Addressing Sexual Misconduct in Healthcare

This transcript of the discussion has been edited for clarity and length.

Mike Sacopulos: My guest today is Matthew Mazurek. Dr. Mazurek is an assistant professor in the Department of Anesthesiology at Yale School of Medicine and author of Sexual Misconduct, Harassment, and Discrimination in Healthcare , published by the American Association for Physician Leadership. Matthew Mazurek, welcome to SoundPractice.

Matthew Mazurek, MD: Thank you very much. I’m excited to be here and discuss this rather difficult topic, but definitely worthy of conversation.

Sacopulos: Absolutely. Maybe difficult, but very important. Before we dive into your new book, could you tell me about your path to becoming a physician leader?

Mazurek: It was circuitous. When I was in college, I was president of the Astronomy Club in Fresno, so I already had kind of a primed pump for leadership. It really came out of that volunteer spirit. When I joined Southern Arizona Anesthesia Services down in Tucson about 20 years ago, about four years into practice, I decided I wanted to be on some committees, make a difference in the hospital, help with patient throughput, and represent our group in a professional way — not just advocate for our own interests, but for all my fellow physicians’ interests as well, including the surgeons and hospitalists. I fell into leadership out of that desire to serve others. Servant leadership is my style and always has been.

Sacopulos: The new book, Sexual Misconduct, Harassment, and Discrimination in Healthcare, is a bit of a departure from your previous work. How did you become interested in the topic?

Mazurek: My first book was on physician professionalism. I wrote that book out of a desire to educate new physicians and even experienced physician leaders navigating the landscape of physician misconduct. It’s very difficult for us to police our peers. The traditional approach has always been one where we kind of slap each other’s hands and say “don’t do that,” but the behaviors persist. That’s why I wrote that book, based on case studies from when I was chair of professional behavior as chief of staff.

I included a brief chapter on sexual misconduct and harassment in that original book. When I joined Yale, someone at one of the insurance companies got hold of my book, and I was invited to be on a sexual misconduct committee here at Yale. I was on it for approximately one year. Just as I knew there was a gap in the professionalism book, I searched for additional information on handling these issues. There really isn’t anything out there that’s as comprehensive as what I wanted to do — addressing sexual misconduct and harassment in healthcare not just from the staff perspective, but from the patient perspective and what contributes to the ongoing issues. It’s really a stopgap book that helps fill a need.

Sacopulos: Let’s start with the scope of the problem. Can you speak about the prevalence of sexual harassment and misconduct?

Mazurek: It’s a lot higher than a lot of people care to realize, and I think that is because a lot of it continues to go unreported. Numerous confidential surveys show that it’s an ongoing problem. Fifty percent to 60% of female medical students graduate having experienced, directly or indirectly, sexual misconduct, or at least having witnessed it. Some are witnessing multiple events, from both patients and faculty and peers. Even in the professional realm, female faculty especially continue to be discriminated against. They have to endure sexual harassment and misconduct. So there are a lot of cases out there. The bottom line is it’s still prevalent and it’s still a problem. Some of the statistics actually startled me. I did not think it would be as high as it remains.

Sacopulos: Is it better, worse, or the same when compared to other industries? I’m just wondering if healthcare has a particular problem with this issue.

Mazurek: As professionals in STEM, I think it’s similar to other industries. However, medicine does differ from, let’s say, engineering or physics, where it’s predominantly men, whereas in medicine there’s a broader mix. I don’t think it’s nearly as prevalent in healthcare on the professional-to-professional level as it is in some of the other STEM fields.

However, from patients to staff and staff to patients, because of that vulnerability and that huge power dynamic, and the fact that we physically touch our patients on a daily basis in most specialties, the opportunity is there for inappropriate touching and inappropriate comments and behavior. So I think it’s higher on that spectrum, and probably lower from peer-to-peer and professional-to-professional.

Sacopulos: Are there certain specialties that seem to be more prone to harassment and misconduct issues?

Mazurek: I really didn’t find a whole lot of evidence in the literature to support an overwhelming difference, but in some specialties — for example, urology, obstetrics, gynecology — where patients are routinely exposing themselves and they’re very vulnerable, it’s a lot more prevalent in those particular specialties. In dermatology, ironically, men or male dermatologists were sexually harassed by some of the female patients. Female patients sometimes make inappropriate comments toward male physicians. For example, they’ll ask them if they’re married and what they’re doing, if they want to go out for dinner, and they’ll even make comments about their appearance. Most men are able to blow some of these comments off, even though they’re wildly inappropriate. That’s the double standard that we also have in healthcare. Men who are harassed — which does occur — just don’t report it out of embarrassment.

Sacopulos: This is one of the good things about the book that you’ve put together — you address patient misconduct to providers and staff. I think often we think only of providers or staff misconduct when we address this issue in healthcare. So first off, hats off for that. Do you have any sense of how common it is for patients to behave inappropriately?

Mazurek: It’s very common. On our committee, we investigate and listen to all types of cases. The ones that we hear about in the news usually are the more egregious cases, but there are numerous instances. For example, medical students going into a patient’s room and the patient making an inappropriate comment about one of the medical student’s appearances, or “will you go out with me?” All of us in acute care settings deal with vulnerable patients who are impaired — anybody on drugs and alcohol — you never know what’s going to happen.

It’s very, very common. I myself, over the course of my 25-year career, have either witnessed or heard numerous comments, especially in the emergency room. And occasionally in the operating room, when we’re giving medications that alter their mental status, they can make inappropriate comments toward the staff in the operating room too. It’s very awkward and uncomfortable, but it’s unfortunately kind of part of the journey of being a physician.

Sacopulos: Dr. Mazurek, I follow the Federation of State Medical Boards and their emails. Sadly, they typically contain reports of physicians being disciplined for sexual misconduct around the country. I have to tell you, I’m shocked at how long a history of sexual misconduct many physicians have before consequences are imposed at the board level. Do you have a feel for this temporal component of addressing sexual misconduct?

Mazurek: If we think about the actual legal process to discipline a physician or investigate concerns and complaints, first of all, you have to verify at least some of the veracity of the allegations. There are patients who — I address this in the book, it’s not common, it’s more rare — will make allegations that are false. So there’s part of that temporal component with just doing the investigation, which sometimes can take several weeks or even a couple of months, unless the behavior was very egregious. Or if there’s camera evidence — those kinds of cases are what I call slam dunks.

But some of these more subtle ones where patients are reporting inappropriate touching or comments in private exam rooms and clinics or in other settings — first of all, who does the patient report it to? They can complain or make a report to the state medical board about the physician. There is no standardized universal approach because we have 50 different state medical boards, and there are different laws on the books on how to approach this. I think that lack of standardization contributes to it.

The other thing is, as physicians are employed, HR gets involved. If the physician is in private practice and has privileges at a hospital, and let’s say an incident occurs in the hospital, then it becomes a medical staff affairs issue as well, which is much different than if the physician is employed. Some people may fail to follow up. I think some of these issues can be very embarrassing for some of the managers and other people to report. So there’s a hesitancy in doing so and also not wanting to set themselves up for reprisal or any type of legal consequence.

It’s difficult to investigate emotionally. It’s also difficult because it can have profound professional and personal consequences beyond just the incident itself. So all of these factors really lead to what I call — there is no straight line. These events occur, and then a spider web ensues. That’s how I like to think of the blueprint. And that does create issues.

Sacopulos: Not every example is as egregious as some of the ones that we might think about or that we read about in the national news. In Chapter Seven of your book, you write about microaggressive behaviors. Can you talk a little bit about microaggressive behaviors and maybe give us some examples?

Mazurek: I like to think of sexual misconduct and egregious conduct as kind of on a continuum. In society, we have stereotypes — stereotypes for both genders, stereotypes for race, stereotypes for age. Those lay the foundation for people having what I call “prejudice.” What I mean by that is prejudice and bias — when you see an individual, you automatically make some assumptions based on their appearance, based on their age and gender. With that kind of foundation, we now have a framework for microaggressions to occur. In other words, we use those stereotypes to lay blame or make assumptions about a particular individual.

For example, men who don’t want to report sexual harassment or misconduct — some people might say, “Well, he probably enjoyed it.” That’s a microaggression. Same thing if there’s a female physician who is a chair of a department, and let’s say the CEO of the organization is in a meeting and addresses the female physician by her first name, but is deferential and says “doctor” to all of the male physicians in the committee meeting. In fact, that’s one of the cases in my book — where there’s that sleight of hand where she’s not being treated with the same level of respect as her male colleagues. That makes the female physician feel a little bit less than her peers. So that’s a form of microdiscrimination.

Sacopulos: Is it easier to overcome or to make an environment where the microaggressions do not occur than maybe some other issues? This seems to me to be maybe one of education.

Mazurek: It is one of education. A lot of training programs don’t address these as much as they should. A good comprehensive training program for all employees would include this. I’m fortunate here at Yale, we include it in our training program. It’s very comprehensive and actually quite impressive. But I’ve had other modules from other organizations that I’ve had to take to be credentialed, and some do a pretty good job at it.

The other thing is, raising that consciousness and awareness about our bias, about those types of behaviors, is also best addressed using case examples — not just telling people about it, but showing them how it actually impacts those individuals. Organizations don’t have the time, but if people were to get into small groups and do some of these case studies live, they would then feel viscerally the emotional impact of these behaviors. That’s what’s really missing in a lot of training programs, because if you don’t feel it and understand the impact from that perspective, it’s difficult to relate to it.

Sacopulos: Early on, we were speaking about patients behaving inappropriately toward staff or providers. Let’s walk through a situation where maybe a patient has said something or done something that falls in the category of harassment. What would you counsel the provider or staff member to do and what should happen with the patient long term?

Mazurek: This is an excellent question. Staff have different reactions to these events, and some don’t get reported. I think the more egregious comments and statements, and especially if there is any physical touching involved, usually do get reported. But the verbal comments alone can become a little bit tricky. First of all, is it witnessed or not witnessed? If it’s an unwitnessed event, then it becomes a little bit more difficult for anything to get substantiated.

What’s best is for staff to extricate themselves from the situation. If they report it to a manager or a superior, if it’s disturbing enough, relieve them of duty. Then take notes, investigate, interview the patient. Some patients actually do admit to saying some of these things; others don’t. From that point forward, the best strategy is that anyone who is walking in that room and seeing that patient can’t go alone. Going forward, some charts can sometimes, if the behavior is egregious enough, get flagged so the staff is at least somewhat aware that this is a possibility.

There are instances where patients are behaving so inappropriately to staff on numerous levels, despite people trying to intervene, that the patient essentially gets fired from the practice or the healthcare system. But without having someone to transfer that patient’s care to, you can’t really abandon the patient either. So it’s a legal, moral, ethical problem. Plus, we also have a responsibility to provide that caring, safe environment for the nurses, physicians, and other workers at the hospital. That’s also a moral ethical duty. We shouldn’t leave them in these situations. Employee support programs are very important. Offering that kind of level of support confidentially also is very important.

Sacopulos: You spoke about being involved in investigations. Our audience today is full of healthcare executives and physician leaders. Unfortunately, some of them will have to investigate claims of sexual misconduct. Do you have some pro tips for them as they head into an investigation?

Mazurek: I bring this up when I’m teaching my course on professionalism for the AAPL. Be objective, be professional, be fair, and be unbiased. I know it’s very difficult for individuals to do, but just get the story and strip away who’s telling the story and just listen to what’s happening. Be exceptionally objective and also be exceptionally curious if something seems unclear. Looking for consistency is also important.

Interviewing complainants and interviewing respondents require somewhat different approaches. With respondents, it’s often best to not interview those individuals alone, whereas with complainants, staff can interview those individuals alone, especially if they’re feeling vulnerable. The problem is when you have an unwitnessed conversation, there’s always this potential of “he said, she said.”

I think the best approach is to have at least two individuals to do the interview. Doing that also takes a lot of the burden off of just one person, sharing that responsibility. With more than two people, the respondent or complainant can sometimes feel ganged up on. If someone’s had an allegation against them and you’ve got three people across the table bombarding them with questions, they’re going to feel more as if they’re at a Spanish Inquisition than at some objective fact-finding mission.

Whenever I was engaged in any of the misconduct allegations, especially when I was chief of staff, I interviewed with just one other person. It’s a lot less intimidating. We take notes and we can corroborate and also verify what was said or not said if there are any issues from a legal perspective. If the stakes are high, involve risk management right away. You don’t want to do this alone.

Sacopulos: Do you recommend the investigations be conducted by individuals who do not know the people involved with the incident?

Mazurek: It depends upon the circumstances. In smaller places, that may not even be possible. A small rural hospital where I practiced in northern Minnesota — everybody knows everybody. It’s absolutely impossible to do something along those lines. But confidentiality has to be discussed, especially in those particular settings.

In larger healthcare systems, such as Yale or Mass General or UCLA — very large institutions — professionally trained interviewers and investigators can take the charge. In those institutions, there are simply more resources to do that and there are more options and there’s more training.

Sacopulos: It should be everyone’s goal to prevent sexual harassment in the workplace instead of being an expert at investigating it. What recommendations can you give to promote prevention?

Mazurek: First of all, as physician leaders, laying the groundwork as a role model is very important. Physician leaders or executives who are engaging in some of these behaviors themselves set a tone in the environment that’s tolerant to the behaviors. Setting that example as a role model is the first goal. Secondly, having managers who are trained and also having those managers be role models helps to foster that kind of an environment where these behaviors really aren’t tolerated.

But I think it’s very difficult to be consistent and be objective and be fair, because in these work environments, favoritism, gender bias, and other instances of politics can really influence some of the investigations or some of the behaviors. For example, someone might even say, “Well, that’s just who they are” if they say an off-color remark or something inappropriate. Well, it doesn’t mean it’s acceptable. You sometimes just have to play cop and go in there and say, “Listen, this may have been something we tolerated in the past, but moving forward, it’s not really a professional behavior and it’s negatively impacting the work environment.”

It’s difficult because we’re trying to contain these behaviors in a box. As soon as the employees or staff or anyone actually exits the building, they can go behave as they want to in their personal lives. So maintaining that professionalism needs to be kind of a locked door. You come in here, this is the expectation. Obviously, we have no control over what happens outside.

Sacopulos: To that end, how much of a problem is social media?

Mazurek: Huge. The bullying, inappropriate pictures, comments, things along those lines. I do put a few examples in the book, but I’m a real stickler for not being friends on social media. Instagram and some of those things at work can be really compromising. It’s just not a good idea. Don’t post anything about work colleagues without permission and never, ever post anything that could be potentially compromising in any way.

Sacopulos: Would you agree with me that this is more of an issue with younger colleagues and staff that have grown up in an environment where so much is shared and so many things are put online that maybe somebody of my age would not think to do?

Mazurek: I definitely agree. The younger physicians and younger staff, they grew up with social media. It’s been a part of their fabric of their life. I’m Gen X. It hasn’t been. We had Facebook. That was our introduction. A lot of us kind of stick to some of those types of platforms, but it’s not as common. Most of the problems are with the younger generations. They share a lot. They send inappropriate texts and pictures and things along those lines.

The other thing is these occurrences happen outside of the workplace. Let’s say somebody goes on a conference to Europe — what’s the jurisdiction for the behavior, since it didn’t happen within the walls or during technical on-duty hours at work? So a lot of organizations now are creating policies that expressly address the fact that social media and any interactions with work colleagues in any way are considered a work environment.

Sacopulos: We talked a little bit about how maybe there’s been a change of terrain over the years, and I’m interested in your thoughts on where we as a country are when dealing with sexual misconduct. I feel sexual misconduct was traditionally a social issue, which more recently, maybe after the Me Too movement, has become a legal issue with some legal protections. And now it feels like sexual misconduct is also becoming a political issue. Would you agree with that?

Mazurek: Absolutely. It’s a political issue. Consider contemporary events, recent cases — the Me Too movement with Weinstein and then the infamous case with Dr. Larry Nassar, the physician for the U.S. women’s gymnastics team. These two cases have really brought the ongoing concerns and issues. into the spotlight

I think, though, some people may disagree that this is continuing to be a problem, only because they say men are like this and women are like that and this is the way we are and this is the way it’s always going to be. I think that’s a cop-out. Changing these types of behaviors and changing the tolerance for them is absolutely necessary, especially in healthcare. Sixty percent of the physician workforce now is women rising through the ranks. But to your original question, I think it’s being challenged. There are a lot of people who are pushing back, saying women are being too sensitive to the issue. I completely disagree with that. I really do. I think they’re empowered and I think they should be listened to. But the power dynamics within our society leave women vulnerable.

Sacopulos: The book is certainly very important and timely. As our time together comes to a close, I’m interested in what we can expect from you in the future. What are you working on?

Mazurek: Right now I’m currently editing a systems thinking book for physicians on navigating change in project management in healthcare with three other editors with the AAPL. The other book I’m going to be writing, probably within the next two to three years, is on physicians and mental health and the journey that they go through. I think that’s another important topic. The Lorna Breen Foundation, which I’m an ambassador for, focuses on preventing physician suicide and physician well-being — a topic that’s been near and dear to my heart for a very long time.

I’m also going to start doing some poetry, novels, and creative writing, veering off a little bit and exploring some other avenues besides some of the objective things that I’ve done. There’s a lot more to come, that’s for sure.

Sacopulos: That’s good news and a high point to wrap up on. You’re certainly doing very important work and are a true physician leader. Thank you, Dr. Mazurek.

Mazurek: Thank you.

Sacopulos: My guest has been Matthew Mazurek. Dr. Mazurek’s newest book is Sexual Misconduct, Harassment, and Discrimination in Healthcare , published by the American Association for Physician Leadership.

Listen to this episode of SoundPractice .