It was a necessary piece of information. The patient had arrived in the Emergency Department complaining of back pain. I knew — even as a fourth-year medical student — that I had to check for sensation in his pelvic area. Numbness would suggest something dangerous was at play. The last patient I had seen with this set of symptoms might have never walked again had we not discovered a vertebral disc smashing into his spinal cord like a determined, bony wedge.
My own reproach rang in my ears. I reminded myself that medical students often miss key pieces of information in their hesitation to perform more invasive or embarrassing maneuvers — penile exams, skin checks, femoral pulses and now the perineum: the swatch of real estate that runs between the anus and scrotum. I thought about how underserved populations receive worse care, how this man was in a tragically difficult life situation, how his substance abuse was probably altering his behavior with me. I tasted my reluctance and it made me feel like a bad person. I told myself firmly that my discomfort should not take precedence over his clinical care.
I also considered less noble reasoning. I was in the middle of a month-long job interview, vying for an excellent letter of recommendation. At the end of 14 eight-hour shifts, supervising physicians would grade my skill and rank me in the top 10 percent, top 30 percent, middle 30 percent or bottom 30 percent of all medical students they worked with that year. Time was limited. I had 112 hours to substantiate myself as an asset to emergency medicine. Outstanding students are efficient. They do not leave their exams incomplete.
I told my patient I was going to check for sensation in his groin. He grabbed my wrist and placed it on his penis. I twisted. He held my wrist down. I wrenched. He laughed.
It was a mean, empty sort of laugh that echoed in my ears as I made my way back to my team. I stumbled through my oral presentation, reporting diligently that the patient exhibited no perineal numbness. I offered up my differential diagnosis and an initial treatment plan. I did not say anything else.
At the end of that shift, my attending physician told me I had done a good job. I said thank you. I handed him my evaluation form.
I keep a hair clip on my wrist so when trauma patients burst into the Resuscitation Bay, it takes only seconds to sweep hair away from my face. I like to work unencumbered. The patient — my patient — gripped me so tight it left a bruise that lasted a week. The five teeth of the hair clip’s jaws dug purple dashes over my radial pulse. Five fangs to tear at my focus, a grid of five lines to count slow breaths, five furrows — to bury what I’m not sure.
I am not alone in my mourning. The data on gender violence in medical training is coming to light, and it is alarming. A report from the National Academies of Science, Engineering and Medicine (NASEM) revealed that female medical students are 220 percent more likely than nonscience students to suffer sexual harassment.
In an essay in the New England Journal of Medicine, three female authors prompted an ominous hypothetical: “Imagine a medical-school dean addressing the incoming class with this demoralizing prediction: ‘Look at the woman to your left and then at the woman to your right. On average, one of them will be sexually harassed during the next 4 years, before she has even begun her career as a physician.’ ”
The harassment pours in from all directions. This wraparound threat is part of the drowning.
So many of my friends from medical school have stories. A moment when a male patient placed himself between a female student and the room’s door, closed it, and wouldn’t let her leave. Disparaging remarks about race, weight, looks. Come-ons and comments and nasty flirtations. Dark rooms. Offers. Nonconsensual physical exams as demonstrations to other peers. A joke that if a female student allowed a psychiatric patient to sexually assault her, the course leader would prohibit an honors grade because it would mean more paperwork for him. One patient licked my friend’s face as she was examining his ankle. One friend disclosed that she could remember more instances of inappropriate behavior from her supervising physicians than her patients.
Faculty and staff members are the perpetrators of almost half of the sexual violence female medical students endure. When such violence comes from above, the options for resolution become even more scarce.
I remember what a friend told me, heaving in between sobs, after sexual harassment from a faculty member pushed her into a year-long leave of absence from medical school: “I did nothing wrong.” Her tears were hot and wet on my skin. I felt grief. I felt impotent. All I could do was hold her. Help her pack.
Peer-to-peer harassment persists as well.
During my first anatomy laboratory session in 2014, a classmate noticed my discomfort and leaned toward me to mutter something in my ear. “The entire class voted,” he said. “They decided you have to smell your cadaver’s [penis].” He laughed. It was the first month of medical school.
I have spent countless hours learning how to save people. I was never taught how to deal with this.
Struggling to find a solution
This summer, at another rotation, the senior resident I was assigned to work with told me she had only one rule for medical students who work with her. “My one rule,” she told me, “is that you tell me at any point if you are uncomfortable.”
I remembered my earlier patient’s hollow laugh. What would I have told the senior resident?
Even in my imagination, it still sounded too much like complaining. Whiny. Unattractive. An extraneous burden to my team, a mark of my oversensitivity they could ridicule later in the resident’s room over lunch. A possible tick mark on my performance sheet. Inadequate temperament, they could write. Okay, so? They could say.
But I heard the seriousness in her voice. Of all things, it was her only rule. It was my senior’s expectation of me: suddenly a part of my job description, an explicit responsibility of mine as a trainee — as a good student. A command as much as a kindness.
I wished she had been my resident two months before.
The words of my resident gave me a permission I sorely needed. But if almost half of the gendered violence in medicine comes from faculty — who do indeed have the power to collide into career paths and decimate dreams — reporting can’t possibly constitute a method of earnest protection. Victims will continue to be punished over and over again. They alone will bear the cost.
I graduated from medical school in May. This year, I will learn how to slam fluids into vessels before they bleed dry, navigate plastic tubes into winding throats gasping for breath, assess a heart attack, sew wounds, think through homelessness, violence and need. These are daunting tasks, but my shelf is lined with textbooks. Directed educational sessions are scheduled for five hours a week. My supervisors will guide me through each puncture, clinical decision and medical complication.
Soon, I will also be expected to oversee medical students. I take this job as seriously as my other responsibilities, but I do not know who will teach me to do this. I have few resources to guide me in this endeavor.
One thing is sure: I will tell them I have only one rule. I want to remind medical trainees — and those responsible for them — that their safety is not a burden or luxury, but a necessity. But as one person, I don’t know how I can possibly guarantee it.
Besides compassion, I don’t know what action I can take if they come to me in compliance of the one rule I claim. What if their distress is born from someone who is my superior, too?
I need help. I don’t know how to protect them. I’m not even sure I know how to protect myself.
Jennifer Tsai is an emergency medicine resident in New Haven, Conn.
Title IX of the Education Amendments Act of 1972 (“Title IX”) and the Clery Act are federal laws that require educational programs to address and remedy any known sex and gender discrimination, including sexual assault and harassment on campus. All institutions that accept federal financial support are required to stop discrimination, prevent the recurrence of the behavior and mitigate its effects. Contact the Title IX coordinator at your institution for information about your rights and resources.
Some institutions also have nonreporting, confidential resources on campus, such as privileged or confidential advocate programs (resources will vary by institution and state). If you need help navigating issues related to sexual assault or harassment, the National Sexual Assault Hotline is a free, 24-hour resource: 800-656-HOPE (4673).