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Ruchika Talwar: Hi everyone, and welcome back to UroToday's Health Policy Center of Excellence. I'm joined today by Dr. Catherine Nam, who's a resident at the University of Michigan. We're going to be doing a deep dive into a really important topic that she recently published on in the Gold Journal, "Self-reported Health Care Clinician Experiences with Patient-Perpetrated Sexual Harassment in Urology and OB-GYN."

Thanks so much, Dr. Nam, for taking the time to chat with us.

Catherine Nam: Thank you so much for the opportunity to share our work.

There have been some prior studies looking at patient-perpetrated sexual harassment in internal medicine and general surgery, but we were particularly interested in whether the clinical focus of urologists and OB-GYNs makes us particularly vulnerable to patient-perpetrated sexual harassment, given the sensitive GU exams as well as our history taking. So we wanted to evaluate the urologists' and OB-GYNs' self-reported experiences of patient-perpetrated sexual harassment.

To do so, we had a multiple choice anonymous online survey that was administered in the Department of Urology and OB-GYN at Michigan Medicine from September 2022 to October 2022. And we did a Pearson Chi-square test or Fisher's Exact test by gender and by department to compare and contrast the experiences of patient-perpetrated sexual harassment among the clinicians. We also did a logistic regression analysis adjusting for clinician demographics.

And we had a response rate of 76% of the clinicians that were surveyed.

This figure demonstrates the frequency of types of patient-perpetrated sexual harassment experienced by healthcare clinicians, by sex and department. And what we found was that female urologists report gender harassment and unwanted sexual attention at a statistically significantly higher rate compared to male urologists.

On the other hand, more male OB-GYNs reported statistically significantly higher rates of unwanted sexual attention, compared to their female counterparts.

And in our adjusted logistic regression analysis, we found that being a female trainee in urology are all clinician demographic factors that are associated with reporting more patient-perpetrated sexual harassment.

Ruchika Talwar: Thank you so much for giving us an overview of your study. I cannot overstate how important this is. I think as urologists and urology trainees, who may be listening in on this presentation, anecdotally, we've all heard or experienced events like this, and having the data to back up how often this really happens is going to help us create protocols. I mean, at minimum, ideally a culture shift, but at minimum having protocols on how to deal with this. Because I can tell you, from experience during my training, as well as hearing other people's experiences when stuff like this happens, it's really a shock, and you don't know how to proceed. Who do I talk to? How do I make sure this doesn't happen again? And I think, really, kudos to you and to all of the authors on this important, important work.

Tell me, what did you find most surprising from your results?

Catherine Nam: Yeah. So from our perspective, I think two surprising findings. One is, I did not appreciate how common patient-perpetrated sexual harassment is to our male urologists. And so, anecdotally, just like you, I've also had personal experiences in just sharing these stories among female urologists, and that was kind of the impetus to do this research in the first place. But 40 plus percent of male urologists experiencing this was not something that I expected. And so, I think that finding really made us change the lens in which we wanted to highlight some of our findings, and saying, this is not just a female urologist issue. Obviously, we're at a higher risk, and we experience it at higher rates compared to the male urologists, but 40% is not a small proportion of people who experience it. And so, we really need to have an inclusive policy that protects both male and female urologists from this inappropriate behavior.

So that was one. And then the other one was the comparison with the male OB-GYNs. And so, their increased experience with the patient-perpetrated sexual harassment and gender harassment, or unwanted sexual attention, was, I think, very striking. That being said, we had a very small number of male OB-GYNs that responded to the survey, and so, it would be interesting to see on a larger scale if we were to be able to repeat the survey to a wider audience, if that were to carry through.

But that kind of brings up the point of part of the reason why we wanted to do a comparison among these two subspecialties is because urologists, the patient population is mostly male, and the providers are mostly male, whereas in OB-GYN, the providers are mostly female and the patient population is also mostly female. And so, given the fact that we take care of similar organ systems and sensitive pelvic exams, but the provider and patient demographics being so different, is the discordance of the sex of the provider and the patient, one of the risk factors of experiencing this. And I think, to be completely honest, we did not find that association in our logistic regression. That being said, it would be fascinating to see at a larger scale, with bigger numbers and powers, for us to be able to answer that question.

Ruchika Talwar: Yeah, of course. I mean, this is definitely limited by the fact that it's a single institution study, but I think it's a great step in even getting the ball rolling on having these conversations.

And I think your point, showing that regardless of statistical significance or not, the fact that N is not even zero, it is a tangible number, tells us this is a problem. It should be zero, and at least that's information. When things like this happen, that's information that physicians can take to administration and say, "Look, this is a problem, not just for me, but for other people in my specialty and in other specialties." And so, it really, I think, gives the right amount of recognition to an issue that has long been, I don't want to say swept under the rug, but it's something that hasn't received the attention that it should.

Catherine Nam: Absolutely. And I think it certainly has been under recognized. And I think, part of the thing that's really fascinating is Dr. Viglianti, who was my mentor on this project, who is a pulmonary critical care doctor, really has an area of expertise in patient-perpetrated sexual harassment. And one of her research areas has extensively looked at the patient bill of rights. And so, they are protected from inappropriate behaviors from clinicians, and they absolutely deserve that.

But on the flip side, the physicians do not have the same protection that's written in the bill of rights either. And so, I think there are very pertinent and important policies that can be made, both at a hospital level and on a national or specialty level, to make sure that, like you said, the number should be zero, but it certainly is not. And so, what can we do on a specialty level, or on a national level, to make sure that we're moving in the right direction, and recognize when these things are happening?

Ruchika Talwar: Yeah. And I think, again, this project is a right step in the direction of creating these sorts of pathways, so people know how to deal with these sorts of situations.

What, in your mind, is the next step? What would you like to see? Whether it's physicians, health systems, residency programs, what should they do with this data?

Catherine Nam: Yeah. So I think what we can do is, I think it would be really nice to have an equivalent of the patient bill of rights, in terms of a clinician or provider bill of rights, in terms of making sure that we are protected from inappropriate behaviors, or patient-perpetrated sexual harassment. We would want the same for our patients. And so, I would want the same for my colleagues as well. And so, I think having something like that in writing, and knowing the steps of escalation, would be really helpful to make sure that our workforce is able to provide the patient care that the patients deserve to our utmost capacity. And so, I think that's one of the things that we can do. And I think the other thing is, making sure that we have very clear reporting steps written down as well. And I think, in general, I think the culture shift has happened, where it is more transparent, in terms of having clear reporting mechanisms.

That being said, because of the amount of stigma surrounding it, I think there is still very much under-reporting of these behaviors, even when physicians do experience it. And I think there is some literature to say that just going through the process is also an additional emotional burden onto the person who's going through the process as well. And so, I think the general culture shift, in terms of de-stigmatizing that, and having additional education around that, is also very helpful.

I think one of the things that was also interesting is, we didn't highlight this in the PowerPoint, but looking at chaperones, and the use of chaperones as a way to protect the clinicians from inappropriate behaviors, in terms of patient-perpetrated sexual harassment. And a lot of the physicians or clinicians that answered the surveys were not sure if it helped. And so, I think there is also a little bit of a disconnect between what we cognitively think would be helpful, in terms of minimizing these behaviors, and what actually comes to fruition. And so, I think no matter what reporting mechanisms or policy changes happen, I think being able to follow up with the people who are providing patient care, to see if it does actually have the effect that we want, to protect the workforce would be very important.

Ruchika Talwar: Perfect. You addressed my next question about chaperones without me even asking.

Catherine Nam: Yeah. Just flowed right in. Yeah.

Ruchika Talwar: Exactly. But the thought of chaperones, I think it is definitely protective, and makes the patients feel more comfortable, and I totally support having that integrated into practices. But a lot of these events tend to not be physical, but rather verbal.

Catherine Nam: Verbal. Mm-hmm.

Ruchika Talwar: Or innuendo, or things like that. And so, it's hard to know whether the chaperone would make a difference. But you know what? I think the fact that your data sheds a little light on that is helpful, and it'll at least help the field come up with solutions that may be a bit more sustainable.

Catherine Nam: Yeah. And I think another next natural step is, I think, exactly like you said, having the chaperones for sensitive physical exams is very protective to the patients, but maybe it shouldn't be just chaperones. They should also undergo bystander training, so that when these verbal comments or passive-aggressive or microaggressions happen, they also know how to intervene, especially as things start to escalate. And so, I think that's another natural next step, because we're not reinventing the wheel. This is an infrastructure that exists in a lot of hospital systems, and so, it can just be an added layer of protection.

Ruchika Talwar: Absolutely. Well, thank you so much, again, for spending a little time with us, and giving us an overview of your very important study. I think this is just the start of what I hope is a long conversation, on how to address this problem that clinicians should not be facing, and often contributes to burnout and workforce challenges. So thank you again for being here with us.

Catherine Nam: Thank you so much.

Ruchika Talwar: To our audience, we'll see you next time.