Rantner: A very warm welcome to a new episode of ‘Focus on Vessels’. My name is Barbara Rantner. I am a vascular surgeon and senior consultant at the TUM Medical Centre in Munich, and I am delighted to be presenting this podcast with you again today.
This podcast is designed to offer you, our listeners, a platform to delve deeply into the topics that shape and advance our speciality. Together with our guests, we’ll be exploring the latest developments in surgical, endovascular and preventive vascular medicine, and discussing current issues from the worlds of science, teaching, clinical practice and the healthcare sector. True to our motto: We’re taking vascular medicine further. Today we’re turning our attention to a non-vascular surgical topic – a highly controversial and topical issue that has attracted widespread attention, at least since the MeToo campaign originated in the US, and which, as has now been confirmed once again, is, unfortunately, omnipresent in the medical environment. Today we want to talk about sexual harassment and abuse of power in everyday medical practice.
I’ll be discussing just how relevant and widespread this problem is, particularly in surgical specialities, with my guest today, Dr Johna. She is herself a specialist in internal medicine and the chair of the Marburger Bund, which recently conducted and published a nationwide survey of its members on this topic. I believe you presented the highly alarming results back in April at a press conference, so you are very familiar with the findings.
Dr Johna, I’m delighted to have you here today and would like to thank you in advance for taking the time to speak with me.
Johna: Yes, I’m very happy to do so, Ms Rantner.
Rantner: I briefly mentioned the Marburger Bund’s survey at the start; that’s the perfect starting point, so to speak, for looking at this topic in detail. It was a very impressive project; a total of around 9,000 doctors took part in this survey, and the majority were hospital-based, meaning there were few Vascular Surgeons in private practice. The survey included questions on both abuse of power and sexual harassment. Ms Johna, would you be so kind as to summarise the most relevant findings of the survey for our listeners once again, and perhaps also explain what prompted you to design this survey in the way you did – and perhaps also why now, of all times?
Johna: Yes, ‘why now?’ is certainly a valid question. We found, in two smaller surveys – one in Hamburg and one in Bavaria, both conducted by our regional associations – that a regional survey had taken place, naturally with fewer participants. In some respects, these were even slightly more extensive and, in Hamburg for example, also covered issues such as racist abuse and other forms of discrimination. But we saw there that, yes, abuse of power and sexual harassment are relevant issues. We’re no longer just talking about isolated cases here, which is why it was so important to us to organise a truly wide-ranging survey – so that we wouldn’t have to keep hearing arguments like, ‘Well, only about 400 people took part, so how relevant is that really?’
We’ve now got a survey for which we took a very long time to finalise the questions, because it was absolutely vital to us that there was absolutely nothing in there that was unclear or where one might say the question already suggests a certain kind of answer. We also worked with Professor Clemens from the University of Ulm, who guided and supported us a bit along the way. We also looked closely at a survey that was published in Switzerland in December – or actually, it wasn’t published until January – and adopted some elements from it; for example, we simply asked: ‘Have you experienced abuse of power or sexual harassment in the last year?’ So the survey period covers just one year. This gives us the chance to follow up in a few years’ time, carry out another survey and then, hopefully, find that the measures have taken effect and the problem is diminishing. So, what exactly was the problem?
Just under half of those surveyed told us that they had experienced abuse of power in the past year. More than half of them experienced it several times a month, and in some cases several times a week. And particularly common are verbal comments, a condescending tone, disrespect, and the unfounded questioning of the professional competence of those affected. And only then – thank goodness, at least – does the public humiliation of doctors follow, for example in a large meeting. In this respect, the forms of abuse of power are often subtle, but sometimes also very explicit. We have also received more than 400 pages of open-ended responses from our members. And when doctors take the time to write such extensive free-text responses, it tells us quite clearly just how deeply this issue weighs on their minds.
Yes, that was one area of the survey, and the other area was sexual harassment. And whilst abuse of power does predominantly affect women, though male colleagues are also affected, in the case of sexual harassment it was overwhelmingly women who reported this to us, and overwhelmingly men who were the perpetrators of the sexual harassment. Thirteen per cent stated that they had experienced sexual harassment in the past year – in this context, too, predominantly verbal comments of a sexual nature. Let me give you an example from the open-text responses: ‘So, how was your holiday? I hope you had enough sex.’ That’s very clear indeed. But physical contact is also reported – sometimes seemingly accidental, but at other times quite explicit. And I must tell you quite honestly, when you read the open-text responses, it sometimes leaves you speechless. The examples cited are that shocking, and they often occur in the context of clear power imbalances, that is, clear hierarchical relationships, where doctors in training are the ones affected, and those who should actually be taking responsibility and leading responsibly are the very ones who end up being the perpetrators of such sexual harassment.
And for me personally, almost the most shocking finding of the survey is that most of these incidents are not reported anywhere. We asked both those affected and witnesses. So, in cases of both abuse of power and sexual harassment, we also asked: ‘Did you witness this, and how did you react as a witness?’ And we found that, yes, witnesses do react slightly more often, though not by much, and this silence – that’s actually terrible, and that’s what we want to break, this silence among other things; you do too, otherwise we wouldn’t be having this conversation today.
Rantner: Yes, well, those are truly very striking and sobering figures. It’s very easy to find the survey results online; you’ve already provided a set of slides, so to speak, where people can take their time to look at the results, and I can only recommend that anyone who’s interested take a closer look at the findings.
My first thought was that we’d looked at the survey carried out by Professor Clemens, who conducted this survey at the university hospitals. So, are these results, so to speak, a consequence of people being more aware of the issue, of the fact that talking about it is now at least somewhat less taboo? But as you’ve already said, there’s still very little response to it. Or is it simply the harsh reality we live in – and that’s at least what’s happening, with unreported cases not yet accounted for? What’s your impression on this?
Johna: I do think so; that is essentially the reality. Of course, it’s true that perhaps because the issue is being discussed more widely across society, it’s being noticed a bit more – or perhaps perceived even more clearly. But I’ve often been asked in this context, ‘Well, we had this 30 years ago too – has it actually increased at all?’ I can’t answer that question with certainty, but I do think that, on the one hand, we’re talking about a problem affecting society as a whole. We’re dealing with a societal issue here, and one might well ask why it’s so particularly pronounced in medicine – is it actually more or less prevalent? There are surveys from other professional contexts to draw on. They’re generally much smaller in scale, but we can still see that this happens in other professional contexts too. But as you mentioned, it was mainly hospital doctors who responded; we have a pronounced hierarchy in hospitals, even more so than is often the case in other professional contexts. And our professions also involve a high degree of physical contact. We’re used to crossing boundaries. We’re used to seeing people who are scantily clad or not at all. And one might perhaps speculate whether that has something to do with it. We are used to standing very close together at the operating theatre table – particularly you as surgeons – sometimes for hours on end. Perhaps that also plays a part in the end, but the biggest factor is certainly this stark power imbalance and the dependency, which is undoubtedly particularly acute for colleagues in training and perhaps even more so in surgery than in other specialities, as everyone relies on being allocated to the operations they need.
Rantner: This, which we’re already used to, brings me to a little story I’d like to share with you from my student teaching sessions over the last few months, where we role-play such hospital ward scenarios in small groups. So, there are the roles of the senior registrar and the ward doctor during a post-operative round, and actors were invited to play the patients. And the university actively incorporated a scene of sexual harassment – in quotation marks – into the exercise. Not just between colleagues, but also to reflect the reality of medical practice, including harassment by patients and perhaps even relatives. And in this specific case, what happened was that during the ward round discussion, after the junior doctor had told the patient he could soon be discharged from inpatient care, the patient said to her, that she was such a lovely and kind doctor, so pretty, and that he’d like to stay a few days longer. When you’re in such good hands, you don’t feel the need to rush home, and as she was so very pretty, he’d like to extend his stay. And the female medical students really did handle that scene – I wouldn’t go so far as to say it was alarming, but it was certainly surprising to me – with great composure. It didn’t rattle any of the girls at all, and we discussed it afterwards; overall, the feedback was that this sort of communication and this experience hadn’t really been categorised as sexual harassment, one way or another. Yes, and from my own career experience, I must of course say that the boundaries do become a bit blurred. You experience a great deal, as they said, particularly now at this stage of my surgical career. There’s contact with patients, and amongst colleagues, a lot of it is physical; a lot of it takes place in confined spaces with little personal distance. How do you see it? Is this something we now take for granted? Where do you draw the line, because that naturally also implies the question of at what point one must or should react – either oneself or perhaps when one finds oneself in the position of an observer? Yes, what is acceptable – or is anything at all acceptable in this context? How do you see it?
Johna: Well, there’s certainly no clear-cut line there at all. There’s probably a clear-cut ‘black’ in the sense of, ‘that’s crystal-clear sexual harassment’ – so, let’s say, if someone touches your breast or if someone makes comments like the ones I mentioned earlier about the skiing holiday, that’s obvious. Then there are certainly things where everyone agrees that it’s simply not a problem at all, and in between there’s a whole lot of grey area between black and white. But the crucial thing is how the person who is, so to speak, the recipient of the message feels about it. It’s just like any form of communication: there’s a sender and a receiver. And the very same remark, made by, say, a colleague of the same age whom you’ve known for three years and who might even be a friend, can be harmless. But if that exact same sentence comes from someone who is 30 years older and where there’s a significant power imbalance, then it’s simply no longer acceptable. And then the recipient also feels this sense of dependence and perceives it as disrespectful towards her, even though in the other situation it might be completely harmless. Just as we might give someone we know well a hug when we greet them, that simply wouldn’t be acceptable if we barely know the person and there’s a power imbalance.
And I think that’s the key message: ultimately, it comes down to how someone experiences it. And that’s why it’s also important, if it’s experienced negatively, to call it out and set boundaries. To say, ‘I found that completely unacceptable.’ Ideally, straight away.
I’ve also been involved in quality assurance and patient safety for many years, and unfortunately we see similar results in surveys: when we notice that someone has just done something incorrectly – even something as trivial as failing to disinfect their hands before changing a dressing – we say nothing. So people – colleagues – do see it, but they say nothing. And I think we still have a problem here, even in communication amongst doctors themselves, in that it’s taken for granted that even the students, the clinical trainees, can now say, ‘Hold on, remember to sanitise your hands.’ That this should be a matter of course – it isn’t in medicine, but it must become so.
And this ‘peak-up’ – as it’s called in patient safety – is exactly what we need when it comes to the issues of abuse of power and sexual harassment. Because when we look at these, as I said, from these open-text responses, when we read through them and see that, yes, there’s the humiliation in front of all their colleagues – then it’s, so to speak, doubly traumatising. On the one hand because it happens, and on the other because everyone else remains silent. And something urgently needs to change here, because we’re losing colleagues. Those of us who experience this sort of thing frequently go into a state of ‘internal emigration’ and can no longer devote our full energy to our patients. And in that respect, it is absolutely essential that we address this issue and, yes, that we also raise awareness of it amongst managers and make it clear that, for those in positions of power, words carry greater weight.
Rantner: You’ve already mentioned it several times: when it comes to women, there is, unfortunately, very often a combination of abuse of power and sexual harassment, which certainly makes the whole situation more difficult. One can well imagine that when trainees find themselves in a situation where they are being sexually harassed, but are also exposed to abuse of power, they fear that their training will suffer if they were to stand up to someone higher up in the hierarchy.
Throughout my own career in surgery, I’ve often been asked whether I’ve experienced this myself. Fortunately, I can say quite clearly that I haven’t. I’ve never found myself in a situation where I’ve been harassed in that way whilst an abuse of power was taking place at the same time. Fortunately, I have generally had little experience of abuse of power. But do you think that this naturally leads to such a situation? As you said, it is astonishing how little of this is made public. The fact that even bystanders rarely speak out suggests that everyone is somehow afraid that it will have negative consequences for them too. I mean, as I said, you can certainly understand those directly affected, but also the observers or witnesses to these scenes – the fact that, on the whole, so little is done about it – what do you make of that?
Johna: Yes, I do think so. For one thing, people are bound to say: ‘No, I’m worried about that now. What might my training certificate look like in the end? Will I be able to stay in surgery? Will I be assigned to the operation I need? Might I be transferred to a ward I don’t want to work in? And so on. So there are certainly very specific fears, and we can see that too – it’s quite clear from the results of our survey, because we also asked why they hadn’t reported the incident, both those who had to experience it and the witnesses. And very often, people state that they fear personal repercussions, and very often they say they believe that reporting it won’t change anything at all. So the lack of consequences is cited just as frequently, and that, of course, is also a warning sign.
And then we asked those who had reported the incident – those who said, ‘Yes, I did report the incident, what were the consequences?’ And unfortunately, it became clear that those who said ‘nothing will happen anyway’ were proved right, because in most cases nothing changed; in some instances, at least, there was some clarification – that is, discussions took place. That’s important, of course, but very often nothing actually happened at all, and we’ve even found that works council members – to whom such matters are sometimes reported – sometimes struggle and say, ‘Well, how do we deal with this now? Should we even advise the person to at least make it public within the company, to contact a general equality officer, or perhaps even to take legal action? Should we advise this person to do so at all? Is that sensible, or would it be detrimental to the individual? It’s not always easy to weigh this up, which makes it all the more important to set out clear reporting procedures.
And one goal we’d really like to implement in the near future is for hospitals to adopt their own codes of conduct and say, ‘No, we don’t want this; we won’t tolerate it’ – just as many employers in industry, for example, do. And we encourage people to report such cases so that we can address them. Once a year, we run a training session at our hospital on raising awareness of these issues; all of this is possible, and we’re striving to take these steps. We have a meeting coming up with the German Hospital Association; the Association of Senior Hospital Directors has also approached us and said, ‘We want to change things here,’ and these are the goals we’re now working towards.
Rantner: Yes, well, I’ve—I’ve seen that in the slides too; I said, at first I wasn’t at all sure whether that could actually be true, but what you’ve just said – that there were so few consequences – well, even if someone, as one might imagine, plucked up the courage and thought, ‘OK, let’s press ahead bravely’, I don’t want to tolerate this any longer’ – that there were still so few positive outcomes from these, from these reports to various levels; well, the question would have been: does it actually have an impact, and who should I turn to? But when you say that even works councils are often unable to draw relevant, positive consequences from this for those affected, that really does give one pause for thought.
And on the other hand, I must say that in my management role over the last few years, I’ve also noticed that, as a manager, one is certainly made aware of this issue. As a woman in particular, I’ve very often been asked recently to join male line managers in discussions with female – but also male – staff, in order, so to speak, to demonstrate or simply to set the framework to ensure that sexual harassment does not take place. I don’t think this is just a pleasant experience for the men either; to be honest, if you’re constantly having to think about it: can I even engage critically with someone in a one-to-one conversation, or do I always have to worry that a complaint of sexual harassment will be made afterwards, or that it will somehow be brought up? How do you see it? Is this something that, quite frankly, doesn’t always make the working atmosphere easy, when you constantly have to be so careful within hierarchical structures that are already difficult enough? But would you actually advise people now – perhaps not just at management level, but also those in training – to have a ‘six-eyes’ conversation rather than a ‘one-on-one’? What are your thoughts on that?
Johna: Well, to answer quite directly, no, I don’t think that’s always necessary. Of course, it is necessary if a conflict has already arisen. So if we’re actually going to be discussing sexual harassment in our next meeting, then I wouldn’t hold such a conversation in private. But a completely normal – let’s say – conversation, I don’t know, a staff appraisal, the annual one, or as part of further training or restructuring measures or something like that – I don’t consider that necessary in principle. And even though I recognise the point – and it is a real one – it’s so vanishingly small compared to the other issue, so to speak, the problem from the other side, that it’s almost, well, I’d almost say it’s a reductio ad absurdum. So it’s always dangerous to say, well, but then we’re suddenly completely restricted and can no longer talk to one another openly. No, nobody wants that – quite the opposite, in fact. And that’s why I believe it’s all the more important to make it clear: where, where, where is it still acceptable, and where is it no longer acceptable to even engage with the issue at all.
I’d say it does us all good to sit in a training session like this every now and then, just to listen to what’s being said and reflect on ourselves: where might I, too, have abused my power – which, incidentally, can also come from women – and where haven’t I realised this myself? There’s a difference between me saying something and one of the medical students saying something. It’s simply a difference, even if we’re saying the same thing, and we need to be aware of that. But to say now, ‘No, following the Medical Association Conference, there was a comment, so we’re not going to have any more social evenings together.’ I just don’t understand why people overreact like that straight away. We’ve got so much to sort out first – things we’d all agree can’t go on like this – so let’s deal with that first.
Rantner: That’s very good; it reassures me a bit that you do still see room for togetherness in a neutral sense, because certain things are, of course, simply better discussed in private – you have to accept that. You’ve already mentioned it – it’s very much about awareness; it’s probably also about raising awareness; and it’s about making statements against certain things. Is this something that needs to remain within hospitals, given that there may now be a legal framework in place for staff there? Is this – and this is perhaps a slightly self-serving question – something that a Scientific Society like the DGG could also support? How could we now support our members? What can we, as a Scientific Society, contribute to this? Or do you think that, well, primarily it’s something that needs to stay within hospitals, because that’s where consequences via the works council – and perhaps warnings, disciplinary action or transfers – all these issues naturally have to be dealt with?
Johna: Well, we should do both. I do believe it’s very helpful when Scientific Societies also address the issue, when they publish a report on it in their journals, because it naturally also empowers those affected, knowing that they’re not the only ones affected. Victims sometimes withdraw into themselves, don’t talk to anyone about it, and may then actually feel that they have to shoulder this burden alone. But that’s not the case; simply knowing that no, there are many others affected too, helps in this situation. In that respect, I think it’s good when Scientific Societies also address the issue, which is what we’re doing now in your podcast.
And the other aspect is, of course, the organisational level; here we’re really making a very clear appeal to hospitals to address this issue.
And last but not least, there’s of course the matter of legal advice, which we at the Marburger Bund naturally also provide through our regional associations. I’ve, of course, been looking into this issue for some time now, but I’ve also realised that there were things I simply didn’t know before – for example, that Germany’s General Equal Treatment Act, which in theory could lead to legal consequences, actually only stipulates a reporting period of two months. We’re unique in Europe in this respect; most countries have a period of two to three years, so two months is, of course, incomprehensible. That’s why we at the Marburger Bund have issued a statement on this law, saying that things cannot remain as they are. Because by the time you’ve come to terms with it yourself, by the time you’ve thought about what to do next – and you’ll probably raise the issue at company level first – every employer with more than 50 employees is required to appoint an equality officer. Those two months will be over in a flash. So there are things to be changed even at this level, and it’s quite astonishing that we in Germany have such a unique European feature with this very short deadline.
Rantner: Yes, overall I think it’s certainly positive, as you’ve just pointed out, that those affected can seek help from various sources, and perhaps it’s a bit of an encouragement for one person or another to pluck up the courage after all. Now, as for the two-month period – as you’ve already said – that’s a bit of a challenge, but perhaps people will just pluck up the courage and realise that things really do need to change. Those in positions of responsibility – as you’ve so aptly put it – must be fully aware of this, and abuse of power, regardless of gender, is not something we can afford to have in hospitals. We’re faced with such complex tasks that our working relationships should actually be supportive and enriching; and this is certainly another appeal from the DGG at this point: that, particularly in vascular surgery and the surgical disciplines, as we’ve already mentioned, unfortunately do tend to see repeated instances of abuse of power and sexual harassment, that we as the DGG also want to send a clear message that we stand against this and wish to support everyone who finds themselves at the mercy of such behaviour.
Dr Johna, thank you very much for this excellent discussion. This is an issue that will continue to be with us. I can imagine that, following this survey, you at the Marburger Bund have also – I’m not sure whether you’ve set up a task force yet or whether you’ve increased the number of staff dedicated to this issue. Because I imagine that, following these survey results and the press conference that took place, you’re under a great deal of pressure now in terms of providing information, offering support and perhaps also addressing the issue.
Johna: We held the press conference, so to speak, quite shortly before our Annual General Meeting, which we hold twice a year. We’ve also received important resolutions from the delegates at our Annual General Meeting that are addressed to us. So, for example, we’ll be providing further training specifically on this issue for the 55 lawyers we have in the association, because, of course, labour law is the main focus for our legal team. And yes, we’ll also be addressing the issue at our Annual General Meeting of actually appointing designated points of contact, so that if – for example – something like this were to happen at such a meeting, including at the Marburger Bund – I hope it doesn’t, but it’s conceivable – people would know straight away who to turn to. So this applies internally, certainly within the association, but of course also externally – as I mentioned earlier, these are our objectives. In that respect, I believe it will benefit us all to address this issue.
And this applies beyond the field of medicine; yes, we’ve naturally been talking specifically about surgery just now, but I’d like to make it clear that – whilst I’d love to think, I could almost say, that it were only a problem in surgery – no, it goes far beyond that, and in that respect it concerns us all – and in particular it concerns those in leadership roles, as well as the – I can’t quite recall the Frenchwoman’s name at the moment – who has also highlighted this issue very strongly and said that the shame must be turned on its head. I thought that was a very good point; that’s exactly how it is, and everyone must have a stake in ensuring that our teamwork is positive and not one in which abuse of power or sexual harassment takes place.
Rantner: Wonderful, that’s a very, very lovely closing remark. Thank you once again for the great conversation and for the time you’ve taken. I’d also like to thank you, dear listeners, for joining us again and, I hope, for following the discussion with interest. If you have any feedback or questions, please do get in touch. You can email us at podcasts@medizinkommunikation.org. If you’re listening to us on Spotify, you can also leave us a review. Until next time, I wish you a wonderful summer – the temperatures are rising. I wish you all a lovely holiday, stay healthy and stay curious.
