive 2002/73/EC of the European Parliament and of the Council of 23 Sept 2002.

5* Stratton, T.D.McLaughlin, M.A.Witte, F.M.et al. (2005). Does students’ exposure to gender discrimination and sexual harassment in medical school affect specialty choice and residency program selection? Acad Med80(4), 400–8.

6* Robinson, G.E. and Stewart, D.E. (1996). A curriculum on physician-patient sexual misconduct and teacher-learner mistreatment Part 1: Content. CMAJ154, 643–9.

7* Hinze, S.W. (2004). Am I being too sensitive? Women’s experience of sexual harassment during medical training. Health (London)8(1), 101–27.

8* Nagata-Kobayashi, S., Maeno, T.Yshizu, M., and Shimbo, T. (2009). Universal problems during residency: abuse and harassment. Med Edu43(7), 628–36.

9* Fridner, A.Belkic, K.Marini, M.et al. (2009). Survey on recent suicidal ideation among female university hospital physicians in Sweden and Italy (the HOUPE study): cross-sectional associations with work stressors. Gend Med6(1), 314–28.

10* Biaggio, M.Paget, T.L., and Chenoweth, M.S. (1997). A model for ethical management of faculty-student dual relationships. Prof Psychol Res Prac28(2), 184–9.

11 Glaser, R.D., and Thorpe, J.S. (1986). Unethical intimacy: a survey of sexual contact and advances between psychology educators and female graduate students. Am Psychol41(1), 43–51.

12 Paulson A. (2004). Student/teacher romances: off limits. Christian Science Monitor, February 17.

Further reading

Bumiller, K. (1988). The Civil Rights Society: The Social Construction of Victims. Baltimore MD: The Johns Hopkins University Press.

Changing the Face of Medicine: Dr. Frances K. Conley. shttp://www.nlm.nih.gov/changingthefaceofmedicine/physicians/biography_68.html

Conley F. Why I’m leaving Stanford: I wanted my dignity back – sexism: a brain surgeon gives up her teaching job in protest over a system that reinforces men’s ideas that they are superior beings. The Los Angeles Times, June 9, 1991.

Maddi, R. (2000). Sexual Harassment. In The ASA Syllabus on Ethics. Park Ridge, IL: American Society of Anesthesiologists.

Robinson, G.E. and Stewart, D.E. (1996). A curriculum on physician–patient sexual misconduct and teacher–learner mistreatment Part 2: Teaching method. CMAJ154, 1021–5.

Witte, F.M.Stratton, T.D., and Nora, L.M. (2006). Stories from the field: students’ descriptions of gender discrimination and sexual harassment during medical school. Acad Med81(7), 648–54.

Zippel, K.S. (2006). The Politics of Sexual Harassment: A Comparative Study of the United States, the European Union, and Germany. Cambridge, UK: Cambridge University Press.