Getting SMART About Harassment

Residents at an urban teaching hospital shuffle into a conference room as the lights go down. On a screen in front of them, an animated video starts, showing two illustrated surgeons chatting. The dramatization unfolds on an elevator with a senior male surgeon commenting on the attractiveness of a junior female surgeon standing next to him. The animation concludes with the junior surgeon visibly upset and rushing off the elevator.

As the lights come up, the surgical residents are guided through a discussion of the scenario… as they sit at the center of an initiative at Massachusetts General Hospital, in response to the sexual harassment workplace issues left in the wake of the “Me Too” movement.

Recent data from the National Academies of Science, Engineering, and Medicine show that sexual harassment and gender discrimination affect up to 50 percent of women medical students and more than 50 percent of women faculty in medicine. It affects men too.

Dr. Sareh Parangi is a leader and creator of the training intervention. It is called SMART, for Smart Appropriate Response Training, and it’s a role-play training toolkit for surgical residents to help address sexual harassment. The kit was partially funded through a grant from CRICO, the employment practices liability insurer for most of the Harvard medical institutions and their affiliates. Dr. Parangi is an endocrine surgeon at Massachusetts General Hospital and Professor of Surgery at Harvard Medical School.

“In general my sense from surgical leadership is that at Harvard, at MGH, at the Brigham, BIDMC, at all the chairs that I spoke to personally were super enthusiastic about this program and really wanted it to get going…”

The idea is to view the animated scenarios and learn good ways to respond to bad behavior. Dr. Susan Pories is a co-creator of the training program. Dr. Pories is an Associate Professor of Surgery at Harvard Medical School and the Chief of Breast Surgery at Mount Auburn Hospital in Cambridge. She said that she and Dr. Parangi were attending a conference, when, during one of the breaks, the conversation turned to sexual harassment. These two well-established leaders in medicine realized they didn’t feel any more prepared for inappropriate comments than their young residents were. Despite their seniority and experience, they too were often caught off guard when confronted with harmful comments and actions.

“There’s so many times even as senior-experienced surgeons when somebody will make a comment to us and it’s not appropriate and yet you can’t think of a thing to say because you haven’t practiced it and you feel taken off guard by something that you didn’t see coming. And so, we started to just talk about the fact that we could train people to learn effective responses to inappropriate behaviors and that that would really be a great thing to do especially for younger surgeons and residents because even with all of our experience if we felt speechless, then they must feel just the same way.”

This kind of harassment often looks like comments on someone’s appearance, or jokes, or persistent requests for dates, among other things. Dr. Parangi says that, for the creation of the videos, it was critical that trainees see scenes that would resonate and lead to rich discussion. To make sure they captured realistic vignettes, they looked outside their team for story plots.

“Well, we sort of crowd sourced them. We asked surgical residents and surgical attendings to send in comments of things that had happened to them on a national level. And then we took those and made them into these short, almost like tiny little movie plots of 30 seconds and they’re quite powerful.”

Trained facilitators who are faculty at the institution show the videos and lead questions of the residents. Then they share a toolbox of potential responses for anyone who finds themself in that situation, either as a target or a bystander.

“We sort of pre-showed some of the scenarios to a number of surgical residents who’ve worked with our group but who weren’t part of our group. And they uniformly said that at first the behavior shown seemed shocking but as they discussed it with a co-resident who happened to be sitting next to them when they watched the animation, they both said, ‘oh my God, that really has happened to so and so or me or my friend.’”

Dr. Vinod Narra is one of the facilitators. “Frankly I didn’t know quite what to expect.”

Dr. Narra is an endocrine surgeon at Mass General, and a Clinical Instructor in Surgery at Harvard Medical School.

“One of the things that stood out to me in particular is that any particular incident in the workplace can be perceived differently by different people involved, but it’s the victim that has to bear the sexual harassment. And they’re often confused, isolated, diminished and then often question themselves. And the aggressor may think nothing of that incident and I think that was reflected in a couple of the scenarios.”

That leads to a key aspect of the training: the importance of supporting victims. Witnesses often feel powerless or ashamed or confused after an incident. In the training, participants are encouraged to find a way to transition from bystander to “upstander.” Helpful ways to respond may include using humor, re-direction, policy, etcetera. Dr. Narra says the training has brought up memories of situations from his own past.

“There were several instances where I was the bystander. But there was a huge power dynamic. I was in the operating room with a junior resident and, you know, in a field that I was considering applying to for a fellowship. And the attending there was making racist comments and at that time, you know what? I wasn’t strong enough to say anything, to be able to either redirect the conversation or kind of get into the middle of this. It was kind of more was I, I was dumbfounded and plus, you know, also thinking about those power dynamics in there. And it brought up a lot of raw emotions of that instance and how I should have been a better person.”

Two resources that were added to the training team after some initial testing were a psychiatrist and a lawyer. The legal lines may seem unclear to attendees and the attorney in the sessions helps them understand and navigate the law. The psychiatrist helps them cope with what comes up during discussion of the scenarios. Dr. Pories:

“I really was surprised to realize that I could actually be triggered myself during one of these training sessions. I had to turn my camera off for a while and kind of get myself back together before I could rejoin the meeting.”   

A common misconception about harassment is that if you didn’t mean to offend, then it’s ok. But the lawyer helps trainees see that this area of the law puts the emphasis on impact, not intent. It is the experience of the victim. Dr. Pories says that this is often a break-through realization during training, especially for the men. During training, a husband and wife pair of surgeons, for example, looked at the scenarios, and the wife recognized the harassments they depicted, but the husband said he never had to deal with them.
“I think for some of the men, it was a little bit more eye-opening and they were a little bit surprised that these things actually did go on and as I said, they weren’t necessarily exposed to it themselves... And I think they’re extremely supportive of the whole effort and saw that they were learning from it. They really felt that it increased their awareness of things around them in the operating room, and they really were passionate about bringing this learning tool to the residents.”

For Dr. Narra, it was a chance to bring these stories back to his own operating room and discuss them there. He even brought them to family conversations. He believes it shouldn’t just be a one-time training with two sessions, but something that involves more on-going exercises. He and other course leaders think it could be easily applied beyond surgery, and would be fruitful if it were adapted for attendings as well as trainees. Dr. Parangi says that after the training, some of the facilitators shared the impact on them.

“Some of them actually commented, either during the training or called me afterwards to, I would say with tears in their eyes, to say that they felt so honored to be able to do the training because they felt that they had lived with this kind of sexual harassment shadow over their career while they were residents. And they hadn’t realized what a mental burden it had created and that now they felt that they were going to change, and they were going to be able to help the next generation not live with that burden. And they felt like it was worth all the time in the world. They were willing to give their time and work on it because they really felt like they were going to make things better for the next generation. And aren’t we all about that? I mean we want to always make things better for the next generation.”