Keywords
sexual harassment - faculty - ophthalmology - graduate medical education - residency
- academic medicine - professionalism mentor - education - Title IX - prevention
In a recently published anonymous survey study,[1] 59% of female ophthalmologists reported experiencing sexual harassment in the workplace,
with the majority of experiences occurring during residency training. These results
are consistent with other studies regarding sexual harassment in academic medicine
(range = 30–59.4%),[2]
[3]
[4] and surgical fields in particular have reported higher rates of sexual harassment
(60%).[5] In the ophthalmology study,[1] only 15% of victims reported their most significant experience to an authority.
Particularly troubling were described cases of coercion by department chairs and residency
program directors.[1] Federal Title IX policy requires that universities provide resources to report and
investigate sexual harassment or assault; however, these resources are often unfamiliar,
and victims of assault may not feel comfortable reporting such sensitive incidents.
Furthermore, faculty and trainees may not feel that their department supports reporting
through such pathways and may fear retaliation.[6]
We are proposing a new departmental role, called a professionalism mentor (an approachable
internal faculty member(s) independent from departmental leadership who coordinates
education regarding sexual harassment and gender discrimination), who receives reporting
and could serve as liaison with the university's Title IX department. By providing
such a role in addition to existing resources and reporting pathways, faculty and
trainees would have an alternate local departmental structure for education and reporting
outside of residency program directors and chairs, who may be intimidating or may
themselves be the perpetrators. Furthermore, departmental structure that includes
a professionalism mentor sends a strong message to faculty and trainees that the department
takes the issue of sexual harassment seriously and supports reporting and prevention.
This randomized controlled study assigned academic ophthalmology departments to a
professionalism mentor group and a control group for a 6- to 10-month period, anonymously
assessing the opinions and experiences of residents, fellows, and faculty both before
and after the study period. The goal of this study was to identify an impact on rate
and reporting of sexual harassment, with a secondary goal to understand satisfaction
of participants in this program. This study also collected opinions from participating
residency program directors and professionalism mentors.
Methods
This prospective and multicenter study received institutional review board (IRB) approval
at the University of Washington for administration of online anonymous surveys to
faculty and trainees at 16 participating academic ophthalmology departments. The IRB
approval or exemption was obtained at all participating study sites, and this work
adhered to the tenets of the Declaration of Helsinki and the Health Insurance Portability
and Accountability Act. All federal and state laws were followed. Informed consent
was obtained from all survey participants via email. This study included academic
ophthalmology departments with residency programs and excluded departments with preexisting
sexual harassment programs that were felt to deviate significantly from the study.
This study also excluded departments unable to obtain IRB approval and/or administer
all surveys. We allowed for one-time crossover between study groups prior to the administration
of surveys, if necessary, to maximize participation.
The authors contacted the 36 largest United States academic ophthalmology departments
(based on resident numbers), primarily communicating with residency program directors
and/or department chairs. Although results are less generalizable to smaller departments
based on this study design, larger departments would capture a higher sample size.
Of these, three programs declined due to existing sexual harassment requirements interfering
with the research protocol. Three additional programs declined due to inadequate support
for this research. Another seven declined without explanation. Of the remaining 23
programs, 11 were randomly assigned to the control group and 12 to the professionalism
mentor group. We used a stratified randomization approach to evenly distribute programs
with female chairs and/or residency program directors as well as top 10 programs based
on U.S. News and World Report rankings.[7] Subsequently, one program crossed over from control to professionalism mentor group
due to a preexisting professionalism mentor-like role. Another program crossed over
from professionalism mentor to control group due to onerous local IRB requirements
for participating in the professionalism mentor group. There were seven programs that
dropped out after randomization: two from each group due to failure to obtain IRB
approval, one from the professionalism mentor group, and two from the control group
due to lack of survey participation. Of the remaining 16 departments, nine were in
the professionalism mentor group and seven were in the control group. Among the final
groups, 3/9 (33%) in the professionalism mentor group and 4/7 (57%) in the control
group had a female chair and/or residency program director.
Professionalism Mentor Group
We specified that the professionalism mentor be an individual whom trainees and faculty
would likely feel comfortable approaching; department chairs or program directors
were excluded from this role. The residency program director and/or department chair
typically selected the mentor from a voluntary faculty pool. Each professionalism
mentor was advised to receive university bystander and victim advocate training—usually
through their Title IX office—primarily to learn their university's specific policies,
resources, and procedures. The professionalism mentor's responsibilities included
participating in a pre- and postsurvey, administering a 30- to 60-minute departmental
educational session and introducing the new professionalism mentor role. Suggested
educational curriculum included approaches to patient-initiated sexual harassment,
bystander training, and confidentiality. Specific curriculum content was not distributed,
however. Each university's Title IX department provided additional campus resources
to most sessions. Although lack of uniformity disadvantaged the study, the authors
felt that university-specific training and guidance were important for the relevance
and utility of this program. For the next 6 to 10 months, the professionalism mentors
served as a resource for dialog around and assistance with reporting complaints of
sexual harassment. As a familiar faculty member, the professionalism mentor could
provide trauma-informed support to individuals experiencing sexual harassment. Nonetheless,
the professionalism mentor was asked to serve as a conduit to the Title IX office
based on local university policy and not charged with investigation of any reported
sexual harassment. Subsequent follow-up for the victim as well as remediation or other
actions against the perpetrator were left to the discretion of the Title IX officers
according to standard university, local, and federal policies and procedures. We selected
the general title of professionalism mentor because it is more discreet than a title
containing the words sexual harassment and allows for future expansion of the role
to include other professionalism topics, such as racial discrimination. Other areas
of professionalism outside of sexual harassment were not evaluated in this study,
however.
Control Group
The control group was not assigned a professionalism mentor during the study period
nor was an educational session organized through the research study. To maintain adequate
enrollment, the study did not prohibit educational sessions or online educational
modules if they were required by university policy or occurred as part of standard
departmental curriculum over the course of the study period.
Anonymous Survey
The recently published ophthalmology sexual harassment survey[1] informed development of the current survey, and an additional category of sex discrimination
was included as recommended by the National Academies of Sciences, Engineering, and
Medicine.[4] Questions regarding feedback on the professionalism mentor, educational sessions,
and departmental support were included. Each institution's representative (typically
the professionalism mentor or residency program director) emailed the department's
faculty and trainees the anonymous WebQ (Catalyst, Seattle, WA) survey before and
after the 6- to 10-month study period, using a standardized email invitation containing
embedded informed consent ([Supplementary Material S1], online only). The email notified prospective participants that clicking on the
survey link constituted consent to participate with an optional $150 incentive gift
card raffle. The representative was encouraged to send reminder emails prior to the
1-week deadline. Each participating residency program director and professionalism
mentor responded to a different online pre- and postsurvey including their opinion
on the program, their assessment of their home ophthalmology department's response
to unprofessional behavior, and formal complaints (requiring prior communication with
their Title IX office). Some institutional IRB or Title IX policies prevented the
residency program director from sharing this information, and instead the Title IX
representative reached out to the first author (M.T.C.) directly. We did not exclude
other institutions that prohibited any sharing of reporting data.
Statistical Analysis
The change in rate from pre- to postsurvey of reporting sexual harassment to an authority
among faculty and trainees were compared between the two groups as the primary outcome
measure. We also compared change in rate of anonymously reported sexual harassment.
Two slightly differently worded Likert-style survey questions were included for professionalism
mentor and educational session opinions. In general, a Cronbach's α reliability coefficient
of 0.7 or higher is considered acceptable.[8] A Cronbach's α (0.79 and 0.92, respectively) confirmed internal consistency between
the two questions, and the average was used for final analysis. The Cronbach's α statistic
also validated identical questions for residency program directors (0.91 and 0.86,
respectively) and professionalism mentors (0.84 and 0.87, respectively). Multinomial
logistic regression was used for comparisons between groups in change from pre- to
postsurvey. For all other analyses, Chi-square test assessed categorical data, and
a t-test and ANOVA assessed continuous data. All analyses were based on the groups that
participants ended in after crossover rather than intent-to-treat analysis. A two-sided
p-value of ≤0.05 was considered statistically significant. All analyses used SPSS V24
(IBM Corporation, New York City, NY).
Results
Among 16 participating ophthalmology departments, 605 faculty and trainees responded
(adding both the pre- and postsurveys), with an unknown number of participants taking
both the pre- and postsurveys. Of these, 16/605 (3%) were prohibited by their IRB
to reveal personal sexual harassment experiences, and 43/605 (7%) failed to answer
without explanation. Among the remaining 546 respondents, 86/546 (16%) anonymously
reported experiencing sexual harassment over the prior 10 months an average of 7.7 ± 11.3
times from 4.8 ± 7.4 perpetrators. Women represented 65/86 (76%) of sexual harassment
victims. [Table 1] depicts the most common experiences, including offensive comments (28%), unwanted
attention (17%), unwelcome verbal advances (13%), and gender discrimination (17%).
Victims included residents (39%) and academic attendings (49%), while perpetrators
were often patients and their family members (44%) or academic attendings (35%; [Table 1]).
Table 1
Characteristics of sexual harassment experiences over prior 10 months among faculty
and trainees responding to anonymous survey (all pre- and postsurveys included).
|
Specific sexual harassment experiences, n = 86[b]
|
N (%)[a]
|
|
Offensive comments
|
52 (28)
|
|
Unwanted attention
|
31 (17)
|
|
Unwelcome verbal advances
|
25 (13)
|
|
Unwanted and persistent invitations
|
7 (4)
|
|
Unwelcome explicit proposition
|
2 (1)
|
|
Offensive displays
|
5 (3)
|
|
Offensive body language
|
18 (10)
|
|
Unwanted physical advances
|
8 (4)
|
|
Sex discrimination
|
32 (17)
|
|
Other
|
7 (4)
|
|
Victim's gender, n = 86[b]
|
|
|
Male
|
17 (20)
|
|
Female
|
65 (76)
|
|
Nonbinary/third gender
|
1 (1)
|
|
Prefer not to say
|
3 (4)
|
|
Victim's role, n = 86[b]
|
|
|
Medical student[c]
|
1 (1)
|
|
Resident
|
33 (39)
|
|
Fellow
|
6 (7)
|
|
Academic attending
|
42 (49)
|
|
Other
|
3 (4)
|
|
Perpetrator's role
|
|
|
Resident
|
2 (2)
|
|
Fellow
|
4 (3)
|
|
Academic attending
|
45 (35)
|
|
Patient or patient's family member
|
56 (44)
|
|
Residency program director
|
1 (1)
|
|
Fellowship program director
|
1 (1)
|
|
Department chair
|
5 (4)
|
|
Faculty research mentor
|
1 (1)
|
|
Other
|
12 (9)
|
a Percentage represents proportion of those who selected that answer among all responses.
Allows for more than one response per participant; therefore, sum of values exceeds
total “n” and sum of percentages exceeds 100.
b Respondents experienced sexual harassment over the prior 10 months in 86 of 546 survey
responses (16%).
c A first-year resident responding to the survey described their experience when they
were a medical student during the prior 10 months. Medical students were not surveyed
in this study.
For the presurvey, there were 338 faculty/trainee participants with mean age 42.9
(± 13.0, range = 27–84). Of these, 40 (12%) did not answer demographic questions.
Of the remaining 298, 221 (74%) were among nine departments randomized to the professionalism
mentor group and 77 (26%) were among the seven departments randomized to the control
group. For the postsurvey, there were 267 faculty/trainee participants with a mean
age of 43.9 (± 12.8, range = 27–84) years. Of these, 10 (4%) did not answer demographic
questions. Among the remaining 257 participants, 171 (67%) were in the professionalism
mentor group and 86/257 (34%) were in the control group. Characteristics of the two
groups are shown in [Table 2].
Table 2
Comparison of faculty and trainee opinions and experiences regarding sexual harassment
over prior 10 months for programs randomized to control group versus professionalism
mentor group based on anonymous pre- and postsurvey
|
Professionalism mentor
N (%)
|
Control
N (%)
|
p-Value[a]
|
|
Pre
|
Post
|
p-Value[b]
|
Pre
|
Post
|
p-Value[b]
|
|
|
n = 221[c]
|
n = 171[c]
|
|
n = 77[c]
|
n = 86[c]
|
|
|
|
Gender
|
|
|
|
|
|
|
|
|
Male
|
105 (48)
|
92 (54)
|
0.62
|
45 (58)
|
49 (57)
|
0.97
|
0.60
|
|
Female
|
109 (49)
|
75 (44)
|
30 (39)
|
35 (41)
|
|
Other
|
7 (3)
|
4 (2)
|
2 (3)
|
2 (2)
|
|
Race
|
|
|
|
|
|
|
|
|
White
|
159 (69)
|
115 (64)
|
0.47
|
52 (67)
|
56 (64)
|
0.96
|
0.18
|
|
Black
|
3 (1)
|
1 (1)
|
1 (1)
|
3 (3)
|
|
Asian
|
56 (24)
|
46 (26)
|
15 (19)
|
16 (18)
|
|
Hispanic
|
3 (1)
|
2 (1)
|
3 (4)
|
3 (3)
|
|
Other
|
9 (4)
|
15 (8)
|
7 (9)
|
9 (10)
|
|
Geographic region
|
|
|
|
|
|
|
|
|
South
|
0 (0)
|
0 (0)
|
0.40
|
27 (35)
|
22 (26)
|
0.48
|
0.70
|
|
Northeast
|
38 (17)
|
23 (13)
|
18 (23)
|
26 (30)
|
|
West
|
114 (52)
|
85 (50)
|
9 (12)
|
8 (9)
|
|
Midwest
|
69 (31)
|
63 (37)
|
23 (30)
|
30 (35)
|
|
Department supports reporting
|
184 (83)
|
150 (88)
|
0.46
|
64 (83)
|
69 (80)
|
0.50
|
0.72
|
|
Professionalism mentor would be useful[d]
|
138 (62)
|
116 (68)
|
0.15
|
43 (56)
|
52 (60)
|
0.41
|
0.75
|
|
Educational sessions would be useful[d]
|
126 (57)
|
110 (64)
|
0.006
|
35 (45)
|
58 (67)
|
0.02
|
0.53
|
|
Departments should have:
|
|
|
|
|
|
|
|
|
Professionalism mentor + educational session
|
146 (66)
|
116 (68)
|
0.93
|
46 (60)
|
51 (59)
|
0.12
|
0.57
|
|
Educational session alone
|
55 (25)
|
40 (23)
|
21 (27)
|
31 (36)
|
|
Neither
|
20 (9)
|
15 (9)
|
10 (13)
|
4 (5)
|
|
Respondents[e]
|
n = 213
|
n = 163
|
|
n = 77
|
n = 86
|
|
|
|
Experienced sexual harassment
|
27 (13)
|
22 (13)
|
0.85
|
15 (19)
|
17 (20)
|
0.96
|
0.95
|
|
Reported sexual harassment[f]
|
2 (7)
|
5 (23)
|
0.22
|
4 (27)
|
2 (12)
|
0.37
|
0.07
|
Abbreviation: N/A, not applicable.
a Difference between pre- and postsurvey were compared between professionalism mentor
and control groups by using multinomial logistic regression.
b Chi-square test was used for all comparisons of categorical data, and t test and ANOVA for continuous data. For Likert's questions, p-values compare overall results, even though only strongly agree or agree are shown.
c Excludes 50 respondents who did not answer demographic questions. For this reason,
these numbers differ from that of [Table 1].
d Averages the results of two differently worded Likert style survey questions.
e Excludes 16 additional respondents who did not answer the sexual harassment question.
f Among those who experienced sexual harassment.
Geographic distribution of the two groups differed (p < 0.001; postsurvey) but did not change from baseline ([Table 2]). Demographics were similar between the two groups without change from baseline
([Table 2]). Both the professionalism mentor and control groups did not experience a change
in anonymously reported sexual harassment experiences over time (p = 0.85 and p = 0.96, respectively; p = 0.95 comparing delta between groups, [Table 2]). At baseline, the professionalism mentor group already experienced a lower rate
of anonymously reported sexual harassment, although not statistically significant
(27/213 [13%] vs. 15/77 [19%]; presurvey, p = 0.15). This difference was similar in the postsurvey (22/163 [13%] vs. 17/86 [20%],
p = 0.20). Number of experiences was similar between the two groups (8.9 ± 12.9 vs.
7.5 ± 10.7, respectively; p = 0.75). Programs with a professionalism mentor had an increase in rate of reporting
to an authority from baseline (7–23%), whereas the control group had a decrease from
baseline (27–12%). The difference in change over time between groups approached statistical
significance (p = 0.07; [Table 2]). Among those with access to a professionalism mentor, only 1/5 (20%) victims reporting
to an authority utilized the professionalism mentor. The remaining reporters in both
groups reported to one or more of the following (percentages exceed 100 since individuals
could select more than one): another academic attending within the department (43%,
3/7), the residency program director (57%, 4/7), the university ombudsperson office
(14%, 1/7), department chair (43%, 3/7), the university advocacy office (14%, 1/7),
or other (43%, 3/7). Location in the Northeast (6%, 6/105) or West (13%, 28/216) was
associated with lower anonymously reported sexual harassment compared with the South
(16%, 8/49) or Midwest (21%, 39/185; p < 0.001). Departments led by a female chair and/or program director had similar anonymously
reported sexual harassment compared with all-male-led departments (24/187 [13%] vs.
57/352 [16%], respectively, with 16 unable to respond, p = 0.31).
When asked whether the department supports faculty and trainees who report unprofessional
behavior, 88% in the professionalism mentor group and 80% in the control group responded
“agree” or “strongly agree” (p = 0.15, postsurvey; p = 0.72 comparing change from baseline; [Table 2]). The professionalism mentor group favored the concept of a professionalism mentor
at a similar rate to the control group (68 vs. 60%, postsurvey; p = 0.49). These opinions did not significantly change over time for either group (p = 0.75 comparing change from baseline between groups). In contrast, both groups developed
a more favorable opinion toward the educational sessions from the pre- to postsurvey
(p = 0.006 and p = 0.02, respectively; p = 0.53 comparing change between groups). Both professionalism mentor and control
groups recommended both professionalism mentor and educational session for academic
departments (68 vs. 59%, respectively; postsurvey) as opposed to educational session
alone (23 vs. 36%, respectively; postsurvey). These trends did not change over time
(p = 0.57 comparing change from baseline between groups).
All nine professionalism mentors responded to both pre- and postsurveys (100%). All
6/7 (86%) residency program directors in the control group responded to both surveys.
All nine (100%) residency program directors in the professionalism mentor group responded
to the presurvey, while 8/9 (89%) responded to the postsurvey. Among the remaining
participants, all (100%) residency program directors in both groups agreed with the
statement that their department supports trainees and faculty who report unprofessional
behavior in both surveys. Residency program directors and professionalism mentors
in the professionalism mentor group strongly believed in the efficacy of both a professionalism
mentor and educational program in both surveys. The program directors in the control
group had less enthusiastic opinions regarding both these approaches (p = 0.03; postsurvey), though neither group significantly changed from baseline (p = 0.67 comparing change between groups; [Table 3]). For the presurvey, all nine (100%) residency program directors from the professionalism
mentor group, and all six (100%) from the control group identified no departmental
complaints received by their Title IX office over the prior 10 months (one control
Title IX department notified the lead author directly). For the postsurvey, 2/8 (25%)
from the professionalism mentor group and 1/6 (17%) from the control group were prohibited
from answering this question. Among 11 remaining departments, only one (9%), from
the control group launched a Title IX complaint.
Table 3
Comparison of residency program director and professionalism mentor opinions regarding
sexual harassment over prior 10 months for programs randomized to control group versus
professionalism mentor group based on anonymous pre- and postsurvey
|
Respondents
|
Professionalism Mentor
N (%)
|
Control
N (%)
|
p-Value[a]
|
|
Pre
|
Post
|
p-Value[b]
|
Pre
|
Post
|
p-Value[b]
|
|
|
Residency program directors
|
n = 9
|
n = 8
|
|
n = 6
|
n = 6
|
|
|
|
Department supports reporting
|
9 (100)
|
8 (100)
|
1.00
|
6 (100)
|
6 (100)
|
1.00
|
1.00
|
|
Professionalism Mentor would be useful[c]
|
8 (89)
|
8 (100)
|
0.52
|
3 (50)
|
3 (50)
|
1.00
|
0.53
|
|
Educational sessions would be useful[c]
|
8 (89)
|
8 (100)
|
0.52
|
4 (67)
|
5 (83)
|
0.66
|
0.41
|
|
Academic medical departments should have:
|
|
|
|
|
|
|
|
|
Professionalism mentor + educational session
|
9 (100)
|
8 (100)
|
1.00
|
4 (67)
|
3 (50)
|
0.58
|
0.67
|
|
Educational session alone
|
0 (0)
|
0 (0)
|
2 (33)
|
3 (50)
|
|
Neither
|
0 (0)
|
0 (0)
|
0 (0)
|
0 (0)
|
|
Professionalism mentors
|
n = 9
|
n = 9
|
|
N/A
|
N/A
|
|
Department supports reporting
|
7 (78)
|
8 (89)
|
0.52
|
N/A
|
N/A
|
|
Professionalism Mentor would be useful[b]
|
8 (89)
|
8 (89)
|
0.15
|
N/A
|
N/A
|
|
Educational sessions would be useful[b]
|
8 (89)
|
8 (89)
|
0.58
|
N/A
|
N/A
|
|
Academic medical departments should have:
|
|
|
|
|
|
|
Professionalism mentor + educational session
|
8 (89)
|
7 (78)
|
1.00
|
N/A
|
N/A
|
|
Educational session alone
|
1 (11)
|
2 (22)
|
|
Neither
|
0 (0)
|
0 (0)
|
Abbreviation: N/A, not applicable.
a Difference between pre- and postsurvey were compared between professionalism mentor
and control groups using multinomial logistic regression.
b Chi-square test was used for all comparisons of categorical data, and t test and ANOVA for continuous data. For Likert questions, p-values compare overall results, even though only strongly agree or agree are shown.
c Averages the results of two differently worded Likert-style survey questions.
Discussion
In a recent survey of 7,409 surgical residents (comprising 99.3% of the participants
in the 2018 American Board of Surgery In-Training Examination), 31.9% reported gender
discrimination and 10.3% reported frank sexual harassment.[9] Rates of gender discrimination and sexual harassment were higher among women, with
65.1 and 19.9% of women reporting episodes of these mistreatments, respectively, associated
with higher risk of symptoms of burnout (odds ratio: 2.94; 95% confidence interval
[CI]: 2.58–3.36) and suicidal thoughts (odds ratio: 3.07; 95% CI: 2.25–4.19).[9] In a recent survey of ophthalmologists, 59% reported experiencing sexual harassment,[1] with 25% impacting their ability to work and 15% resulting in changed jobs or careers.
The reporting rate was only 15%. We set out to determine whether a professionalism
mentor could help improve workplace climate and sexual harassment reporting within
academic ophthalmology departments.
In this study, anonymously reported rates of sexual harassment over two 10-month periods
were high (16%) among 546 male and female faculty and trainee respondents across 16
academic institutions. As in prior studies,[9] most victims were females (76%), including both faculty (49%) and residents (39%).
Programs with professionalism mentors had an increase in incidents reported to an
authority from baseline (7–23%) compared with the control group, which had a decrease
from baseline (27–12%). The reasons for a decreasing reporting rate in the control
group are unknown, but possible explanations include decreasing enthusiasm for the
#MeToo movement over time and/or perceived increasing backlash against the movement.[10] The difference in change from baseline between groups approached statistical significance
in this brief study (p = 0.07).
The National Academies of Sciences, Engineering, and Medicine recently published a
comprehensive review of sexual harassment literature in academic departments revealing
that departmental and institutional culture, including leadership attitudes and subtle
forms of harassment (i.e., microaggressions), are the strongest predictors of sexual
harassment rate and severity.[4] The professionalism mentor is one approach to addressing departmental culture. Obstacles
to successfully implementing a professionalism mentor program include a lack of leadership
commitment and inadequate funding or interest in the voluntary role. Nonetheless,
faculty seemed eager to take this on. As one professionalism mentor commented: “[The
professionalism mentor] is an opportunity to have a key person in the department serve
as the go-to person for reporting, organizing educational events, and being the grassroots
cheerleader for spreading awareness and understanding of sexual harassment. When you
just bring in outsiders to educate or receive reporting, there is skepticism and distrust.”
Another professionalism mentor focused on the issue of gender and leadership: “I think
particularly in a department like mine, with men in all positions of leadership, having
a female professionalism mentor is absolutely critical in the residents feeling supported
in reporting any incidences of harassment.” For these reasons and others, most faculty
and trainees in the interventional arm of this study recommended instituting a professionalism
mentor with educational session (68%), compared with educational session alone (23%)
or neither (9%). Residency program directors in the interventional arm were even more
enthusiastic, with 100% recommending a professionalism mentor with educational session
program. Nonetheless, the sexual harassment rate did not change from the pre- to the
postsurvey, regardless of randomization. These results seem promising, but a large
shift in culture may take more time than was assessed in this study.
Only one report was provided to the professionalism mentor during this 10-month period,
suggesting that the reporting role of the professionalism mentor may have been less
impactful than the educational role. Sexual harassment education is a necessary component
of any prevention program,[6] both to encourage reporting of serious unprofessional behavior and to learn to respond
to milder forms of sexual harassment directly as a victim or bystander. Bystander
training is one of the few interventions shown to successfully prevent sexual harassment.[11] Training can help prepare clinicians to provide direct feedback to patients who
initiate sexual harassment, although education on reporting mechanisms for rare serious
allegations is also necessary.[12] These steps help build a departmental culture and climate in which individuals feel
empowered to speak out against and ultimately prevent sexual harassment.
The American Academy of Ophthalmology endorsed a clear zero tolerance policy toward
sexual harassment in 2018.[13] Rule 18 was later added to the code of ethics, creating an enforceable antiharassment
and discrimination standard for all fellows and members.[14] Despite existing structures and policies, sexual harassment and underreporting continue
in academics. The Academy and individual departments must explore new ways to address
this problem. While anonymous mechanisms and nondepartmental ombudsman are crucial,
a departmental professionalism mentor can clarify institutional reporting mechanisms
to minimize barriers to reporting more serious forms of harassment while creating
educational opportunities to learn preventative strategies. Clear definitions and
processes reviewed on a semiannual basis by a designated individual may help reduce
confusion among residents and faculty faced with deciding what, when, and how to report
incidents of harassment. Nonetheless, this study did not establish the feasibility
of a professionalism mentor outside a university setting, where lack of an investigative
Title IX infrastructure may introduce greater complexity to the role.
The results of our study should be understood within the context of its limitations.
Importantly, this study was based on a voluntary survey from a select number of ophthalmology
departments in which there may be bias toward over-reporting (victims may be more
likely to participate) or under-reporting (victims may be frightened to participate).
The higher response rate, greater program director enthusiasm, and lack of Southern
states (identified to have a higher sexual harassment rate) in the professionalism
mentor group may also bias the study results. Furthermore, we had seven programs drop
out and two groups switch after randomization, which may have led to unintended bias.
Because the control group did not exclude programs who went on to require sexual harassment
educational sessions or modules, this study may have underestimated the impact of
the professionalism mentor. Moreover, professionalism mentors were selected by departmental
leadership; it is possible that a different selection process would have resulted
in a more effective individual. Finally, given the large number of departments included
with individual departmental listservs, it is not possible to determine how many surveys
were sent and received, whether more than one response came from an individual and
a response rate cannot be obtained.
Despite its limitations, this study is the first to examine a method by which to improve
the reporting of sexual harassment in academic ophthalmology departments. We are hopeful
that departments across the country will consider a more formalized approach to education
and support of trainees and faculty with regard to this important issue.
