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Sexual harassment is a particularly pernicious form of harassment that can result in long-lasting psychological damage to victims. In health care, it has deleterious effects on teamwork and communication and may affect patient care. Although concerns regarding sexual harassment in the workplace, including within health care, are not new, increased attention has been focused on this topic since late 2017 as a result of the #MeToo movement. As in other sectors, health care centers have experienced instances of sexual harassment. Evidence indicates that harassment in health care centers is not uncommon and has not decreased with time. Beyond reporting and addressing, health care institutions must establish policies that clearly outline the unacceptability of harassing behaviors. Moreover, institutions must have a systematic method to thoroughly investigate allegations of sexual harassment and to impose fair and consistent corrective actions when allegations are substantiated. This article describes Mayo Clinic's approach to this complex problem, including targeted efforts toward developing a culture intolerant of sexually harassing behavior.
In late 2017, allegations that a prominent Hollywood movie producer sexually harassed numerous female actors over the course of his career led to a tremendous outpouring of like stories. These stories swiftly coalesced into a social movement known as #MeToo. Although sexual harassment is not a new or rare problem, the #MeToo movement has led to an era in which cultural mores are changing rapidly, profoundly influencing both society and workplaces. An important social benefit of the #MeToo movement has been empowerment of victims to speak up and report allegations of harassment, sexual or otherwise. Victims who previously may have suffered in silence now expect and demand appropriate institutional responses to their concerns and allegations. As one of the largest sectors of the US economy, health care has experienced numerous high-profile instances of sexual harassment,
To date, most publications on sexual harassment have described the problem and have not delved into detail regarding how organizations manage and address it proactively. This article describes how a large, national health care institution has formally responded to and is addressing the problem of sexual harassment.
The goals of this article are to (1) describe how Mayo Clinic, a large, geographically dispersed integrated health care network, addresses allegations of sexual harassment, (2) report the recent number of sexual harassment allegations and their outcomes at Mayo Clinic, (3) describe attempts to inculcate a cultural environment of fairness, equity, and safety for all employees, and (4) foster greater transparency and discussion around these issues within the health care setting and encourage best practices to emerge.
Mayo Clinic, founded in Rochester, Minnesota, has more than 65,000 employees, including more than 4000 physicians and scientists nationwide. It has multiple operational sites with a considerable presence and facilities in Minnesota, Wisconsin, Arizona, and Florida. A private, not-for-profit institution, it is a values-driven organization (Appendix 1). It has a 150-year history and a rich tradition of multidisciplinary medical and surgical collaboration, medical education, and scientific research (the 3 “shields” of practice, education, and research).
At Mayo Clinic, addressing allegations of sexual or other types of harassment involves close collaboration among the leadership of individual departments, the site Personnel Committee (an institutional committee charged with oversight of physician and scientist employment issues), the Department of Human Resources (HR), and the Legal Department. A thorough understanding of institutional policies, HR procedures, and employment law is necessary to determine appropriate investigative steps and to apply consistent, proportionate corrective actions in response to findings of employee misconduct. The US Equal Employment Opportunity Commission defines harassment as “unwelcome conduct that is based on race, color, religion, sex (including pregnancy), national origin, age (40 or older), disability or genetic information.”
If learners are involved, the mandates of Title IX of the Education Amendments of 1972 must be followed. Other relevant statutes include Title VII of the Civil Rights Act, the Age Discrimination in Employment Act, the Americans with Disabilities Act, and various state human rights statutes.
Mayo Clinic’s Sexual and Other Harassment Policy was updated just before the start of the #MeToo movement in 2017 (Appendix 2). The policy defines harassment of all types, sexual and otherwise, and outlines the framework of our institutional approach to harassment. It describes physical, verbal, nonverbal, and electronic types of harassment, reporting mechanisms, and the responsible bodies for the conduct and oversight of investigations and corrective actions. The policy also defines and proscribes false accusations and retaliation relating to allegations of harassment. Although a clear and well-communicated policy is necessary, it alone is insufficient for addressing allegations and mitigating the problem of sexual harassment. The policies, procedures, and data described in this article apply to Mayo Clinic (Rochester, Arizona, and Florida) and to the Mayo Clinic Health System.
Addressing the Problem
Clinical care, scientific research, and health care education are complex endeavors and require highly functional teams for optimal performance. An individual team member’s ability to capably perform his or her work and be effective depends on a conducive work environment. When harassment of any sort occurs, team dynamics break down, and ultimately patient care may suffer. Serious and lasting damage may occur to the victim. Experience suggests that situations that involve allegations of sexual harassment are complex and often ill-defined. Miscommunication and misinterpreted behaviors may also occur, and varying recollection of facts is common. In recent years, Mayo Clinic has developed a stepwise approach to thoroughly and consistently address allegations of harassment (Table 1). This process is designed to protect the reporter, to be fair and objective to both the reporter and the accused, and to maintain appropriate checks and balances throughout the process to ensure that consistent and fair action is taken in response to any substantiated findings of sexual harassment.
Table 1Institutional Approach to Sexual Harassment Allegations
1. The allegation is assigned to a trained Human Resources investigator
2. If there is an immediate danger to the reporter or others, the employee whose conduct is under investigation (the accused) may be placed on administrative leave. The reporter is provided support by Human Resources advisors and offered Employee Assistance Program services. The accused is also offered these services
3. An experienced Human Resources investigator and partner interview the reporter, the accused, and any potential witnesses. Relevant information is gathered, including, if authorized, an investigation of electronic communications between relevant parties. The accused has the opportunity to respond to allegations and present his or her version of events, along with any relevant evidence or potential witnesses
4. An investigative report is prepared and presented to departmental leadership, Human Resources, the Personnel Committee, and the Legal Department. A decision is made based on review of all evidence, interviews, and the investigative report and taking mitigating factors into account. Principles of a Fair and Just Culture are used as a guide for consistency. The severity of the alleged infraction, prior history, and any past or current corrective actions are all considered
5. If the allegations are deemed to be substantiated, appropriate action is taken. The action taken will depend on the seriousness of the infraction(s) and could include coaching, written warning, a final written warning with or without suspension, or termination of employment
6. If termination proceedings are recommended, the accused is notified of the intent to terminate. Resignation in lieu of termination may be requested and is at the discretion of Mayo Clinic to allow in limited situations
7. For the physician and scientist staff, a separate and independent 3-person panel of peers reviews the evidence, including the recommendation for termination, and makes the final decision. The panel has the authority to reinterview anyone if deemed necessary
8. If terminated, the employee may choose to appeal pursuant to the Mayo Corrective Action policy. If appealed, a second independent 3-person panel of peers reviews all evidence and is empowered to uphold or overturn the corrective action decision. The panel is also empowered to reinterview
9. If state law requires that the conduct giving rise to termination be reported to a state licensing board, an appropriate report is filed
10. Postaction activities include providing closing communication to the complainant (including instructions to report any retaliation), debriefing senior leadership, and responding to external requests for references. The situation is analyzed and opportunities for improvement, if any, are identified
The staff at Mayo Clinic can report concerns about sexual harassment through several resources, including an anonymous hotline. Once a complaint is received, an experienced HR investigator specifically trained in the investigative process for sexual harassment allegations is assigned. When needed, the HR investigator works in conjunction with the Legal Department to outline and manage the investigative process, and the chief executive officer is informed. The investigation includes interviews with the reporter, all potential witnesses, and the employee whose conduct is being investigated (the accused). Additional information, including emails, text messages, photographs, and other relevant materials, is collected and reviewed, if available. The accused is informed of the allegations, interviewed, and provided the opportunity to present his or her version of events. The accused can also provide any supporting materials or identify witnesses who have relevant information. If additional information is obtained after the interview with the accused, a subsequent interview or interviews are conducted to ensure that he or she is fully informed of and has an opportunity to respond to any information that may affect the findings of the investigation. More than one person is always present during interviews to ensure that a witness to the conversation is present.
There is no presumption about the outcome of the investigation, and no decisions are made until the investigation has been completed. Early in the investigation process, both the reporter (usually, but not always, the person who experienced the harassing behavior) and the accused are advised of resources available through Mayo’s Employee Assistance Program. This program provides support, including counseling and other services, to employees. Once all interviews have been conducted and information reviewed, the investigators collate all evidence and prepare a final written report, which is presented to the Personnel Committee and the accused’s department leadership. This report documents the information gathered during the investigation from all witnesses and from the related electronic and documentary review. It also provides preliminary conclusions regarding the sexual harassment allegations and recommendations for corrective action. The Personnel Committee, which includes physician leaders, senior HR leaders, and institutional legal counsel with expertise in employment law, reviews the report and initial recommendations. After consideration of all facts, a decision is reached about whether the allegations are substantiated, and a judgment is reached as to what, if any, corrective action is indicated.
The principles of a Fair and Just Culture (Appendix 3)
are used to guide a decision about corrective action. This framework considers the effect of behaviors, their nature, and their severity. When allegations of serious misconduct are substantiated and termination is recommended for a member of the physician-scientist staff, a 3-person panel (Termination Review Committee) of peers reconsiders all the evidence gathered in the course of the investigation and affirms or overturns the recommendation for termination. This committee is intended to provide checks and balances to the process and is empowered to reinterview or question any aspect of the investigation. The committee may affirm the recommendation for termination or recommend a lesser form of corrective action. In either instance, the accused has the right to appeal any corrective action to another separate 3-person panel that can uphold or overturn any aspect of the corrective action. The corrective action is not finalized until this full process has been exhausted. For employees who are not physician-scientists, investigative reports are reviewed by HR, legal, and departmental leadership, who make the ultimate decision on appropriate corrective action, if any.
Sexual harassment was not tracked separately from other types of harassment at Mayo Clinic until late 2017. As with many organizations, Mayo experienced an increase in sexual harassment reports and associated investigations in late 2017 and early 2018 as awareness regarding workplace sexual harassment increased as a result of external media coverage, the #MeToo movement, and an internal institutional awareness campaign (Figure). Of the total 153 allegations and associated investigations, the accused was male in 125 instances (81.7%) and female in 28 (18.3%). In 10 instances (6.5%), the sex of the complainant and accused was the same. Of the investigations of allegations of sexual harassment conducted, 88 (57.5%) were substantiated following investigation and resulted in corrective action. Of the 153 accused, 43 (28.1%) were members of the physician-scientist staff. Of these 43 investigations, 22 (51.2%) were substantiated. Unsubstantiated reports were due to misunderstandings, lack of evidence, or lack of corroboration to support the allegations, but specific data on the reasons for unsubtantiation were not kept. Among the 88 accused with substantiated reports, 59 were found to have engaged in conduct in violation of Mayo policies and were members of the nonphysician and nonscientist staff (of more than 65,000 employees), 22 were staff physicians or scientists (of more than 4000 physician-scientist staff), and 7 were nonemployees (patients, visitors, contractors or vendors). In some instances, a dysfunctional work area subculture that tolerated unprofessional comments and behaviors was identified as contributing to the situation. In 70 instances (45.7%), the complainant and accused were on a peer-to-peer footing with one another, while in 43 (28.1%), the accused was in a leadership role over the complainant. A patient was accused of sexual harassment in 5 allegation (3.3%) and a vendor in 5 (3.3%).
For the 88 accused who had substantiated reports of sexual harassment, various levels of corrective action were imposed on the basis of the nature and severity of the misconduct: 31 received formal coaching (9 physicians-scientists), 22 (3 physicians-scientists) received written warnings ranging from first to final, and 35 (including 10 physicians-scientists) were terminated from employment or resigned before termination. Of the 88 substantiated reports, 71 (80.7%) included inappropriate comments and/or unwelcome sexual advances, 22 (25%) unwanted touch or physical contact, and 16 (18.2%) virtual or electronic harassment (eg, email, messenger, text).
Because of the confidential nature of the Employee Assistance Program, data regarding long-term psychological sequelae to victims are unavailable.
Sexual harassment is one of the most damaging forms of harassment and can have long-lasting effects. Pervasive psychological damage, low self-esteem, and impaired work performance can result.
Support for victims of sexual harassment is critical, and many large employers have an employee assistance program. Experiencing harassment and discrimination during medical training is not a new phenomenon. We report a 2-year experience at a major medical center with a national footprint, detail the process used for investigation of allegations, the decision making used to reach decisions on corrective action, including termination from employment, and outcomes. We found the overwhelming number of accused were male, and nearly half were at the same organizational level as the victims. Just under 60% of investigations were substantiated, and almost 30% of accused were physicians or scientists. Electronic means of harassment were not uncommon. Our findings can be placed in the context of prior reports.
A detailed review of 59 studies performed between 1987 and 2013 and including more than 38,000 medical trainees found that nearly 60% of medical trainees overall had experienced harassment or discrimination at least once.
The most common form of harassment reported was verbal, reported by 63% of more than 27,000 trainees. The mean prevalence of reported sexual harassment was 33.1%. Less common, but still unacceptably high, was physical harassment, reported by 15%. The harassment most frequently emanated from the trainees’ superiors (63%), patients (34%), or patients’ families (22%). In this analysis, no evidence was found that the incidence of harassment declined over time. No other recent time-trend data are available that address whether the incidence of sexual (and other) harassment has changed with time. This deficiency highlights the need for further prospective research.
from the University of Michigan published a survey of 1066 recipients of National Institutes of Health career development awards (K awardees; 493 female, 573 male). Slightly more than 30% of women and 4% of men reported having experienced sexual harassment. The most common forms of harassment were verbal comments (92%), unwanted advances (41%), and coercion (9%). A 2018 online survey provides the largest and most recent data set regarding sexual harassment in health care.
The survey included 6235 health care workers including 3711 physicians across all specialties, 440 resident physicians, 1007 nurses, 286 nurse practitioners, and 791 physician assistants who responded between March 2 and April 23, 2018, and as such, provides a contemporary snapshot of the scope of the problem in the United States. Among female physicians, 12% reported unwanted sexual harassment in the previous 3 years, as did 4% of male physicians (7% overall). Among harassers, approximately half were physicians, 37% were in a superior organizational position, 26% in an equal or peer role, and 37% in a subordinate role. Only 40% of harassing behaviors were reported (for a variety of reasons related to lack of confidence in the institutional response). Harassing behaviors were clearly upsetting to victims and interfered with their ability to do their job (including 14% who quit). In a 2018 survey of medical students, 30% experienced unwanted advances during medical school from faculty, fellow students, and patients.
The vast majority of instances involved male-toward-female harassment, although female-toward-male and male-toward-male instances were also reported. Half of perpetrators were physicians, and 30% were administrators in positions of power. These findings indicate that any successful institutional education program must pay special attention to employees in positions of relative power. Importantly, more than 50% of respondents who suffered harassment at work chose to remain silent, a finding possibly indicating a lack of confidence that harassment can be safely reported without retribution and that an appropriate institutional response will occur. Even more worrisome, less than 25% of the instances that were reported were investigated. The reasons for not investigating are unclear but may relate to uncertain policies and procedures, a history of tolerance of harassment, lack of an experienced HR department, or lack of appropriately trained investigators.
Sexual victimization and harassment are not limited to clinical medicine; high-profile scientists and scientific institutions have also been implicated.
The power differential between principal investigators who direct a large research laboratory and their staff and trainees is extreme. For example, students and technicians are often entirely dependent on one investigator for funding, mentorship, research, publications, and professional references. That one person can hold the key to career advancement. This power differential has the potential for abuse, as has been recognized by national organizations. The National Academies of Sciences, Engineering, and Medicine has drawn attention to the negative impact of sexual harassment on careers and has called for solutions that will lead to the prevention of harassment through empowerment of victims and bystanders.
Its 2018 report points out that sexual harassment is a subset of gender harassment, and regardless of personal characteristics, these behaviors will continue unless the cultural climate is one of fairness and respect. It has made 15 evidence-based recommendations for preventing and mitigating the effects of sexual harassment in academic science, engineering, and medicine (Appendix 4) and urges public disclosure of organizational climate surveys.
Impact on Institutions and Staff
As noted previously, the impact of harassment on employees and institutions cannot be overstated. Psychological damage, at times permanent, can occur and can include chronic stress, feelings of low self-worth and esteem, increased risk of substance abuse, impaired decision-making ability, and impaired professional and personal relationships. Disordered team dynamics in the health care workplace have the potential to be damaging to patient care, particularly if communication, trust, and teamwork are disrupted. Additionally, hospitals and health care systems experience increased turnover and costs. Incurred costs arise from multiple sources: complex investigations and responding to allegations and findings, employee time off work including administrative leave, staff turnover, and recruitment costs (Table 2). Replacing physicians, scientists, and administrators is extremely costly in terms of recruitment, training, on-boarding, and retention. Allowing dysfunctional behaviors to continue unabated degrades organizational health over time and impairs the ability of the organization to achieve its mission and recruit outstanding new staff, and it has the potential to allow competitors to eclipse the organization. Thus, a strong business case can be made for the creation of a positive cultural environment and dealing with harassment promptly and decisively.
Table 2Direct and Indirect Costs and Institutional Impact of Sexual and Other Harassment
Person-hours of time incurred performing investigations
Recruiting and on-boarding replacement staff
Dysfunctional cultural environment
Decreased operating performance and competitiveness
Employees found to have engaged in harassing conduct also may experience long-lasting effects. Being terminated or resigning while under investigation often must be disclosed by physicians and other licensed professionals during subsequent credentialing processes or by the institution to a state licensing board. Colleagues and past employers may be reluctant or unable to serve as references. The employee may not accept the findings, disavow personal responsibility, or fail to disclose the circumstances of the departure to a new employer. Hearsay and gossip may abound. These factors can adversely affect job prospects.
In any organization, a strong culture of fairness and justice is an important foundation for success and appropriate reaction against harassment. No organization should consider itself immune from sexual harassment. A culture with the appropriate ethical and foundational elements will empower victims and observers to actively disapprove of and report harassment. Leaders at all levels must be empowered to take action to deal with harassment. In addition to a robust sexual harassment policy and investigatory process, Mayo Clinic has placed considerable emphasis on fostering a values-driven workplace based on mutual respect.
for its clinical expertise and the collaborative, teamwork-based nature of its practice. Cross-functional teams able to bring their expertise to bear on a patient’s problems are critical to its success. This multidisciplinary practice is based on its values-driven culture (Appendix 1). A recent staff survey showed that dedication to Mayo Clinic’s mission and culture is strong in that 98% of respondents responded affirmatively. Because harassment may be insidious and subtle, the intentional nurturing of a positive workplace culture can be a strong deterrent to harassment. The importance of supporting a strong workplace culture is the charge of Mayo Clinic’s People and Culture Committee, which reports directly to the Board of Governors. This committee includes a multidisciplinary group of senior physician and administrative leaders from all clinic sites and representing the practice, education, and research shields.
During the past 2 years, Mayo Clinic has taken several steps to educate employees about and reinforce its strong cultural expectations of mutual respect and intolerance of sexual harassment (Table 3). The education has centered on important themes observed in relation to matters of sexual harassment, including the complexity of personal relationships in the workplace, the effect of power differentials in the context of sexual harassment, and the importance of bystanders taking action when they observe questionable behavior by a colleague.
Table 3Mayo Clinic Approach to Sexual Harassment Education
Email messages from the president and chief executive officer to all staff, reinforced in leadership messages at all levels
Video message on Mayo Clinic policy and frequently asked questions by the chair of the People and Culture Committee and chief human resources officer
Facilitated dialogues with top leadership teams, including the Board of Governors and management team, using case examples
Education and establishment of expectations of mutual respect and intolerance of sexual harassment in new-hire orientation. Scenario training for new supervisors
Required online training of all supervisors on their role in handling individuals involved in sexual harassment, including the complainant, accused, bystander, and supervisor
Case-based education with new staff
Required online acknowledgment of the sexual harassment policy by all staff
Sexual harassment reference card provided to every employee describing what to do with references to policy and frequently asked questions
Access to the website #WeAreMayoClinic with links to relevant policies
The reasons for variation in the rate of reports received are unclear but may relate to increased awareness, organizational training programs, efforts to shift the culture, and the visible impact of perpetrators no longer being in the workplace. As society and workplaces continue to evolve, the impact of changing cultural mores will continue to have an impact.
Careful consideration has been given to personal relationships and dating in the workplace. Normal human interactions occur in all workplaces, and they can be a positive influence when positive, respectful, and mutually affirming. Alternatively, unwanted attention or advances are unacceptable behavior in a workplace, and if they cannot be handled on a one-to-one basis, they should be escalated to higher levels of leadership. Like many other organizations, Mayo Clinic has a substantial number of employees who have personal relationships with other employees. These relationships can be familial or romantic and create special circumstances. Mayo Clinic’s Significant Relationships in the Workplace policy does not prohibit personal relationships (or employment of family members in the same unit). If a personal relationship occurs within a work unit, the expectation is that the relationship will be disclosed to the supervisor and steps taken to mitigate the workplace impact. A romantic relationship that fails may lead to subsequent unwanted advances and harassing behavior. Relationships between supervisors and subordinates present special circumstance with heightened risks. Coercion, whether explicit or implied, may exist, and perceptions of favoritism are commonplace. Mayo Clinic’s expectation is that supervisory responsibilities (including performance reviews) be transferred to a third party. Staff members are educated regarding these risks, and they are encouraged to be thoughtful and transparent when considering a relationship with a colleague. Because of the considerable power differential involved, romantic or sexual relationships between faculty and students are not allowed.
In addition to the challenges of personal relationships and power dynamics in the workplace, Mayo Clinic’s ongoing educational efforts focus on the role of bystanders. A bystander is a person who sees or becomes aware of sexual or other harassing behavior by another employee. Bystanders are encouraged to offer support to the person who experienced the harassing behavior and to report the incident through one of the many available options.
Summary and Conclusions
This article outlines Mayo Clinic’s approach to the investigation of and response to allegations of sexual harassment in the workplace. We specifically report experience numbers to encourage more transparency and benchmarking of data among institutions.
Sexual harassment is a particularly pernicious form of harassment that can have long-lasting psychological impact on victims, impair working relationships, damage the cultural environment, increase costs, and ultimately threaten the mission of an organization. Current evidence, including the data presented here, suggests that sexual harassment is not uncommon in health care organizations and likely is not decreasing with time. More time-trend data are needed for firm determinations. In our experience and that of others, the predominant victims are women, and the predominant accused are men. Also in our experience, a minority of instances involved accused in a direct power position over complainants, whereas almost half of allegations occurred among people in peer positions. Electronic harassment was not infrequent. A range of corrective action was applied dependent on the seriousness and nature of the infractions.
Robust policies and procedures against sexual harassment that are widely promulgated throughout the organization are important for addressing the problem but are insufficient in and of themselves. Thorough and fair investigations that lead to appropriate action are necessary when harassment occurs. Perhaps most importantly, creating a strong values-driven culture with inherent psychological safety to speak up is crucial for addressing sexual harassment. Health care organizations must rise to this challenge, and their organizational leadership must support and set the necessary expectations.
Supplemental material can be found online at http://www.mayoclinicproceedings.org. Supplemental material attached to journal articles has not been edited, and the authors take responsibility for the accuracy of all data.
Yale Medical School removes doctor after sexual harassment finding. New York Times website.
Potential Competing Interests: Dr Noseworthy is a member of the board of directors for Merck & Co, Inc, UnitedHealth Group, and AlixPartners, LLP (no payments received) and has stock/stock options from Merck & Co, Inc, and UnitedHealth Group unrelated to the current work.
Sexual harassment in the workplace has existed from time immemorial. Increased exposure of the problem arose in 2017 with the very public allegations of sexual harassment in the entertainment industry, which quickly spread to charges of impropriety and ousters of high-level leaders in multiple other settings. Studies have identified that the medical field is not immune from sexual harassment, despite our focus on improving health, advancing science, and curing disease. Although many studies have addressed the magnitude of sexual harassment in the medical field, few institutions have put forward their experience with addressing the problem.