The first of this trilogy of articles highlights stories of some of our peers who have faced harassment or discrimination while at work and demonstrates the need for obstetrician–gynecologists to build professional environments that embrace inclusion and diversity.1 The second article uses the example of racial discrimination as a framework around which to provide tools individuals may use when they experience or observe discriminatory and biased behavior in the workplace.2 Finally, this article provides recommendations that the larger health care team, organization, or institution can use to foster a culture in which individuals are supported to combat harassment, discrimination events, or both in the workplace. In these articles, as outlined by the U.S. Equal Employment Opportunity Commission, harassment is unwelcome conduct that is based on race, color, religion, sex (including pregnancy), national origin, age, disability, or genetic information.3 We define discrimination as treating someone less favorably because of a personal characteristic protected by law.4
Although overt bigotry about any characteristic is relatively easy to identify by most witnesses, these instances tend to occur rarely in the health care environment. Far more common and insidious, microaggressive behavior can contribute to poor health outcomes for patients, physician burnout, and dysfunctional teams. Sue defines migroaggressions as “the brief and commonplace daily verbal, behavioral, and environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial, gender, sexual-orientation, and religious slights and insults to the target person or group.”5 Examples from our colleagues' stories in the first article include the nurse suggesting that her patient would not want to be cared for by a “gay male Jewish doctor” and a patient noting that an Asian medical student reminded him (a veteran) of a prostitute he once frequented when deployed in Asia.1
We propose a bundle of resources that organizations may consider to prepare their health care teams for harassment and discrimination events, whether overt macroaggressions, or the microaggressions described previously. These organizations may include but are not limited to medical schools, academic or community hospitals, private practices, multispecialty groups, or residency programs. We have chosen to use the obstetric safety bundle rubric here, because it is both familiar to practitioners in our field and because its use has been proven effective in decreasing morbidity from serious adverse events, a category in which harassment and discrimination in medicine may well be described. Although it is our belief as authors that the individual bundle components listed subsequently have the potential to improve outcomes around harassment and discrimination in our field, we recognize little robust evidence exists to support this assertion and have included the need for peer-reviewed data around best practices in the “Reporting/Systems Learning” domain subsequently.
RECOGNITION AND PREVENTION
Assess your unit's risk for events before they occur
Has a survey been done to assess the experience of discrimination or harassment among your team? Consider using pre-existing surveys on racial discrimination or sexual harassment or create your own.6 Consider asking all team members to complete a validated survey about diversity and inclusion addressing your institutional culture. As an example, the Diversity Engagement Survey is available at AAMC.org.7 This 22-item survey has been used at the health system level to assess baseline strengths and opportunities for growth in diversity and inclusion efforts; measure workplace engagement among specific groups; define strategic growth directions; and collect longitudinal data on diversity and inclusion.8 The Association of American Medical Colleges website also includes an hour-long instructional webinar on application of the Diversity Engagement Survey in your institution.
Take the pulse of your unit with implicit bias testing; Require that all members of your team complete implicit bias testing
The Implicit Association Test is online and allows individuals to complete a confidential assessment of their implicit biases, and can focus on a number of areas including gender, race–ethnicity, and disability.9 Consider interdisciplinary didactics or an educational series around implicit bias to set the stage for this topic. Depending on your practice environment, potential collaborators in this activity could include the highest level of organization leadership along with a diversity and inclusion committee representative, chief executive officer, chief medical officer, and human resources director. Although taking the test may not change behavior, it does allow acknowledgment of the issues and a starting point for further exploration.
Establish, communicate, and enforce patient and guest responsibility to treat all people in your facility with respect and without threat
Develop a unit- or facility-wide policy that is communicated to patients and which establishes your commitment to all of your staff by indicating that health care providers will not be changed at the patient request on the basis of discrimination or bigotry. An example of this is in the Patient Rights Policy from the Penn State Health Milton S. Hershey Medical Center, which states that “requests for changes of provider or other medical staff based on the provider's race, ethnicity, religion, sexual orientation or gender identity will not be honored” (available online at https://bit.ly/2BssGgX). Consider how such a policy would be implemented to avoid escalation of difficult situations while maintaining the commitment not to support a patient's bigotry in the clinical setting. Learners are particularly at risk for such behavior and their supervisors must be aware of clinical policy and how to support their learners.10
It is reasonable to consider introducing the unit- or facility-wide policy early during a patient's first visit to an office practice or in the hospital. For instance, during prenatal care, patients could be advised about the policy in labor and delivery to allow the patient time to seek care elsewhere if such a policy is not acceptable to her and to avoid high-emotion encounters in labor and delivery when alternative plans may not be possible. For instance, if a woman requests that a female-only health care provider participate in her care, the reasons for this request can be explored and the limits of the unit's ability to comply with this request discussed. There are women whose religious cultures preclude male health care providers, and there are women who have had traumatic assaults or abuse by men in the past for whom a male health care provider intrapartum, for instance, would be emotionally devastating. Early discussions about the policy and culture of the unit (health care team, inpatient unit) are important. A balance between supporting staff and providing patient-centered care in questions such as this can be hard to strike. Overt clarity within the group and around communication with patients will at least promote the opportunity to do so in a rational and systematic way.
Build a team that is diverse and inclusive
Partner with diverse groups to increase the talent pool. For example, Indeed.com, an employment business leader, suggests that a multipronged approach is needed to increase workforce diversity. As such, this company partners with Girls Who Code, StemConnectors, and other nonprofit groups that focus on young women and underrepresented minority students gaining science and technology skills to better compete in the workforce.11 For academic programs, critically review your residency selection process with an eye toward increasing applicant diversity. This could include cultivating a cadre of faculty and residents specifically trained to consider the needs of diverse candidates, developing relationships with specific institutions where underrepresented candidates are plentiful (for example, historically black colleges and universities) and deliberately developing a resident match list to address the goal of enhanced diversity, however that may be defined. Finally, investigate the offerings and activities within your hospital, health system, medical school institution's office, or all of these for diversity and inclusion, if it exists. This would allow your diversity and inclusion commitment to be aligned with the mission of the larger institution. The Association of American Medical Colleges' Diversity and Inclusion Strategic Planning Tool Kit may be a valuable resource for practices or institutions without an existing diversity and inclusion office.12 Another resource available through the Association of American Medical Colleges, Striving Toward Excellence: Faculty Diversity in Medical Education, could serve as a primer for a department or practice committed to developing a diverse and inclusive workforce.13
Train your team to identify and respond to microaggressions
Consider formal didactic or team-building sessions around microaggressions, because such training in medicine has been associated with an increased ability for individuals to recognize microaggressions when they occur.14–17 Encourage teams to work together to develop scripted language for how they would respond to microaggressions in the workplace. What is the role of an ally in that situation? Role-playing might be a useful tool.
Practice your team's response plan to harassment or discrimination events
Simulations or drills around rare but potentially morbid events are now a mainstay of most medical safety bundles. Consider using a book or journal club setting as an opportunity for your team to process how they would respond to a hypothetical harassment or discrimination event. For example, Picoult's18 novel Small Great Things may be particularly relevant to our field, because it navigates the complexities of a highly accomplished labor and delivery nurse denied the right to provide care on the labor ward for a family with white supremacist beliefs and the downstream consequences thereof. Consider asking the questions: what would we do if this happened here? How would we respond? To whom would we report the event? Who has decision-making rights in these settings? As an alternate resource, Reynolds et al published a discussion article about the refusal of a parent in the pediatric emergency department to allow a black female medical resident to touch his child because he “preferred a white doctor.”19 The discussion focuses on how the preceptor and the resident should respond and those responses could be applied to other instances of discrimination, harassment, or both.
Codify the expected responses and ladder of responsibility to activate if a team member experiences bigoted or discriminatory behavior
Identify an interdisciplinary group of champions around this issue and create a standard checklist of the steps someone should take if he or she becomes aware of harassment or discrimination that is unable to be addressed by the team members directly involved. As with any checklist, be specific. Include phone numbers and email addresses where appropriate. Include a backup plan if the first contact is unavailable. Consider whether these events may be reported anonymously online through a risk management portal. If so, ensure that the portal is set up to capture all metrics your champions deem critical. Make sure this checklist is widely available for all of your staff to access. If this checklist is completed before you run unit-based simulations (see previously), include it during your simulation.
If the harassment or discrimination event originates with a patient, the individuals at the bedside should try to mitigate the situation. One helpful contextual framework is that of Paul-Emile in “Dealing With Racist Patients” (https://www.nejm.org/doi/10.1056/NEJMp1514939), in which she outlines five ethical and practical factors for institutions to consider in developing standards to approach these difficult situations.20 Although her focus is on racial bigotry, the information is generalizable to other targets of bigotry such as gender, age, religion, sexual orientation, and ability. Importantly, these factors include not only delving into the patient circumstances that guide a response, but also the effect that response and interaction has on the person providing care. This important resource provides an actionable framework both for training care providers to manage these interactions and also for individuals and teams to help build patient-centered responses that help to build resilience and support for affected teams. This work is highlighted in more depth in the article by Premkumar et al in this issue (p. 820).2
Debrief the event
The medical, nursing, and administrative staff involved in the event may experience anger, frustration, shame, and victimization. It is reasonable to have a facilitator who was not involved directly to discuss the event and offer support. Developing the skills to be effective in such debriefs will likely require faculty and staff education. These emotionally charged events can be unfamiliar and uncomfortable to many participants. A short standardized debrief instrument such as the debrief checklist recommended by TeamSTEPPS may be amended for use in these situations.21
Track data on harassment and discrimination events as you would any other quality measure
Use this information to review and design interventions to address systemic problems. Specific diversity and inclusion goals should be articulated with metrics measured and reported back to the end-users. We suggest developing a dashboard for harassment, discrimination, and diversity and inclusion metrics, similar to that used for institutional quality metrics. High-functioning teams rely on transparent and timely communication of outcome metrics.
Ask to be graded
Consider conducting periodic surveys, focus groups, or exit interviews with team members who are historically at higher risk for experiencing discrimination (eg, women; underrepresented minorities; gay, lesbian, and transgender staff; and people with disabilities). Ask the important questions: What are our institutional blind spots? What can we do to create a healthier work environment? If you were asked to be in charge of fostering our culture of diversity, inclusion, and safety, what would you do?
Share best practices
Report your successes and failures to allow others to learn from these experiences. Define core outcome measures for diversity, inclusion, and safety in our field. Rigorously test the interventions suggested as well as others and share best practices widely, including at national meetings such as the American College of Obstetricians and Gynecologists or the Council on Resident Education in Obstetrics and Gynecology and the Association of Professors of Gynecology and Obstetrics.
The time to address harassment and discrimination is now. When employees or patients exhibit racism and bigotry, it can interfere with patient care, damage a relationship, destabilize a working team, and disrupt a unit. Developing an organizational culture that does not tolerate such behavior is critically important. A diverse workforce that is aware of their own unconscious or conscious bias can more effectively provide care for patients and each other when harassment and discrimination events occur. By adopting this bundle of interventions to create a diverse workforce focused on fostering a culture of inclusion, hospitals and other health care units can help patients receive the best care possible while supporting its entire staff.
1. Chescheir NC, Benner RS. Bias in obstetrician–gynecologists' workplaces. Obstet Gynecol 2018;132:813–19.
2. Premkumar A, Whetstone S, Jackson AV. Beyond silence and inaction: changing the response to experiences of racism in the health care workforce. Obstet Gynecol 2018;132:820–27
5. Sue DW. Microaggressions in everyday life: race, gender, and sexual orientation. Hoboken (NJ): John Wiley & Sons, Inc.; 2010.
6. Atkins R. Instruments measuring perceived racism/racial discrimination: review and critique of factor analytic techniques. Int J Health Serv 2014;44:711–34.
10. Whitgob EE, Blankenburg RL, Bogetz AL. The discriminatory patient and family: strategies to address discrimination towards trainees. Acad Med 2016;91(11 Association of American Medical Colleges Learn Serve Lead: Proceedings of the 55th Annual Research in Medical Education Sessions):S64–9.
15. White-Davis T, Edgoose J, Brown Speights JS, Fraser K, Ring JM, Guh J, et al. Addressing racism in medical education an interactive training module. Fam Med 2018;50:364–8.
16. Almond AL. Measuring racial microaggression in medical practice. Ethn Health 2017 Aug 1 [Epub ahead of print].
17. Sue DW, Capodilupo CM, Torino GC, Bucceri JM, Holder A, Nadal KL, et al. Racial microaggressions in everyday life: implications for clinical practice. Am Psychol 2007;62:271–86.
18. Picoult J. Small great things: a novel. New York (NY): Ballantine Books; 2016.
19. Reynolds KL, Cowden JD, Brosco JP, Lantos JD. When a family requests a white doctor. Pediatrics 2015;136:381–6.
20. Paul-Emile K, Smith AK, Lo B, Fernández A. Dealing with racist patients. N Engl J Med 2016;374:708–11.