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April 2, 2018

Building on #MeToo to Enhance the Learning Environment for US Medical Schools

Author Affiliations
  • 1Boston University School of Medicine, Boston, Massachusetts
JAMA. Published online April 2, 2018. doi:10.1001/jama.2018.3812

Surveys of graduating medical students in the United States annually document intimidation and harassment of student learners, often on the basis of sex, ethnicity, race, or gender identity, reflecting US culture as a whole but also the historical hierarchical, competitive culture of US medical schools. Of 14 405 US medical school doctor of medicine graduates in 2017 who answered the specific questions on the Association of American Medical Colleges 2017 graduate questionnaire, 33% reported personally experiencing sexist, racist, or other offensive comments; lower grades; or denial of training or awards based on sex, gender identity, sexual orientation, race, or ethnicity.1 Reports of sexual harassment, one of a number of behaviors surveyed, have remained stable since 2013 and have not improved (Table).

Medical Student Reports of Inappropriate Treatment in the Association of American Medical Colleges 2017 Graduate Questionnaire (N = 14 405)a
Medical Student Reports of Inappropriate Treatment in the Association of American Medical Colleges 2017 Graduate Questionnaire (N = 14 405)a

Both mainstream media2 and medical professional journals3-5 regularly report instances or surveys suggesting that sexual harassment remains an issue in medical schools in the United States and other countries. Reviews3 and meta-analyses estimate that a third to half of women medical school faculty report at least 1 episode of sexual harassment, with older women faculty reporting higher rates.

A survey of younger women faculty published in 2016 reported rates of perceived sexual harassment of 30%.4 Of 1066 respondents to a survey of 1719 new Research Career Development award (K award) recipients from 2006 through 2009, women were significantly more likely than men to perceive gender bias (70% of women vs 48% of men) and to have experienced gender bias (66% of women vs 10% of men) and harassment (30% of women vs 4% of men). Of the 150 women who reported experiencing harassment, 92% reported sexist remarks or behavior; 41%, unwanted sexual advances; 6%, subtle bribery to engage in sexual behavior; 1.3%, threats to engage in sexual behavior; and 9.3%, coercive advances.4

The Current National Conversation and #MeToo

The escalation of the intense national conversation around sexual harassment began during the most recent national election. First, Roger Ailes stepped down as chief executive officer of Fox News on July 21, 2016, after allegations of sexual harassment by a series of women. The very public fall of Harvey Weinstein on October 8, 2017, propelled the #MeToo movement to document the prevalence of sexual assault and harassment in the workplace, which spread virally. Women certainly had previously reported sexual harassment, but even after multiple complaints, often nothing of consequence happened to the perpetrator. The consequences of sexual harassment changed almost overnight. Most recently not only was Larry Nassar, USA Gymnastics team physician and osteopathic physician at Michigan State University, convicted of sexual misconduct, but the responsibility for not acting on evidence earlier led to the resignation of Lou Anna Simon, president of Michigan State University, and the entire USA Gymnastics board.

This surprisingly rapid national social transformation, long overdue, is actively under academic study. The psychological forces behind the sudden cultural change were reviewed in a recent Hidden Brain podcast.6 Briefly, if women lose their jobs for stepping forward to accuse serial offenders and nothing happens to the perpetrator, other women will no longer come forward. However, the recognition that such allegations are now not only believed but have consequences has unleashed an avalanche of allegations toppling the careers of a number of powerful men in many industries, including academia and medicine.

What has happened at medical schools since October 2017 and #MeToo? A brief questionnaire was sent to 140 US medical school deans on February 26, 2018. Fifteen of 21 responders noted no change in the number of complaints of sexual harassment since October 2016. Particularly interesting, however, was that half of the 6 deans who did report an increase in complaints had received new serious allegations against current or former faculty by alumnae who had graduated years before (1 alumna reported being advised by school administration not to report a serious allegation because it would jeopardize her chances of gaining a residency, which may have been accurate advice at the time).

A majority of deans reported enhancing education and training programs over the last few years as awareness of sexism, racism, and gender identity discrimination increased reflecting the brisk national discussions. A few noted that education programs led to increased complaints, predominantly of offensive comments, presumably because of increased awareness and less fear of reprisal. One dean observed that teaching slides faculty had used for decades with no complaints now sometimes generated student complaints of insensitivity.

Best Practices Moving Forward

Certainly leaders in medicine and science need to take advantage of the momentum. At a national level, the National Science Foundation (NSF) has announced new reporting requirements for scientists on NSF grants found guilty of sexual harassment, and the National Academies of Sciences, Engineering, and Medicine have sponsored a study of sexual harassment in academia and its effects on women's career advancement. The study will review research on how sexual harassment on university medical campuses affects the recruitment, retention, and advancement of women and will identify policies, strategies, and practices to prevent and address sexual harassment.

Many medical schools have already enhanced their Title IX and human resources teams and developed optional or mandatory educational programs to ensure that faculty, students, and staff recognize sexual misconduct, leaders know their reporting requirements, and learners have support to report incidents they experience and observe.

Institutions are also pursuing sexual harassment investigations to their completion rather than terminating investigations if the accused faculty member resigns before the investigation has concluded (often resulting in the faculty member moving on to another academic or practice position with no violation established). Institutions are also reconsidering the practice of entering into confidentiality agreements with faculty found to have violated sexual misconduct policies in return for their voluntary departure.

Although physicians can be reported to state medical boards for such conduct, no central registry exists for offending PhD faculty. Some professional societies are considering ways to identify such faculty. In addition to holding faculty accountable, supervisors who do not promptly investigate complaints are also now being held to a higher standard.

The issue for medical schools is the learning environment—a frequent topic of formal discussions at meetings of deans. Behaviors for which medical schools should have zero tolerance include sexual harassment as well as harassment based on ethnic or racial origin, gender identification, or personal beliefs. The Liaison Committee for Medical Education in its accreditation processes has emphasized the responsibility of medical schools for a supportive learning environment.

Although some complaints involve clear harassment, deans have recognized that frequently faculty are unaware that their comments or behaviors are offensive. Many have adopted the “cup of coffee” approach of having a conversation with the offending faculty member as a strategy for first reports of inappropriate comments. Many faculty either regretfully acknowledge that their comment was offensive, or alternately are horrified to learn how their comment was interpreted by trainees or colleagues.

Given that sexual harassment will not disappear, medical schools must equip learners, faculty, and staff to prevent or escape abuse, not only to protect themselves but also to intervene if they observe a colleague being targeted, particularly at professional meetings. Professional societies who sponsor meetings should consider ways to protect women who attend.

#MeToo and the national discussion of sexual harassment has increased awareness and, at least for now, has resulted in increased willingness to hold offenders (and enablers) accountable. Decreasing the incidence of sexual harassment (and harassment and discrimination behaviors in general) will improve the learning and working environment of US medical schools.

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Article Information

Corresponding Author: Karen Antman, MD, Boston University School of Medicine Provost, Boston University Medical Campus, 72 E Concord St, Boston, MA 02118 (kha4@bu.edu).

Published Online: April 2, 2018. doi:10.1001/jama.2018.3812

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and reports being the dean of Boston University School of Medicine and her spouse a professor at a medical school; they both belong to many professional organizations unrelated to this article.

Association of American Medical Colleges.  Medical School Graduation Questionnaire. https://www.aamc.org/download/481784/data/2017gqallschoolssummaryreport.pdf. Accessed March 11, 2018.
Lewin  T.  Handling of sexual harassment case poses larger questions at Yale. https://www.nytimes.com/2014/11/02/us/handling-of-sexual-harassment-case-poses-larger-questions-at-yale.html. Accessed March 11, 2018.
Bates  CK, Jagsi  R, Gordon  LK,  et al.  It is time for zero tolerance for sexual harassment in academic medicine.  Acad Med. 2018;93(2):163-165.PubMedGoogle ScholarCrossref
Jagsi  R, Griffith  KA, Jones  R, Perumalswami  CR, Ubel  P, Stewart  A.  Sexual harassment and discrimination experiences of academic medical faculty.  JAMA. 2016;315(19):2120-2121.PubMedGoogle ScholarCrossref
Siller  H, Tauber  G, Komlenac  N, Hochleitner  M.  Gender differences and similarities in medical students’ experiences of mistreatment by various groups of perpetrators.  BMC Med Educ. 2017;17(1):134.PubMedGoogle ScholarCrossref
Vendantam  S.  Hidden Brain: the psychological forces behind a cultural reckoning: understanding #MeToo. https://www.npr.org/2018/02/05/582698111/the-psychological-forces-behind-a-cultural-reckoning-understanding-metoo. Accessed March 10, 2018.