Thread by @arghavan_salles

Folks, this is a big study out today in @nejm by @kbilimoria et al. This is the most comprehensive assessment of mistreatment in surgical training that I have seen. Kudos to the authors for taking on this important issue. Here's my #tweetorial on it.

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https://twitter.com/kbilimoria/status/1188870807763636224

@NEJM @kbilimoria I’m going to focus on the women but want to acknowledge there are other important data—about racial discrimination and men—in this paper.

They surveyed residents at 262 programs and got responses from >7400 residents. Of those, 40% were women.

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@NEJM @kbilimoria @YueyungHu @ryanellismd A few points before going into the results: 1. These data were collected after the in-training exam. I have concerns about people’s mindset after a several-hour exam and their ability to really engage with the sensitive questions asked by this group.

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@NEJM @kbilimoria @YueyungHu @ryanellismd 2. Importantly, the authors have asked questions about “gender discrimination” and “sexual harassment” without defining them. For the record, gender discrimination IS sexual harassment.

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@NEJM @kbilimoria @YueyungHu @ryanellismd 3. They asked about discrimination based on gender, race, pregnancy/childhood. They also asked about verbal/emotional abuse, physical abuse, and sexual harassment. They combined all of these into a measure of “mistreatment.”

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@NEJM @kbilimoria @YueyungHu @ryanellismd Results: Almost 1/3 of women experienced gender discrimination at least monthly. The primary perpetrators were patients and their families. Nurses & staff were the second most likely perpetrators.

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@NEJM @kbilimoria @YueyungHu @ryanellismd About 1/3 of women experienced verbal or emotional abuse. The most common perpetrators were attendings.

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@NEJM @kbilimoria @YueyungHu @ryanellismd 10% of residents (20% of women) experienced sexual harassment. This is a lower-than-expected number and likely reflects a lack of understanding of what sexual harassment is rather than a low incidence of it.
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@NEJM @kbilimoria @YueyungHu @ryanellismd Overall, 71% of women experienced some form of mistreatment at least a few times a year.

THAT’S ALMOST THREE OUT OF EVERY FOUR WOMEN.

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@NEJM @kbilimoria @YueyungHu @ryanellismd I would love to know what the residents (and faculty) think sexual harassment is, and I suspect the data would look different if they had been given the definitions that are widely accepted (find them here: nap.edu/resource/24994…)

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@NEJM @kbilimoria @YueyungHu @ryanellismd My one note about men: they experience mistreatment as well, but far less than women across the board. The authors mention this in the context of burnout, which is important. I would have loved to see a discussion of how mistreatment affects women’s careers.

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@NEJM @kbilimoria @YueyungHu @ryanellismd Even though 40% of respondents (therefore residents) are women, only about 10% of full professors are women. Harassment is without a doubt a major contributor to the attrition of women from academic surgery.

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@NEJM @kbilimoria @YueyungHu @ryanellismd I would have loved to see a discussion of this in the manuscript. Lacking that, here’s my piece from last week: blogs.scientificamerican.com/voices/sexual-…

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@NEJM @kbilimoria @YueyungHu @ryanellismd cc @drjessigold @darakass @choo_ek @ETSshow @TIMESUPHC @HarrietHopfMD @JulieSilverMD @LillianErdahlMD @BuyskeJ @JFreischlag @MichaelaWst @LFiellin @TomVargheseJr @ultrasoundREL @heatheryeomd @AmaliaCochranMD @kipsDS2010 @EricTopol @picardonhealth @DrSinhaEsq @apoorvenayyar

@NEJM @kbilimoria @YueyungHu @ryanellismd @drjessigold @darakass @choo_ek @ETSshow @TIMESUPHC @HarrietHopfMD @JulieSilverMD @LillianErdahlMD @BuyskeJ @JFreischlag @MichaelaWst @LFiellin @TomVargheseJr @ultrasoundREL @heatheryeomd @AmaliaCochranMD @kipsDS2010 @EricTopol @picardonhealth @DrSinhaEsq @apoorvenayyar @susieQP8 @SarehParangiMD @slsteinmd1 @WomenSurgeons @ShikhaJainMD @MamtaSwa @AMarshallMD @FutureDocs @mcwhmd @sepideh_gholami

Responding to a point of controversy. When I suggested people don’t know what harassment is, I meant they don’t know the actual definitions of harassment (most easily found in the @theNASEM report), not that they don’t know if they are experiencing it. Harassment is rampant...

...in medicine and surgery. We can become numb to it, only seeing the most egregious examples and brushing less egregious things under the rug. That is exactly what could lead to underreporting on a survey. That’s all I meant by that.