Have your staff members been sexually harassed by patients? Due to underreporting, the problem may be more prevalent than some ophthalmologists realize. Such harassment can be a complex issue to address, but there are steps that you should take, said Julia Lee, JD. It is vital to have clear written policies; special training to recognize and respond to sexual harassment; support for ophthalmic team members; and protocols for dealing with patients who transgress, said Ms. Lee, at Lee Vision Associates in Cherry Hill, New Jersey.
Harassment by Patients
Why harassment is underreported. Instances of harassment can be subtle; they often aren’t recognized for what they are; and they can be brushed off as unimportant. Many incidents involve comments by patients, said Ms. Lee, and although staff members can find such remarks discomfiting, they’re not quite sure how to respond and often don’t report the incident. “I think we’ve learned over the years just to make light of it, and tend to report only the more glaring, serious, and readily identifiable instances.”
Why It Matters
Patients’ sexual harassment of staff can have devastating consequences for a medical practice. Even incidents that seem minor may contribute to employee burnout, increased staff turnover,1 and exposure to lawsuits.
Normalization of bad behavior. When patients step over the line, does anybody say anything to them? If not, those patients may feel emboldened to continue the harassment, said Ashley Geary, JD. Furthermore, such nonresponses don’t go unnoticed by staff, who may see the failure to act as a sign that management doesn’t care about how the harassment is affecting them, said Ms. Geary, who is with Wade, Goldstein, Landau & Abruzzo in Berwyn, Pennsylvania.
Impact on team members. Bradley Katz, MD, PhD, said that harassment can add to stress at a time when ophthalmology is “overwhelmed by physician burnout, nurses quitting, and technicians dropping out.” Supporting residents, physicians, and staff is critical for personnel retention, said Dr. Katz, of the University of Utah Health Sciences Center and the John A. Moran Eye Center, Salt Lake City.
Legal risk. Ongoing patterns of harassment could lead to employee lawsuits, said Ms. Geary. If practice owners or management become aware of harassment, they should respond promptly and appropriately to stop or mitigate the problem, she said. “If they don’t do so, they are at risk for a hostile work environment claim.”
Harassment Workshops: Role-Play and Scripted Responses
Recognizing sexual or gender-based harassment in the moment can be difficult, especially for residents and trainees who are just beginning their careers.
That’s why the workshops that Dr. Polski recently presented at Moran Eye Center, which were adapted from a University of Iowa workshop, used role-play so that participants could try responding to different scenarios.
When is the line crossed? Most people know that sexual propositions and touching are inappropriate, but what about comments like “You would be prettier if you smiled more,” and, “Are you sure you’re not the nurse? Where’s the real doctor?” Dr. Polski said that it is sometimes hard to know when a line has been crossed, but interactive sessions can help clarify the boundaries.
Defuse the situation while setting boundaries. In the workshops, physicians practiced strategies for responding to patients whether they are the one being harassed or they observe harassment of a colleague, said Dr. Polski. These techniques defuse situations so that physicians can respond in a way that maintains rapport with patients and preserves the patient-physician bond, “while still protecting yourself and protecting your colleagues.”
Scripts can make it easier to respond. In working with workshop participants, Dr. Polski suggests scripted responses—which had been developed by the University of Iowa workshop—such as:
- “I feel uncomfortable when you comment on my physical appearance.”
- “I’m sure you didn’t mean to be hurtful when you said that, but it made me feel …”
- “I’m sure that you didn’t mean to make me feel this way, but this is how your words impacted me.”
Focus on the behavior, not the person. Addressing the behavior, rather than the harasser, can help de-escalate situations and educate the patient “in a way that allows you to have a productive patient-physician relationship moving forward,” said Dr. Polski. For example, saying, “I felt disrespected when you said that,” is less likely to make a patient respond defensively than, “You are disrespectful.”
Be prepared. “I’ve absolutely experienced uncomfortable situations, even in just two years of residency training,” said Dr. Polski. “And for me, thinking about these different communication strategies ahead of time makes that feeling of uncertainty and surprise so much less.”
Policies and Training
Make policies crystal clear. “What you can do as an organization is to put appropriate policies, procedures, and communication pathways in place,” said Ms. Lee. Indeed, the best way to head off sexual harassment is to ensure that patients, staff, and ophthalmologists understand what behavior will not be tolerated.
Written policies for patients. Ms. Geary advises that practices give patients the sexual harassment policy along with other intake information. These materials also could cover other antidiscrimination policies that the practice stands by, such as prohibiting harassment based on gender, race, ethnicity/nationality, or religion. “It would basically advise patients that harassment of any type is not tolerated in the practice, and that a patient who takes part in harassment may be subject to dismissal,” she said.
Written policies for staff. Internal policies should be clearly defined and available in writing to staff in, for instance, the employee handbook, said Ms. Lee. When an incident is reported, staff and ophthalmologists should know which protocols to follow.
Sexual harassment training. Ms. Lee said that training for all physicians and staff is important, at practices large and small. “Sexual harassment is not exclusive to patient-staff interactions and relationships, so hopefully the practice is creating a culture of safety by having training programs in place,” she said, noting that relevant videos, webinars, and other materials are available.
Interactive role-play sessions. Certain types of training are designed to help ophthalmologists and staff anticipate and prepare for sexual harassment incidents. For example, Ashley Polski, MD, a second-year resident at the University of Utah’s Moran Eye Center, recently led two workshops with support from Dr. Katz and two other Moran ophthalmologists. The workshops featured interactive discussions and role-playing and were offered to faculty, residents, and fellows. Participants could try responding in real time to unwelcome comments, such as “You’re too pretty to be a doctor,” or “Do you have a boyfriend?” Remarks like these often leave staff and physicians uncertain of how to respond, Dr. Polski said.
Dr. Polski did pre- and post-workshop surveys to measure the effect of the interactive sessions. “Participants reported significant improvements” in their ability to recognize and respond to sexual harassment, she said.
How to Respond to Harassment
When sexual harassment occurs, how should the practice respond? Scripted statements can help staff in their initial response to a patient. The incident should be reported to a designated team member, and a practice manager or an ophthalmologist should be engaged in the process.
Let staff know that they can respond to harassment. Ms. Geary said that team members should respond according to the threat level. If it’s a relatively innocent statement such as, “That shirt looks nice on you,” she suggested not ignoring or excusing the remark, but also acknowledged that dismissal or a reprimand is likely not warranted. In such instances, team members can respond with a statement along the lines of, “Thank you, but let’s keep communications limited to your medical issues.”
Prepare scripted responses. Staff can respond in a polite and professional way to redirect the conversation and de-escalate the situation. “Script what you want to say and equip people with talking points in a diplomatic way that doesn’t make light of it,” said Ms. Lee.
Encourage staff to report harassment. Staff members who report such incidents should be reassured and thanked for coming forward, Ms. Geary said. A single report “most likely isn’t going to result in termination of that patient, but it will make the management and the supervisors aware that it’s happening. It will show employees that you care, that they have support, and that you hear them.”
Acknowledge the generation gap, but don’t make it an all-purpose excuse. Ophthalmology patients tend to be older, and sometimes there is a disconnect between what patients and staff view as appropriate remarks. No matter how innocent the remarks may seem, Ms. Lee recommends that all incidents be documented in a patient’s chart so that staff are aware going forward. A more serious situation may develop if such remarks are repeated or become more aggressive.
Prioritize safety. If staff members or ophthalmologists feel unsafe with a patient, they have the right to leave the room immediately, said Ms. Lee. “Once that happens, there should be a policy in place that either the supervisor, an administrator, or the physician have a conversation with that patient while it’s still fresh in everyone’s mind.” That conversation should emphasize that the patient’s words and/or actions were inappropriate, made the staff member or physician uncomfortable, and will not be tolerated. Some patients will be very embarrassed and acknowledge what took place, said Ms. Lee, but others “will get very upset and say, ‘Oh, you’re overreacting!’” When the patient is hostile to the feedback, more steps may be called for, such as written communication from the practice to the patient, a requirement that a family member or caregiver must accompany the patient at all times, or making sure that there are always two staff members in the exam room with the patient.
Taking the final step—discharging problem patients. If all else fails, you may need to terminate the physician-patient relationship. Because of possible legal ramifications, it’s not a step taken lightly, Ms. Geary said. A disgruntled patient could potentially report the physician to the state board or even file a malpractice lawsuit claiming patient abandonment if they suffered injury as a result of the termination. Practices should notify the patient in writing that the relationship will be terminated and internally document the basis for discharging him or her from the practice. For very serious situations, such as sexual or physical assault, discharge can be immediate.
More typically, a 30-day notice is given to the patient directing them to find a new physician while also informing the patient that they can contact the practice if an emergent situation arises during the notice period. Ms. Lee recalled one patient who was terminated because he “came on to a technician.” She noted that there are specific guidelines from the Ophthalmic Mutual Insurance Company and other medical organizations on how to discharge patients. “He was not a patient with a chronic condition, so we didn’t have to transition care for him.”
Misbehavior requiring termination is extremely rare, said Ms. Lee. “What’s much more common is that gray area, and that is, in some ways, much harder to manage.”
See Something, Say Something
Practices should advise staff members to report harassment that happens to them or that they observe happening to other team members. Sometimes “the victim of the harassment may be so embarrassed and so emotional that they don’t want to say anything,” said Ms. Geary. “If everybody around that staff member averts their eyes and says nothing, what does that say to the patient? It suggests that their behavior is permissible or at least is not going to be stopped.” All staff members should feel that they can report harassment without worrying about being penalized for speaking up, she said.
1 Mathews E et al. Ochsner J. 2019;19(4):329-339.
Ms. Geary is a partner attorney with Wade, Goldstein, Landau & Abruzzo, a transactional health care law firm in Berwyn, Pennsylvania. Relevant financial disclosures: None.
Dr. Katz is Professor of Ophthalmology and Neurology at the University of Utah Health Sciences Center and the John A. Moran Eye Center, Salt Lake City. Relevant financial disclosures: None.
Ms. Lee is the practice manager for Lee Vision Associates in Cherry Hill, New Jersey. Relevant financial disclosures: None.
Dr. Polski is an ophthalmology resident at the John A. Moran Eye Center, University of Utah, Salt Lake City. Relevant financial disclosures: None.
For full disclosures and the disclosure key, see below.
Full Financial Disclosures
Ashley Geary None.
Dr. Bradley Katz Avulux: C, PS, P; Iacta Pharmaceuticals: C, SO; VistaGen: SO.
Julia Lee Modernizing Medicine: C; NorthStar Vision Partners: C.
Dr. Ashley Polski None.
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