Cynthia Cooper, MD

Gender-based discrimination refers to “any distinction, exclusion or restriction made on the basis of socially constructed gender roles and norms which prevents a person from enjoying full human rights.”¹ Similarly, sexual harassment encompasses a spectrum of sexual conduct that includes “unwelcome sexual advances, requests for sexual favors, and other verbal or physical harassment of a sexual nature,” as defined by the US Equal Employment Opportunity Commission.² Gender-based discrimination and sexual harassment can be “overt,” which includes explicitly recognizable behaviors, or they can be “implicit,” which includes verbal and nonverbal behaviors that often go unrecognized but convey hostility, objectification, or exclusion of another person. Gender-based discrimination and sexual harassment are commonly described and likely more prevalent in academic settings.^3-6 Female physicians are disproportionately affected by gender-based discrimination and sexual harassment, compared with their male peers.^4,7

Female physicians face workplace harassment from both patients and coworkers. A study in Canada reported that more than 75% of female physicians experienced sexual harassment from their patients.⁸ A recent study showed almost half of the physicians who reported harassment, which was three times more often among female physicians, described other physician colleagues as perpetrators.⁹ In a study among clinician-researchers in the field of academic medicine, 30% of females reported having experienced sexual harassment, compared with 4% of males.⁷ Among females who reported harassment in this study, 47% stated that these experiences adversely affected their opportunities for career advancement. Career stage may also affect experiences or perceptions of gender-based discrimination and sexual harassment, with females in earlier career stages reporting a less favorable environment of gender equity.¹⁰

Hospital medicine is a young and evolving specialty, and the number of hospitalists has increased substantially from a few hundred at the time of inception to over 50,000 as of 2016.¹¹ The proportion of female hospitalists increased from 31% in 2012 to 52% in 2014, reflecting equal gender representation in hospital medicine.¹² Available evidence shows gender disparities exist in hospital medicine disproportionately affecting female hospitalists in their career advancement, including leadership and scholarship opportunities.¹³ However, there remains a knowledge gap regarding the prevalence of gender-based discrimination and sexual harassment experienced by hospitalists.

Our study examines the experiences of academic hospitalists regarding gender-based discrimination and sexual harassment and the impact of gender on career satisfaction and advancement.

Study Design and Participants

An online survey was developed and approved by the institutional board review (IRB) at the Medical College of Wisconsin in Milwaukee. University-based academic centers with hospitalist programs, identified through personal connections, from across the continental United Stated were identified as potential study sites, and leaders at each institution were contacted to ascertain potential participation in the survey. The survey was distributed to Internal Medicine hospitalists at 18 participating academic institutions from January 2019 to June 2019. Participation was voluntary. The cover letter explained the purpose of the study and provided a link to the survey. To maintain anonymity, none of the questionnaires requested identifying information from participants. A web-based Qualtrics online-based survey platform was used.

Survey Elements

The survey aimed to assess several elements of gender-based discrimination and sexual harassment. All questions about these experiences distinguished encounters with patients from those with colleagues, and questions about occurrences either over a career or in the last 30 days were intended to capture both distant and recent timeframes. The theme for the questions for the survey was based on previous studies.^4,7,8 The wording of questions was simplified to make them easily understandable, and the brevity of the survey was maintained to prevent possible nonresponses.¹⁴ Additional questions (mistaken for a healthcare provider other than a physician, feeling respected by patients and colleagues, referred to by terms such as “honey,” “dear,” “sweetheart,” “sugar,” or equivalent), which were deemed relevant in day-to-day clinical practice through consensus among study investigators and discussions among peer hospitalists, were incorporated into the final survey (Appendix). Survey questions were intended to capture several elements regarding interactions with patients and with colleagues or other healthcare providers (HCPs).

Questions on gender-based discrimination included:

• Has a patient [colleague or other healthcare provider] mistaken you for a healthcare provider other than a physician?
• Has a patient [colleague or other healthcare provider] asked you to do something not at your level of training?
• Do you feel respected?
Do you perceive your gender has impacted opportunities for your career advancement?

Questions on sexual harassment included:

• Has a patient [colleague or other healthcare provider] touched you inappropriately, made sexual remarks or gestures, or made suggestive looks?
• Has a patient [colleague or other healthcare provider] referred to you by terms such as “honey,” “dear,” “sweetheart,” “sugar,” or equivalent?

In addition, the survey sought demographic information of the participants (age, gender, and race/ethnicity) and information about their individual institutions (names and locations) (Appendix). The geographical locations of the institutions were further categorized into four different regions according to the United States Census Bureau (Northwest, Midwest, South, and West). At the end of the survey, participants were given an opportunity to provide any additional comments.

Statistical Analysis

Standard descriptive summary statistics were used for demographic data. Associations between the variables were analyzed using chi-square test or Fischer’s exact test, as appropriate, for categorical variables and t test for continuous variables. The variations among institution-based responses were presented in the form of inter-quartile range (IQR). All tests were 2-sided, and P values less than .05 were considered statistically significant. All analyses were performed using IBM^® SPSS^® Statistics software version 24. Relevant responses representative of the overall respondents’ sentiments as provided under additional comment section were discussed and cited.

Eighteen different academic institutions across the United States participated in the study, with 336 individual responses. The majority of respondents were females (57%), in younger age categories (58% were 30-39 years old), Caucasian (59%), and early-career hospitalists (>50% working as hospitalists for ≤5 years) (Table 1). Regarding the overall geographic distribution, the largest number of responses were from the Midwest (n = 115; 35.6%) (Table 1 and Appendix).

Gender Discrimination

Interactions With Patients

Over their careers, 69% of hospitalists reported being mistaken for an HCP other than a physician by patients. This was more common among females than among males (99% vs 29%, respectively; P < .001) (Table 2). Almost half (48%) reported this had occurred in the last 30 days, more frequently by females (76% vs 10%; P < .001).

Of responding hospitalists, 96% stated that, over their careers, they have been asked by patients to do something they did not consider to be at their level of training (eg, help get food or water, help with a bed pan), with a higher prevalence of such experiences among females than males (99% vs 93%, respectively; P = .004) (Table 2). Most (71%) said they had experienced this in the last 30 days, which was again more frequently reported by females (78% vs 62%; P = .001).

The responses from female hospitalists regarding their career-long experiences of being mistaken for an HCP or asked to do something not at their level of training by their patients had both the highest number of positive responses across institutions (median of hospital proportions, 100%) and the least institutional variation since both had the narrowest IQR) (Table 2).

Interactions With Colleagues or Other HCPs

Among hospitalists responding to the survey, 46% felt that, over their careers, they had been mistaken for nonphysician HCPs by colleagues or other HCPs. This was more prevalent among females than among males (65% vs 20%; P < .001) (Table 2). Among respondents, 14% reported these events had occurred in the last 30 days, which was again more common among females (21% vs 5%; P < .001).

Over their careers, 26% of hospitalists reported they have been asked by a colleague or HCP to do something not at their level of training (eg, clean up the physician’s work room, make coffee, take notes in a meeting), with similar prevalence among females and males (29% vs 23%; P = .228). Ten percent reported these occurrences in the last 30 days, which was similar between females and males (12% vs 9%; P = .330).

Feelings of Respect and Opportunities for Career Advancement

When asked to rate the statement “I feel respected by patients” on a 5-point Likert scale, female hospitalists overall scored significantly lower as compared with their male counterparts (mean score, 3.73 vs 4.04; P < .001) (Table 3); this was also true when asked about feelings of respect by physicians (mean score, 3.84 vs 4.15; P < .001). Female hospitalists were more likely than males to report that their gender has more negatively impacted their opportunities for career advancement (mean score, 2.73 vs 3.34; P < .001).

Sexual Harassment

Interactions With Patients

Over half (57%) of hospitalists reported career-long experiences of patient(s) touching them inappropriately, making sexual remarks or gestures, or making suggestive looks. These experiences were more prevalent among females than among males (72% vs 36%, respectively; P < .001) (Table 2). Fifteen percent said they had such experience in rhe last 30 days, which was also more common among females (22% vs 6%; P < .001).

Most hospitalists (84%) reported that patients have referred to them by inappropriately familiar terms such as “honey,” “dear,” “sweetheart,” “sugar,” or equivalent over their careers, with females more frequently reporting these behaviors (95% vs 68%; P < .001). Experiencing this during the last 30 days was reported by 48%, which was again more common among females (68% vs 23%; P < .001).

Interactions With Colleagues or Other HCPs

Within their careers, 15% of hospitalists reported at least one experience of a colleague or HCP touching them inappropriately or making sexual remarks, gestures, or suggestive looks. This was more prevalent for females than males (18% vs 10%, respectively; P = .033). Only 2% of both females and males reported these experiences in the last 30 days (2% vs 2%; P = .981).

Almost one-third of participants (32%) affirmed that another HCP has referred to them by terms such as “honey,” “dear,” “sweetheart,” “sugar,” or equivalent in their career, with a higher proportion of females than males reporting these events (39% vs 23%; P = .002) (Table 2). Experiencing this during the last 30 days was reported by 10%, which was similar between females and males (12% vs 7%; P = .112).

Additional Comments From Respondents

• “Throughout my training and now into my professional career, there are nearly weekly incidents of elderly male patients referring to me as “honey/dear/sweetie” or even by my first name, even though I introduce myself as their physician and politely correct them. They will often refer to me as a nurse and ask me to do something not at my level of training. Sometimes even despite correcting the patient, they continue to refer to me as such. Throughout the years, other female MDs and I have discussed that this is ‘status quo’ for female physicians and observe that this is not an experience that male MDs share.”
• “I frequently round with a male nurse practitioner and the patients almost always, despite introducing ourselves and our roles, turn to him and ask him questions instead of addressing them to me.”
• “Our institution allows female faculty to be interviewed about childcare, household labor division, plans for pregnancy. One professor asks women private details about their private relationships such as what they do with spouse on date night or weekends away.”
• “It’s hard to answer questions related to my level of training. I don’t think it’s unreasonable for people to ask me to do things, no matter my level of training. . . . I don’t think being a doctor means that I am above this, or that it is inappropriate to be asked to do this.”

This survey demonstrated that gender-based discrimination and sexual harassment in the academic hospitalist healthcare environment are common, both in more distant and recent time frames. Notably, these experiences are shared by female and male physicians in interactions with both patients and colleagues, though male hospitalists report most of these experiences at significantly lower frequencies than females. These results support past work showing that female physicians are significantly more likely to be subjected to gender-based discrimination and sexual harassment, but also challenges the perception that gender-based discrimination and sexual harassment are uniquely experienced by females.

A startling number of females and males in the study reported sexual harassment (inappropriate touching, remarks, gestures, and looks) when interacting with patients throughout their careers and in last 30 days. Many males and females reported that patients had referred to them with inappropriately familiar, and potentially demeaning, terms of endearment. For both overt and implicit sexual harassment, females were significantly more likely than males to report experiencing these behaviors when interacting with patients. Although some of these experiences may seem less harmful than others, a meta-analysis demonstrated that frequent, less intense experiences of gender-based discrimination and sexual harassment have a similar impact on female’s well-being as do less frequent, more intense experiences.¹⁵ Although the person using the terms of endearment like “honey,” “sugar,” or “sweetheart” may feel the terms are harmless, such expressions can be inappropriate and constitute sexual harassment according to the U.S. Department of the Interior’s Office of Civil Rights.¹⁶ The Sexual Harassment/Assault Response and Prevention Program (SHARP) also classifies such terms into verbal categories of sexual harrassment.¹⁷

Of female physicians surveyed, 99% reported that they had been mistaken for HCPs other than physicians by their patients over their careers. Although this was also reported by male physicians, the experience was 3.4 times as likely for female physicians. Misidentification by patients may represent a disconnect between the growing female representation in the physician workforce and patients’ conceptions of the traditional image of a physician.

In parallel with this finding of misidentification, an interesting area of the study was the question regarding being asked to do “something not at your level of training.” A recurring theme in the comments was a rejection of the notion that certain tasks were “beneath a level of training,” suggesting a common view that acts of caregiving are not bounded by hierarchy. Analysis of qualitative responses showed that 40% of these responses had comments regarding this question. An example was “It’s hard to answer questions related to my level of training. . . . I don’t think being a doctor means that I am above this, or that it is inappropriate to be asked to do this.” Notably, however, a larger number of female than male physicians responded yes to this question in both study time frames. This points to a differential in how female physicians are viewed by patients, both in frequent misidentification and in behaviors more frequently asked of female physicians than their male counterparts. Given the comments, it may also suggest a difference in how female and male physicians perceive the fluidity of bounds on their care-taking roles set by their “level of training.”

A large number of study participants were early-career hospitalists, which may in part explain some of the study results. In a previous study of gender equity in an Internal Medicine department, physicians practicing medicine for more than 15 years perceived the departmental culture as more favorable than physicians with shorter careers.¹⁰ Additionally, the perception of cultures was most discordant between senior male physicians and junior female physicians.¹⁰ Because many hospitalists are early-career physicians, they may have trained in an environment that had heightened awareness surrounding gender-based discrimination and sexual harassment, which affects the overall study results.

Multiple qualitative comments, mentioned above, were submitted by participants describing their experiences in all categories. Such comments paint a picture of insidious bias and cultural norms affecting the quality of female physicians’ work lives.

Two questions focused on career satisfaction and the sense of respect from patients and colleagues. In both responses, there was a statistically different response between males and females, with females less likely to report that they felt respected and that their gender adversely impacted their opportunities for career advancement. This is disturbing information and warrants more investigation.

The reasons for the observed prevalence of gender-based discrimination and sexual harassment in this broad survey of academic hospitalists are uncertain. Multiple studies to date have demonstrated that gender-based discrimination and sexual harassment have historically existed in medicine and continue to even today. Unlike physicians with long-term relationships with patients, hospitalists may face more exposure due to a lack of long-term continuity with patients. The absence of an established trust in the relationship also may make them more vulnerable to inappropriate behaviors when interacting with patients. Hospital medicine, however, is a young specialty with equal gender representation and should be at the forefront of addressing and solving these issues of gender-based discrimination and sexual harassment.

The survey had a good distribution between female and male participants. Additionally, the survey reflected the general distribution of the national hospitalist workforce in gender, age, and ethnic/racial distribution, as well as number of years in practice.¹² The study surveyed respondents regarding experiences in both long- and short-term time frames, as well as experiences with patients and colleagues.

Our study reflects a cross-sectional snapshot of hospitalists’ perceptions with no longitudinal follow-up. Since the survey was limited to academic medical centers, it may not reflect experiences in community/private practice settings. The small number of participants limited the ability to perform subgroup analyses by age, race, or years in practice, which may play a role in interactions with patients and colleagues. Since the number of respondents varied greatly by institution, a minority of institutions could have influenced some of the findings. Narrow IQRs of the hospital proportions as shown in Table 2 would suggest similar responses across institutions, whereas wide IQRs would suggest that a smaller number of institutions were possibly driving the findings. Because of the survey distribution method, it is unknown how many physicians received the survey and a response rate could not be calculated. Further, selection, recall, and detection biases cannot be ruled out.

This survey shows that gender-based discrimination and sexual harassment in the academic hospitalist healthcare environment are common and more frequently experienced by female physicians, both in interactions with patients and colleagues. Our study highlights the need to address this prevalent issue among academic hospitalists.

Gender-based discrimination refers to “any distinction, exclusion or restriction made on the basis of socially constructed gender roles and norms which prevents a person from enjoying full human rights.”¹ Similarly, sexual harassment encompasses a spectrum of sexual conduct that includes “unwelcome sexual advances, requests for sexual favors, and other verbal or physical harassment of a sexual nature,” as defined by the US Equal Employment Opportunity Commission.² Gender-based discrimination and sexual harassment can be “overt,” which includes explicitly recognizable behaviors, or they can be “implicit,” which includes verbal and nonverbal behaviors that often go unrecognized but convey hostility, objectification, or exclusion of another person. Gender-based discrimination and sexual harassment are commonly described and likely more prevalent in academic settings.^3-6 Female physicians are disproportionately affected by gender-based discrimination and sexual harassment, compared with their male peers.^4,7

Female physicians face workplace harassment from both patients and coworkers. A study in Canada reported that more than 75% of female physicians experienced sexual harassment from their patients.⁸ A recent study showed almost half of the physicians who reported harassment, which was three times more often among female physicians, described other physician colleagues as perpetrators.⁹ In a study among clinician-researchers in the field of academic medicine, 30% of females reported having experienced sexual harassment, compared with 4% of males.⁷ Among females who reported harassment in this study, 47% stated that these experiences adversely affected their opportunities for career advancement. Career stage may also affect experiences or perceptions of gender-based discrimination and sexual harassment, with females in earlier career stages reporting a less favorable environment of gender equity.¹⁰

Hospital medicine is a young and evolving specialty, and the number of hospitalists has increased substantially from a few hundred at the time of inception to over 50,000 as of 2016.¹¹ The proportion of female hospitalists increased from 31% in 2012 to 52% in 2014, reflecting equal gender representation in hospital medicine.¹² Available evidence shows gender disparities exist in hospital medicine disproportionately affecting female hospitalists in their career advancement, including leadership and scholarship opportunities.¹³ However, there remains a knowledge gap regarding the prevalence of gender-based discrimination and sexual harassment experienced by hospitalists.

Our study examines the experiences of academic hospitalists regarding gender-based discrimination and sexual harassment and the impact of gender on career satisfaction and advancement.

Study Design and Participants

An online survey was developed and approved by the institutional board review (IRB) at the Medical College of Wisconsin in Milwaukee. University-based academic centers with hospitalist programs, identified through personal connections, from across the continental United Stated were identified as potential study sites, and leaders at each institution were contacted to ascertain potential participation in the survey. The survey was distributed to Internal Medicine hospitalists at 18 participating academic institutions from January 2019 to June 2019. Participation was voluntary. The cover letter explained the purpose of the study and provided a link to the survey. To maintain anonymity, none of the questionnaires requested identifying information from participants. A web-based Qualtrics online-based survey platform was used.

Survey Elements

The survey aimed to assess several elements of gender-based discrimination and sexual harassment. All questions about these experiences distinguished encounters with patients from those with colleagues, and questions about occurrences either over a career or in the last 30 days were intended to capture both distant and recent timeframes. The theme for the questions for the survey was based on previous studies.^4,7,8 The wording of questions was simplified to make them easily understandable, and the brevity of the survey was maintained to prevent possible nonresponses.¹⁴ Additional questions (mistaken for a healthcare provider other than a physician, feeling respected by patients and colleagues, referred to by terms such as “honey,” “dear,” “sweetheart,” “sugar,” or equivalent), which were deemed relevant in day-to-day clinical practice through consensus among study investigators and discussions among peer hospitalists, were incorporated into the final survey (Appendix). Survey questions were intended to capture several elements regarding interactions with patients and with colleagues or other healthcare providers (HCPs).

Questions on gender-based discrimination included:

• Has a patient [colleague or other healthcare provider] mistaken you for a healthcare provider other than a physician?
• Has a patient [colleague or other healthcare provider] asked you to do something not at your level of training?
• Do you feel respected?
Do you perceive your gender has impacted opportunities for your career advancement?

Questions on sexual harassment included:

• Has a patient [colleague or other healthcare provider] touched you inappropriately, made sexual remarks or gestures, or made suggestive looks?
• Has a patient [colleague or other healthcare provider] referred to you by terms such as “honey,” “dear,” “sweetheart,” “sugar,” or equivalent?

In addition, the survey sought demographic information of the participants (age, gender, and race/ethnicity) and information about their individual institutions (names and locations) (Appendix). The geographical locations of the institutions were further categorized into four different regions according to the United States Census Bureau (Northwest, Midwest, South, and West). At the end of the survey, participants were given an opportunity to provide any additional comments.

Statistical Analysis

Standard descriptive summary statistics were used for demographic data. Associations between the variables were analyzed using chi-square test or Fischer’s exact test, as appropriate, for categorical variables and t test for continuous variables. The variations among institution-based responses were presented in the form of inter-quartile range (IQR). All tests were 2-sided, and P values less than .05 were considered statistically significant. All analyses were performed using IBM^® SPSS^® Statistics software version 24. Relevant responses representative of the overall respondents’ sentiments as provided under additional comment section were discussed and cited.

Eighteen different academic institutions across the United States participated in the study, with 336 individual responses. The majority of respondents were females (57%), in younger age categories (58% were 30-39 years old), Caucasian (59%), and early-career hospitalists (>50% working as hospitalists for ≤5 years) (Table 1). Regarding the overall geographic distribution, the largest number of responses were from the Midwest (n = 115; 35.6%) (Table 1 and Appendix).

Gender Discrimination

Interactions With Patients

Over their careers, 69% of hospitalists reported being mistaken for an HCP other than a physician by patients. This was more common among females than among males (99% vs 29%, respectively; P < .001) (Table 2). Almost half (48%) reported this had occurred in the last 30 days, more frequently by females (76% vs 10%; P < .001).

Of responding hospitalists, 96% stated that, over their careers, they have been asked by patients to do something they did not consider to be at their level of training (eg, help get food or water, help with a bed pan), with a higher prevalence of such experiences among females than males (99% vs 93%, respectively; P = .004) (Table 2). Most (71%) said they had experienced this in the last 30 days, which was again more frequently reported by females (78% vs 62%; P = .001).

The responses from female hospitalists regarding their career-long experiences of being mistaken for an HCP or asked to do something not at their level of training by their patients had both the highest number of positive responses across institutions (median of hospital proportions, 100%) and the least institutional variation since both had the narrowest IQR) (Table 2).

Interactions With Colleagues or Other HCPs

Among hospitalists responding to the survey, 46% felt that, over their careers, they had been mistaken for nonphysician HCPs by colleagues or other HCPs. This was more prevalent among females than among males (65% vs 20%; P < .001) (Table 2). Among respondents, 14% reported these events had occurred in the last 30 days, which was again more common among females (21% vs 5%; P < .001).

Over their careers, 26% of hospitalists reported they have been asked by a colleague or HCP to do something not at their level of training (eg, clean up the physician’s work room, make coffee, take notes in a meeting), with similar prevalence among females and males (29% vs 23%; P = .228). Ten percent reported these occurrences in the last 30 days, which was similar between females and males (12% vs 9%; P = .330).

Feelings of Respect and Opportunities for Career Advancement

When asked to rate the statement “I feel respected by patients” on a 5-point Likert scale, female hospitalists overall scored significantly lower as compared with their male counterparts (mean score, 3.73 vs 4.04; P < .001) (Table 3); this was also true when asked about feelings of respect by physicians (mean score, 3.84 vs 4.15; P < .001). Female hospitalists were more likely than males to report that their gender has more negatively impacted their opportunities for career advancement (mean score, 2.73 vs 3.34; P < .001).

Sexual Harassment

Interactions With Patients

Over half (57%) of hospitalists reported career-long experiences of patient(s) touching them inappropriately, making sexual remarks or gestures, or making suggestive looks. These experiences were more prevalent among females than among males (72% vs 36%, respectively; P < .001) (Table 2). Fifteen percent said they had such experience in rhe last 30 days, which was also more common among females (22% vs 6%; P < .001).

Most hospitalists (84%) reported that patients have referred to them by inappropriately familiar terms such as “honey,” “dear,” “sweetheart,” “sugar,” or equivalent over their careers, with females more frequently reporting these behaviors (95% vs 68%; P < .001). Experiencing this during the last 30 days was reported by 48%, which was again more common among females (68% vs 23%; P < .001).

Interactions With Colleagues or Other HCPs

Within their careers, 15% of hospitalists reported at least one experience of a colleague or HCP touching them inappropriately or making sexual remarks, gestures, or suggestive looks. This was more prevalent for females than males (18% vs 10%, respectively; P = .033). Only 2% of both females and males reported these experiences in the last 30 days (2% vs 2%; P = .981).

Almost one-third of participants (32%) affirmed that another HCP has referred to them by terms such as “honey,” “dear,” “sweetheart,” “sugar,” or equivalent in their career, with a higher proportion of females than males reporting these events (39% vs 23%; P = .002) (Table 2). Experiencing this during the last 30 days was reported by 10%, which was similar between females and males (12% vs 7%; P = .112).

Additional Comments From Respondents

• “Throughout my training and now into my professional career, there are nearly weekly incidents of elderly male patients referring to me as “honey/dear/sweetie” or even by my first name, even though I introduce myself as their physician and politely correct them. They will often refer to me as a nurse and ask me to do something not at my level of training. Sometimes even despite correcting the patient, they continue to refer to me as such. Throughout the years, other female MDs and I have discussed that this is ‘status quo’ for female physicians and observe that this is not an experience that male MDs share.”
• “I frequently round with a male nurse practitioner and the patients almost always, despite introducing ourselves and our roles, turn to him and ask him questions instead of addressing them to me.”
• “Our institution allows female faculty to be interviewed about childcare, household labor division, plans for pregnancy. One professor asks women private details about their private relationships such as what they do with spouse on date night or weekends away.”
• “It’s hard to answer questions related to my level of training. I don’t think it’s unreasonable for people to ask me to do things, no matter my level of training. . . . I don’t think being a doctor means that I am above this, or that it is inappropriate to be asked to do this.”

This survey demonstrated that gender-based discrimination and sexual harassment in the academic hospitalist healthcare environment are common, both in more distant and recent time frames. Notably, these experiences are shared by female and male physicians in interactions with both patients and colleagues, though male hospitalists report most of these experiences at significantly lower frequencies than females. These results support past work showing that female physicians are significantly more likely to be subjected to gender-based discrimination and sexual harassment, but also challenges the perception that gender-based discrimination and sexual harassment are uniquely experienced by females.

A startling number of females and males in the study reported sexual harassment (inappropriate touching, remarks, gestures, and looks) when interacting with patients throughout their careers and in last 30 days. Many males and females reported that patients had referred to them with inappropriately familiar, and potentially demeaning, terms of endearment. For both overt and implicit sexual harassment, females were significantly more likely than males to report experiencing these behaviors when interacting with patients. Although some of these experiences may seem less harmful than others, a meta-analysis demonstrated that frequent, less intense experiences of gender-based discrimination and sexual harassment have a similar impact on female’s well-being as do less frequent, more intense experiences.¹⁵ Although the person using the terms of endearment like “honey,” “sugar,” or “sweetheart” may feel the terms are harmless, such expressions can be inappropriate and constitute sexual harassment according to the U.S. Department of the Interior’s Office of Civil Rights.¹⁶ The Sexual Harassment/Assault Response and Prevention Program (SHARP) also classifies such terms into verbal categories of sexual harrassment.¹⁷

Of female physicians surveyed, 99% reported that they had been mistaken for HCPs other than physicians by their patients over their careers. Although this was also reported by male physicians, the experience was 3.4 times as likely for female physicians. Misidentification by patients may represent a disconnect between the growing female representation in the physician workforce and patients’ conceptions of the traditional image of a physician.

In parallel with this finding of misidentification, an interesting area of the study was the question regarding being asked to do “something not at your level of training.” A recurring theme in the comments was a rejection of the notion that certain tasks were “beneath a level of training,” suggesting a common view that acts of caregiving are not bounded by hierarchy. Analysis of qualitative responses showed that 40% of these responses had comments regarding this question. An example was “It’s hard to answer questions related to my level of training. . . . I don’t think being a doctor means that I am above this, or that it is inappropriate to be asked to do this.” Notably, however, a larger number of female than male physicians responded yes to this question in both study time frames. This points to a differential in how female physicians are viewed by patients, both in frequent misidentification and in behaviors more frequently asked of female physicians than their male counterparts. Given the comments, it may also suggest a difference in how female and male physicians perceive the fluidity of bounds on their care-taking roles set by their “level of training.”

A large number of study participants were early-career hospitalists, which may in part explain some of the study results. In a previous study of gender equity in an Internal Medicine department, physicians practicing medicine for more than 15 years perceived the departmental culture as more favorable than physicians with shorter careers.¹⁰ Additionally, the perception of cultures was most discordant between senior male physicians and junior female physicians.¹⁰ Because many hospitalists are early-career physicians, they may have trained in an environment that had heightened awareness surrounding gender-based discrimination and sexual harassment, which affects the overall study results.

Multiple qualitative comments, mentioned above, were submitted by participants describing their experiences in all categories. Such comments paint a picture of insidious bias and cultural norms affecting the quality of female physicians’ work lives.

Two questions focused on career satisfaction and the sense of respect from patients and colleagues. In both responses, there was a statistically different response between males and females, with females less likely to report that they felt respected and that their gender adversely impacted their opportunities for career advancement. This is disturbing information and warrants more investigation.

The reasons for the observed prevalence of gender-based discrimination and sexual harassment in this broad survey of academic hospitalists are uncertain. Multiple studies to date have demonstrated that gender-based discrimination and sexual harassment have historically existed in medicine and continue to even today. Unlike physicians with long-term relationships with patients, hospitalists may face more exposure due to a lack of long-term continuity with patients. The absence of an established trust in the relationship also may make them more vulnerable to inappropriate behaviors when interacting with patients. Hospital medicine, however, is a young specialty with equal gender representation and should be at the forefront of addressing and solving these issues of gender-based discrimination and sexual harassment.

The survey had a good distribution between female and male participants. Additionally, the survey reflected the general distribution of the national hospitalist workforce in gender, age, and ethnic/racial distribution, as well as number of years in practice.¹² The study surveyed respondents regarding experiences in both long- and short-term time frames, as well as experiences with patients and colleagues.

Our study reflects a cross-sectional snapshot of hospitalists’ perceptions with no longitudinal follow-up. Since the survey was limited to academic medical centers, it may not reflect experiences in community/private practice settings. The small number of participants limited the ability to perform subgroup analyses by age, race, or years in practice, which may play a role in interactions with patients and colleagues. Since the number of respondents varied greatly by institution, a minority of institutions could have influenced some of the findings. Narrow IQRs of the hospital proportions as shown in Table 2 would suggest similar responses across institutions, whereas wide IQRs would suggest that a smaller number of institutions were possibly driving the findings. Because of the survey distribution method, it is unknown how many physicians received the survey and a response rate could not be calculated. Further, selection, recall, and detection biases cannot be ruled out.

This survey shows that gender-based discrimination and sexual harassment in the academic hospitalist healthcare environment are common and more frequently experienced by female physicians, both in interactions with patients and colleagues. Our study highlights the need to address this prevalent issue among academic hospitalists.

Gender-based discrimination refers to “any distinction, exclusion or restriction made on the basis of socially constructed gender roles and norms which prevents a person from enjoying full human rights.”¹ Similarly, sexual harassment encompasses a spectrum of sexual conduct that includes “unwelcome sexual advances, requests for sexual favors, and other verbal or physical harassment of a sexual nature,” as defined by the US Equal Employment Opportunity Commission.² Gender-based discrimination and sexual harassment can be “overt,” which includes explicitly recognizable behaviors, or they can be “implicit,” which includes verbal and nonverbal behaviors that often go unrecognized but convey hostility, objectification, or exclusion of another person. Gender-based discrimination and sexual harassment are commonly described and likely more prevalent in academic settings.^3-6 Female physicians are disproportionately affected by gender-based discrimination and sexual harassment, compared with their male peers.^4,7

Female physicians face workplace harassment from both patients and coworkers. A study in Canada reported that more than 75% of female physicians experienced sexual harassment from their patients.⁸ A recent study showed almost half of the physicians who reported harassment, which was three times more often among female physicians, described other physician colleagues as perpetrators.⁹ In a study among clinician-researchers in the field of academic medicine, 30% of females reported having experienced sexual harassment, compared with 4% of males.⁷ Among females who reported harassment in this study, 47% stated that these experiences adversely affected their opportunities for career advancement. Career stage may also affect experiences or perceptions of gender-based discrimination and sexual harassment, with females in earlier career stages reporting a less favorable environment of gender equity.¹⁰

Hospital medicine is a young and evolving specialty, and the number of hospitalists has increased substantially from a few hundred at the time of inception to over 50,000 as of 2016.¹¹ The proportion of female hospitalists increased from 31% in 2012 to 52% in 2014, reflecting equal gender representation in hospital medicine.¹² Available evidence shows gender disparities exist in hospital medicine disproportionately affecting female hospitalists in their career advancement, including leadership and scholarship opportunities.¹³ However, there remains a knowledge gap regarding the prevalence of gender-based discrimination and sexual harassment experienced by hospitalists.

Our study examines the experiences of academic hospitalists regarding gender-based discrimination and sexual harassment and the impact of gender on career satisfaction and advancement.

Study Design and Participants

An online survey was developed and approved by the institutional board review (IRB) at the Medical College of Wisconsin in Milwaukee. University-based academic centers with hospitalist programs, identified through personal connections, from across the continental United Stated were identified as potential study sites, and leaders at each institution were contacted to ascertain potential participation in the survey. The survey was distributed to Internal Medicine hospitalists at 18 participating academic institutions from January 2019 to June 2019. Participation was voluntary. The cover letter explained the purpose of the study and provided a link to the survey. To maintain anonymity, none of the questionnaires requested identifying information from participants. A web-based Qualtrics online-based survey platform was used.

Survey Elements

The survey aimed to assess several elements of gender-based discrimination and sexual harassment. All questions about these experiences distinguished encounters with patients from those with colleagues, and questions about occurrences either over a career or in the last 30 days were intended to capture both distant and recent timeframes. The theme for the questions for the survey was based on previous studies.^4,7,8 The wording of questions was simplified to make them easily understandable, and the brevity of the survey was maintained to prevent possible nonresponses.¹⁴ Additional questions (mistaken for a healthcare provider other than a physician, feeling respected by patients and colleagues, referred to by terms such as “honey,” “dear,” “sweetheart,” “sugar,” or equivalent), which were deemed relevant in day-to-day clinical practice through consensus among study investigators and discussions among peer hospitalists, were incorporated into the final survey (Appendix). Survey questions were intended to capture several elements regarding interactions with patients and with colleagues or other healthcare providers (HCPs).

Questions on gender-based discrimination included:

• Has a patient [colleague or other healthcare provider] mistaken you for a healthcare provider other than a physician?
• Has a patient [colleague or other healthcare provider] asked you to do something not at your level of training?
• Do you feel respected?
Do you perceive your gender has impacted opportunities for your career advancement?

Questions on sexual harassment included:

• Has a patient [colleague or other healthcare provider] touched you inappropriately, made sexual remarks or gestures, or made suggestive looks?
• Has a patient [colleague or other healthcare provider] referred to you by terms such as “honey,” “dear,” “sweetheart,” “sugar,” or equivalent?

In addition, the survey sought demographic information of the participants (age, gender, and race/ethnicity) and information about their individual institutions (names and locations) (Appendix). The geographical locations of the institutions were further categorized into four different regions according to the United States Census Bureau (Northwest, Midwest, South, and West). At the end of the survey, participants were given an opportunity to provide any additional comments.

Statistical Analysis

Standard descriptive summary statistics were used for demographic data. Associations between the variables were analyzed using chi-square test or Fischer’s exact test, as appropriate, for categorical variables and t test for continuous variables. The variations among institution-based responses were presented in the form of inter-quartile range (IQR). All tests were 2-sided, and P values less than .05 were considered statistically significant. All analyses were performed using IBM^® SPSS^® Statistics software version 24. Relevant responses representative of the overall respondents’ sentiments as provided under additional comment section were discussed and cited.

Eighteen different academic institutions across the United States participated in the study, with 336 individual responses. The majority of respondents were females (57%), in younger age categories (58% were 30-39 years old), Caucasian (59%), and early-career hospitalists (>50% working as hospitalists for ≤5 years) (Table 1). Regarding the overall geographic distribution, the largest number of responses were from the Midwest (n = 115; 35.6%) (Table 1 and Appendix).

Gender Discrimination

Interactions With Patients

Over their careers, 69% of hospitalists reported being mistaken for an HCP other than a physician by patients. This was more common among females than among males (99% vs 29%, respectively; P < .001) (Table 2). Almost half (48%) reported this had occurred in the last 30 days, more frequently by females (76% vs 10%; P < .001).

Of responding hospitalists, 96% stated that, over their careers, they have been asked by patients to do something they did not consider to be at their level of training (eg, help get food or water, help with a bed pan), with a higher prevalence of such experiences among females than males (99% vs 93%, respectively; P = .004) (Table 2). Most (71%) said they had experienced this in the last 30 days, which was again more frequently reported by females (78% vs 62%; P = .001).

The responses from female hospitalists regarding their career-long experiences of being mistaken for an HCP or asked to do something not at their level of training by their patients had both the highest number of positive responses across institutions (median of hospital proportions, 100%) and the least institutional variation since both had the narrowest IQR) (Table 2).

Interactions With Colleagues or Other HCPs

Among hospitalists responding to the survey, 46% felt that, over their careers, they had been mistaken for nonphysician HCPs by colleagues or other HCPs. This was more prevalent among females than among males (65% vs 20%; P < .001) (Table 2). Among respondents, 14% reported these events had occurred in the last 30 days, which was again more common among females (21% vs 5%; P < .001).

Over their careers, 26% of hospitalists reported they have been asked by a colleague or HCP to do something not at their level of training (eg, clean up the physician’s work room, make coffee, take notes in a meeting), with similar prevalence among females and males (29% vs 23%; P = .228). Ten percent reported these occurrences in the last 30 days, which was similar between females and males (12% vs 9%; P = .330).

Feelings of Respect and Opportunities for Career Advancement

When asked to rate the statement “I feel respected by patients” on a 5-point Likert scale, female hospitalists overall scored significantly lower as compared with their male counterparts (mean score, 3.73 vs 4.04; P < .001) (Table 3); this was also true when asked about feelings of respect by physicians (mean score, 3.84 vs 4.15; P < .001). Female hospitalists were more likely than males to report that their gender has more negatively impacted their opportunities for career advancement (mean score, 2.73 vs 3.34; P < .001).

Sexual Harassment

Interactions With Patients

Over half (57%) of hospitalists reported career-long experiences of patient(s) touching them inappropriately, making sexual remarks or gestures, or making suggestive looks. These experiences were more prevalent among females than among males (72% vs 36%, respectively; P < .001) (Table 2). Fifteen percent said they had such experience in rhe last 30 days, which was also more common among females (22% vs 6%; P < .001).

Most hospitalists (84%) reported that patients have referred to them by inappropriately familiar terms such as “honey,” “dear,” “sweetheart,” “sugar,” or equivalent over their careers, with females more frequently reporting these behaviors (95% vs 68%; P < .001). Experiencing this during the last 30 days was reported by 48%, which was again more common among females (68% vs 23%; P < .001).

Interactions With Colleagues or Other HCPs

Within their careers, 15% of hospitalists reported at least one experience of a colleague or HCP touching them inappropriately or making sexual remarks, gestures, or suggestive looks. This was more prevalent for females than males (18% vs 10%, respectively; P = .033). Only 2% of both females and males reported these experiences in the last 30 days (2% vs 2%; P = .981).

Almost one-third of participants (32%) affirmed that another HCP has referred to them by terms such as “honey,” “dear,” “sweetheart,” “sugar,” or equivalent in their career, with a higher proportion of females than males reporting these events (39% vs 23%; P = .002) (Table 2). Experiencing this during the last 30 days was reported by 10%, which was similar between females and males (12% vs 7%; P = .112).

Additional Comments From Respondents

• “Throughout my training and now into my professional career, there are nearly weekly incidents of elderly male patients referring to me as “honey/dear/sweetie” or even by my first name, even though I introduce myself as their physician and politely correct them. They will often refer to me as a nurse and ask me to do something not at my level of training. Sometimes even despite correcting the patient, they continue to refer to me as such. Throughout the years, other female MDs and I have discussed that this is ‘status quo’ for female physicians and observe that this is not an experience that male MDs share.”
• “I frequently round with a male nurse practitioner and the patients almost always, despite introducing ourselves and our roles, turn to him and ask him questions instead of addressing them to me.”
• “Our institution allows female faculty to be interviewed about childcare, household labor division, plans for pregnancy. One professor asks women private details about their private relationships such as what they do with spouse on date night or weekends away.”
• “It’s hard to answer questions related to my level of training. I don’t think it’s unreasonable for people to ask me to do things, no matter my level of training. . . . I don’t think being a doctor means that I am above this, or that it is inappropriate to be asked to do this.”

This survey demonstrated that gender-based discrimination and sexual harassment in the academic hospitalist healthcare environment are common, both in more distant and recent time frames. Notably, these experiences are shared by female and male physicians in interactions with both patients and colleagues, though male hospitalists report most of these experiences at significantly lower frequencies than females. These results support past work showing that female physicians are significantly more likely to be subjected to gender-based discrimination and sexual harassment, but also challenges the perception that gender-based discrimination and sexual harassment are uniquely experienced by females.

A startling number of females and males in the study reported sexual harassment (inappropriate touching, remarks, gestures, and looks) when interacting with patients throughout their careers and in last 30 days. Many males and females reported that patients had referred to them with inappropriately familiar, and potentially demeaning, terms of endearment. For both overt and implicit sexual harassment, females were significantly more likely than males to report experiencing these behaviors when interacting with patients. Although some of these experiences may seem less harmful than others, a meta-analysis demonstrated that frequent, less intense experiences of gender-based discrimination and sexual harassment have a similar impact on female’s well-being as do less frequent, more intense experiences.¹⁵ Although the person using the terms of endearment like “honey,” “sugar,” or “sweetheart” may feel the terms are harmless, such expressions can be inappropriate and constitute sexual harassment according to the U.S. Department of the Interior’s Office of Civil Rights.¹⁶ The Sexual Harassment/Assault Response and Prevention Program (SHARP) also classifies such terms into verbal categories of sexual harrassment.¹⁷

Of female physicians surveyed, 99% reported that they had been mistaken for HCPs other than physicians by their patients over their careers. Although this was also reported by male physicians, the experience was 3.4 times as likely for female physicians. Misidentification by patients may represent a disconnect between the growing female representation in the physician workforce and patients’ conceptions of the traditional image of a physician.

In parallel with this finding of misidentification, an interesting area of the study was the question regarding being asked to do “something not at your level of training.” A recurring theme in the comments was a rejection of the notion that certain tasks were “beneath a level of training,” suggesting a common view that acts of caregiving are not bounded by hierarchy. Analysis of qualitative responses showed that 40% of these responses had comments regarding this question. An example was “It’s hard to answer questions related to my level of training. . . . I don’t think being a doctor means that I am above this, or that it is inappropriate to be asked to do this.” Notably, however, a larger number of female than male physicians responded yes to this question in both study time frames. This points to a differential in how female physicians are viewed by patients, both in frequent misidentification and in behaviors more frequently asked of female physicians than their male counterparts. Given the comments, it may also suggest a difference in how female and male physicians perceive the fluidity of bounds on their care-taking roles set by their “level of training.”

A large number of study participants were early-career hospitalists, which may in part explain some of the study results. In a previous study of gender equity in an Internal Medicine department, physicians practicing medicine for more than 15 years perceived the departmental culture as more favorable than physicians with shorter careers.¹⁰ Additionally, the perception of cultures was most discordant between senior male physicians and junior female physicians.¹⁰ Because many hospitalists are early-career physicians, they may have trained in an environment that had heightened awareness surrounding gender-based discrimination and sexual harassment, which affects the overall study results.

Multiple qualitative comments, mentioned above, were submitted by participants describing their experiences in all categories. Such comments paint a picture of insidious bias and cultural norms affecting the quality of female physicians’ work lives.

Two questions focused on career satisfaction and the sense of respect from patients and colleagues. In both responses, there was a statistically different response between males and females, with females less likely to report that they felt respected and that their gender adversely impacted their opportunities for career advancement. This is disturbing information and warrants more investigation.

The reasons for the observed prevalence of gender-based discrimination and sexual harassment in this broad survey of academic hospitalists are uncertain. Multiple studies to date have demonstrated that gender-based discrimination and sexual harassment have historically existed in medicine and continue to even today. Unlike physicians with long-term relationships with patients, hospitalists may face more exposure due to a lack of long-term continuity with patients. The absence of an established trust in the relationship also may make them more vulnerable to inappropriate behaviors when interacting with patients. Hospital medicine, however, is a young specialty with equal gender representation and should be at the forefront of addressing and solving these issues of gender-based discrimination and sexual harassment.

The survey had a good distribution between female and male participants. Additionally, the survey reflected the general distribution of the national hospitalist workforce in gender, age, and ethnic/racial distribution, as well as number of years in practice.¹² The study surveyed respondents regarding experiences in both long- and short-term time frames, as well as experiences with patients and colleagues.

Our study reflects a cross-sectional snapshot of hospitalists’ perceptions with no longitudinal follow-up. Since the survey was limited to academic medical centers, it may not reflect experiences in community/private practice settings. The small number of participants limited the ability to perform subgroup analyses by age, race, or years in practice, which may play a role in interactions with patients and colleagues. Since the number of respondents varied greatly by institution, a minority of institutions could have influenced some of the findings. Narrow IQRs of the hospital proportions as shown in Table 2 would suggest similar responses across institutions, whereas wide IQRs would suggest that a smaller number of institutions were possibly driving the findings. Because of the survey distribution method, it is unknown how many physicians received the survey and a response rate could not be calculated. Further, selection, recall, and detection biases cannot be ruled out.

This survey shows that gender-based discrimination and sexual harassment in the academic hospitalist healthcare environment are common and more frequently experienced by female physicians, both in interactions with patients and colleagues. Our study highlights the need to address this prevalent issue among academic hospitalists.

Hospitalized patients receive care via a team-based approach. Because of frequent turnover and constant changes in team members, medical teams require rapid establishment of psychological safety. Psychological safety, or “being able to show and employ one’s self without fear of negative consequences of self-image, status or career,”¹ is at the core of successful team functioning. Google studied successful teams and found diverse personalities and skillsets work together most productively if they incorporate certain team dynamics; chief among these are focusing on shared values and psychological safety.² Times of acute crisis, especially those in which clinicians are working in unfamiliar settings and with new teams, increase the need for psychological safety. During the first wave of the coronavirus disease 2019 (COVID-19) pandemic, many hospitals responded by forming ad hoc teams of non-hospitalist clinicians, including redeployed outpatient physicians and subspecialists.³ Because this situation was an acute crisis in which strangers (some new to the field) were suddenly working side by side, it was an excellent example of a moment that required rapid establishment of psychological safety. As subsequent waves of COVID-19 arrive, this will likely occur again. In this perspective, we identify strategies that help to establish psychological safety on medical teams, aiming to increase the effectiveness of teams caring for hospitalized patients, enhance leaders’ abilities to improve team function, and allow for delivery of high-quality patient care.

Psychological safety creates a nonthreatening team environment in which clinicians can ask questions and seek help with unfamiliar clinical scenarios. When psychological safety is present, the team dynamic encourages interpersonal risk-taking, improves learning, and increases the likelihood that team members will suggest new ideas.⁴ A culture of openness where people feel accepted and respected plays a vital role in helping people thrive in challenging and high-stakes work environments.⁵ In healthcare, team members who do not fear punishment for mistakes are more likely to disclose errors.⁶ Psychological safety has been associated with decreased anxiety in stressful situations, thereby freeing learners’ mental capacity to explore, innovate, and absorb new information.⁶

Through a thorough literature review, we identified strategies that can increase psychological safety on clinical teams. We focused on strategies applicable to acute crises, like COVID-19, when dynamic teams and uncertainty are rife. These strategies primarily focus on “team leaders,” generally the attendings or senior residents, who influence the team’s culture.

Discuss Mistakes

Creating a culture in which openly discussing mistakes is normalized and learning is fostered is especially important for healthcare providers redeployed to COVID-19 wards. Acknowledging errors can be challenging, especially in medicine, because success is often celebrated.⁷ Creating an environment where discussing mistakes in a nonjudgmental manner is the norm helps people disclose and learn from errors. By modeling fallibility, team leaders can create an environment where learning from mistakes seems less threatening.⁸ Leaders can say, “I may miss something. I encourage all members of the team to share what they know.”⁹

Provide Frequent Updates and Seek Feedback

Information and guidelines are changing frequently as we learn more about the novel coronavirus. The barrage of new information and periodic policy changes can be disconcerting. Leaders can dispel some of the team’s anxiety by providing a unified message that distills new information into clear and essential updates.⁹ They can reassure the team that updates will be provided frequently, be honest about what is known, and offer some predictability by providing updates at set times via consistent forms of communication during times of crisis. They can show empathy by inquiring about individual worries and responding to concerns about changes that are being made in response to COVID-19.¹⁰ Leaders should routinely seek feedback. They can ask, “How are things going for you? What can we improve? What should we do differently? How can I make you feel more comfortable or help you learn more effectively?” Inviting input communicates that everyone’s opinion is respected and creates a climate where everyone feels comfortable asking questions or respectfully expressing diverging opinions.⁹

Foster Creativity and Seek New Ideas

Curiosity and creativity are associated with better group outcomes.¹¹ Curiosity, or the motivation to learn and seek new ideas, improves individual and group dynamics by stimulating better job performance, inspiring leaders to discover more creative solutions, and encouraging employees to develop more trusting relationships, which makes them less likely to stereotype coworkers and patients as they ask questions and learn about others.¹² People who approach situations with a more creative perspective are less likely to react defensively. Curious people tend to try to learn about and understand different points of view.¹³ For example, if an order is not placed for a patient, a curious team leader might think about why—was there disagreement on the order, confusion on how to place it, or was it inadvertently forgotten?—and be able help avoid similar scenarios in the future. This ability to see things from another person’s point of view helps individuals with diverse clinical, social, and ethnic backgrounds function as a harmonious team. An attitude of curiosity and interest in learning about what each person can contribute based on their unique training and personality will help well-functioning teams form in response to COVID-19. Openness to new ideas allows for more innovative solutions, which are important in times of crisis. To promote curiosity, team members should discuss differences and varied opinions openly. This open dialogue provides individuals opportunities to learn from each other.⁵

Build Connection and Trust

A culture of trust—the belief that others will act for the good of the team—helps create psychological safety.¹⁰ Leaders can build trust by making expectations clear, being consistent, being inclusive, and modeling behaviors they wish to encourage.⁶ Predictability reduces anxiety and promotes psychological safety.⁹ Defining goals and expectations helps people relax, ask questions, and focus on learning.¹⁴ In times of crisis, leaders can tell teams what changes to expect, spell out new priorities, and assign specific tasks to give people a way to contribute.¹⁵

Activities that create connection also build trust, enhancing the team’s sense of psychological safety. Shared experiences foster connections.² Leaders can encourage team bonding by setting aside time to share stories and coping strategies.¹⁰ Chief residents in the early days of the pandemic found defining social distancing only as physical separation and focusing on emotional bonds helped maintain a sense of community. Debriefing about emotional patient encounters and discussing interesting clinical cases during video calls were ways to implement this strategy.¹⁰ Team members feel connected to each other and dedicated to their work if they focus on the meaning of the work to them, as well as its impact on society.² This shared belief that what they are doing matters to their community helps bond them.² Currently, the shared experience of treating a novel illness during the COVID-19 pandemic and the common goal of patient well-being unites healthcare providers across the globe. Leaders can create solidarity by emphasizing the shared identity of fighting COVID-19 and reminding teams of the impact of their work. Leaders can say, “Remember, we are here to improve patients’ health and form emotional bonds with people and their families.” These reminders have been shown to promote psychological safety and connection.¹⁶

Make Team Members Feel Valued

As many healthcare providers work harder or in unfamiliar environments during this pandemic, recognition of their efforts by leaders can be especially motivating and meaningful. When individuals on a team feel their work is valued, it helps create a sense of psychological safety.¹⁷ Employees feel valued when they believe their leaders care, they are in socially supportive environments, and are given resources for professional growth.¹⁷ Diversity and inclusion are also associated with feeling valued.¹⁷ During the height of the initial COVID-19 surge at our hospital, the chief of the Department of Medicine regularly sent messages and photographs of trainees and faculty, showing teams coming together during these unprecedented times. This boosted morale and created comradery and is an excellent example of a leader modeling inclusion.

Gratitude strengthens relationships and motivates people, especially when its expression is thoughtful and unique to individuals.¹⁸ Sincere compliments, acknowledgement of hard work, inclusiveness, and gratitude all contribute to team members feeling at ease and are key to leading, especially in times of crisis.¹⁷ Leaders can provide motivation by affirming the team’s ability to work together. Leaders can say, “I believe in each and every one of your capabilities—and I believe even more so in our joint capabilities. We can do this together.”¹⁹

Psychological safety is a powerful predictor of team performance, increased engagement, and satisfaction. It is critical for creating teams that can deal with uncertainty in high-risk situations, promoting a culture that is safe to acknowledge mistakes and take chances, which is important for optimal team functioning. Crises like the COVID-19 pandemic emphasize the need for psychologically safe team climates to promote learning, safe patient care, and team support. Hospitalists often care for patients when they are at their most vulnerable. Respecting and connecting with patients, through good and efficient teamwork, is important to providing effective care. The strategies suggested in this article strive to help hospitalists create a respectful culture to strengthen relationships with patients and colleagues in order to create an inclusive environment in times of crisis.

Hospitalized patients receive care via a team-based approach. Because of frequent turnover and constant changes in team members, medical teams require rapid establishment of psychological safety. Psychological safety, or “being able to show and employ one’s self without fear of negative consequences of self-image, status or career,”¹ is at the core of successful team functioning. Google studied successful teams and found diverse personalities and skillsets work together most productively if they incorporate certain team dynamics; chief among these are focusing on shared values and psychological safety.² Times of acute crisis, especially those in which clinicians are working in unfamiliar settings and with new teams, increase the need for psychological safety. During the first wave of the coronavirus disease 2019 (COVID-19) pandemic, many hospitals responded by forming ad hoc teams of non-hospitalist clinicians, including redeployed outpatient physicians and subspecialists.³ Because this situation was an acute crisis in which strangers (some new to the field) were suddenly working side by side, it was an excellent example of a moment that required rapid establishment of psychological safety. As subsequent waves of COVID-19 arrive, this will likely occur again. In this perspective, we identify strategies that help to establish psychological safety on medical teams, aiming to increase the effectiveness of teams caring for hospitalized patients, enhance leaders’ abilities to improve team function, and allow for delivery of high-quality patient care.

Psychological safety creates a nonthreatening team environment in which clinicians can ask questions and seek help with unfamiliar clinical scenarios. When psychological safety is present, the team dynamic encourages interpersonal risk-taking, improves learning, and increases the likelihood that team members will suggest new ideas.⁴ A culture of openness where people feel accepted and respected plays a vital role in helping people thrive in challenging and high-stakes work environments.⁵ In healthcare, team members who do not fear punishment for mistakes are more likely to disclose errors.⁶ Psychological safety has been associated with decreased anxiety in stressful situations, thereby freeing learners’ mental capacity to explore, innovate, and absorb new information.⁶

Through a thorough literature review, we identified strategies that can increase psychological safety on clinical teams. We focused on strategies applicable to acute crises, like COVID-19, when dynamic teams and uncertainty are rife. These strategies primarily focus on “team leaders,” generally the attendings or senior residents, who influence the team’s culture.

Discuss Mistakes

Creating a culture in which openly discussing mistakes is normalized and learning is fostered is especially important for healthcare providers redeployed to COVID-19 wards. Acknowledging errors can be challenging, especially in medicine, because success is often celebrated.⁷ Creating an environment where discussing mistakes in a nonjudgmental manner is the norm helps people disclose and learn from errors. By modeling fallibility, team leaders can create an environment where learning from mistakes seems less threatening.⁸ Leaders can say, “I may miss something. I encourage all members of the team to share what they know.”⁹

Provide Frequent Updates and Seek Feedback

Information and guidelines are changing frequently as we learn more about the novel coronavirus. The barrage of new information and periodic policy changes can be disconcerting. Leaders can dispel some of the team’s anxiety by providing a unified message that distills new information into clear and essential updates.⁹ They can reassure the team that updates will be provided frequently, be honest about what is known, and offer some predictability by providing updates at set times via consistent forms of communication during times of crisis. They can show empathy by inquiring about individual worries and responding to concerns about changes that are being made in response to COVID-19.¹⁰ Leaders should routinely seek feedback. They can ask, “How are things going for you? What can we improve? What should we do differently? How can I make you feel more comfortable or help you learn more effectively?” Inviting input communicates that everyone’s opinion is respected and creates a climate where everyone feels comfortable asking questions or respectfully expressing diverging opinions.⁹

Foster Creativity and Seek New Ideas

Curiosity and creativity are associated with better group outcomes.¹¹ Curiosity, or the motivation to learn and seek new ideas, improves individual and group dynamics by stimulating better job performance, inspiring leaders to discover more creative solutions, and encouraging employees to develop more trusting relationships, which makes them less likely to stereotype coworkers and patients as they ask questions and learn about others.¹² People who approach situations with a more creative perspective are less likely to react defensively. Curious people tend to try to learn about and understand different points of view.¹³ For example, if an order is not placed for a patient, a curious team leader might think about why—was there disagreement on the order, confusion on how to place it, or was it inadvertently forgotten?—and be able help avoid similar scenarios in the future. This ability to see things from another person’s point of view helps individuals with diverse clinical, social, and ethnic backgrounds function as a harmonious team. An attitude of curiosity and interest in learning about what each person can contribute based on their unique training and personality will help well-functioning teams form in response to COVID-19. Openness to new ideas allows for more innovative solutions, which are important in times of crisis. To promote curiosity, team members should discuss differences and varied opinions openly. This open dialogue provides individuals opportunities to learn from each other.⁵

Build Connection and Trust

A culture of trust—the belief that others will act for the good of the team—helps create psychological safety.¹⁰ Leaders can build trust by making expectations clear, being consistent, being inclusive, and modeling behaviors they wish to encourage.⁶ Predictability reduces anxiety and promotes psychological safety.⁹ Defining goals and expectations helps people relax, ask questions, and focus on learning.¹⁴ In times of crisis, leaders can tell teams what changes to expect, spell out new priorities, and assign specific tasks to give people a way to contribute.¹⁵

Activities that create connection also build trust, enhancing the team’s sense of psychological safety. Shared experiences foster connections.² Leaders can encourage team bonding by setting aside time to share stories and coping strategies.¹⁰ Chief residents in the early days of the pandemic found defining social distancing only as physical separation and focusing on emotional bonds helped maintain a sense of community. Debriefing about emotional patient encounters and discussing interesting clinical cases during video calls were ways to implement this strategy.¹⁰ Team members feel connected to each other and dedicated to their work if they focus on the meaning of the work to them, as well as its impact on society.² This shared belief that what they are doing matters to their community helps bond them.² Currently, the shared experience of treating a novel illness during the COVID-19 pandemic and the common goal of patient well-being unites healthcare providers across the globe. Leaders can create solidarity by emphasizing the shared identity of fighting COVID-19 and reminding teams of the impact of their work. Leaders can say, “Remember, we are here to improve patients’ health and form emotional bonds with people and their families.” These reminders have been shown to promote psychological safety and connection.¹⁶

Make Team Members Feel Valued

As many healthcare providers work harder or in unfamiliar environments during this pandemic, recognition of their efforts by leaders can be especially motivating and meaningful. When individuals on a team feel their work is valued, it helps create a sense of psychological safety.¹⁷ Employees feel valued when they believe their leaders care, they are in socially supportive environments, and are given resources for professional growth.¹⁷ Diversity and inclusion are also associated with feeling valued.¹⁷ During the height of the initial COVID-19 surge at our hospital, the chief of the Department of Medicine regularly sent messages and photographs of trainees and faculty, showing teams coming together during these unprecedented times. This boosted morale and created comradery and is an excellent example of a leader modeling inclusion.

Gratitude strengthens relationships and motivates people, especially when its expression is thoughtful and unique to individuals.¹⁸ Sincere compliments, acknowledgement of hard work, inclusiveness, and gratitude all contribute to team members feeling at ease and are key to leading, especially in times of crisis.¹⁷ Leaders can provide motivation by affirming the team’s ability to work together. Leaders can say, “I believe in each and every one of your capabilities—and I believe even more so in our joint capabilities. We can do this together.”¹⁹

Psychological safety is a powerful predictor of team performance, increased engagement, and satisfaction. It is critical for creating teams that can deal with uncertainty in high-risk situations, promoting a culture that is safe to acknowledge mistakes and take chances, which is important for optimal team functioning. Crises like the COVID-19 pandemic emphasize the need for psychologically safe team climates to promote learning, safe patient care, and team support. Hospitalists often care for patients when they are at their most vulnerable. Respecting and connecting with patients, through good and efficient teamwork, is important to providing effective care. The strategies suggested in this article strive to help hospitalists create a respectful culture to strengthen relationships with patients and colleagues in order to create an inclusive environment in times of crisis.

Hospitalized patients receive care via a team-based approach. Because of frequent turnover and constant changes in team members, medical teams require rapid establishment of psychological safety. Psychological safety, or “being able to show and employ one’s self without fear of negative consequences of self-image, status or career,”¹ is at the core of successful team functioning. Google studied successful teams and found diverse personalities and skillsets work together most productively if they incorporate certain team dynamics; chief among these are focusing on shared values and psychological safety.² Times of acute crisis, especially those in which clinicians are working in unfamiliar settings and with new teams, increase the need for psychological safety. During the first wave of the coronavirus disease 2019 (COVID-19) pandemic, many hospitals responded by forming ad hoc teams of non-hospitalist clinicians, including redeployed outpatient physicians and subspecialists.³ Because this situation was an acute crisis in which strangers (some new to the field) were suddenly working side by side, it was an excellent example of a moment that required rapid establishment of psychological safety. As subsequent waves of COVID-19 arrive, this will likely occur again. In this perspective, we identify strategies that help to establish psychological safety on medical teams, aiming to increase the effectiveness of teams caring for hospitalized patients, enhance leaders’ abilities to improve team function, and allow for delivery of high-quality patient care.

Psychological safety creates a nonthreatening team environment in which clinicians can ask questions and seek help with unfamiliar clinical scenarios. When psychological safety is present, the team dynamic encourages interpersonal risk-taking, improves learning, and increases the likelihood that team members will suggest new ideas.⁴ A culture of openness where people feel accepted and respected plays a vital role in helping people thrive in challenging and high-stakes work environments.⁵ In healthcare, team members who do not fear punishment for mistakes are more likely to disclose errors.⁶ Psychological safety has been associated with decreased anxiety in stressful situations, thereby freeing learners’ mental capacity to explore, innovate, and absorb new information.⁶

Through a thorough literature review, we identified strategies that can increase psychological safety on clinical teams. We focused on strategies applicable to acute crises, like COVID-19, when dynamic teams and uncertainty are rife. These strategies primarily focus on “team leaders,” generally the attendings or senior residents, who influence the team’s culture.

Discuss Mistakes

Creating a culture in which openly discussing mistakes is normalized and learning is fostered is especially important for healthcare providers redeployed to COVID-19 wards. Acknowledging errors can be challenging, especially in medicine, because success is often celebrated.⁷ Creating an environment where discussing mistakes in a nonjudgmental manner is the norm helps people disclose and learn from errors. By modeling fallibility, team leaders can create an environment where learning from mistakes seems less threatening.⁸ Leaders can say, “I may miss something. I encourage all members of the team to share what they know.”⁹

Provide Frequent Updates and Seek Feedback

Information and guidelines are changing frequently as we learn more about the novel coronavirus. The barrage of new information and periodic policy changes can be disconcerting. Leaders can dispel some of the team’s anxiety by providing a unified message that distills new information into clear and essential updates.⁹ They can reassure the team that updates will be provided frequently, be honest about what is known, and offer some predictability by providing updates at set times via consistent forms of communication during times of crisis. They can show empathy by inquiring about individual worries and responding to concerns about changes that are being made in response to COVID-19.¹⁰ Leaders should routinely seek feedback. They can ask, “How are things going for you? What can we improve? What should we do differently? How can I make you feel more comfortable or help you learn more effectively?” Inviting input communicates that everyone’s opinion is respected and creates a climate where everyone feels comfortable asking questions or respectfully expressing diverging opinions.⁹

Foster Creativity and Seek New Ideas

Curiosity and creativity are associated with better group outcomes.¹¹ Curiosity, or the motivation to learn and seek new ideas, improves individual and group dynamics by stimulating better job performance, inspiring leaders to discover more creative solutions, and encouraging employees to develop more trusting relationships, which makes them less likely to stereotype coworkers and patients as they ask questions and learn about others.¹² People who approach situations with a more creative perspective are less likely to react defensively. Curious people tend to try to learn about and understand different points of view.¹³ For example, if an order is not placed for a patient, a curious team leader might think about why—was there disagreement on the order, confusion on how to place it, or was it inadvertently forgotten?—and be able help avoid similar scenarios in the future. This ability to see things from another person’s point of view helps individuals with diverse clinical, social, and ethnic backgrounds function as a harmonious team. An attitude of curiosity and interest in learning about what each person can contribute based on their unique training and personality will help well-functioning teams form in response to COVID-19. Openness to new ideas allows for more innovative solutions, which are important in times of crisis. To promote curiosity, team members should discuss differences and varied opinions openly. This open dialogue provides individuals opportunities to learn from each other.⁵

Build Connection and Trust

A culture of trust—the belief that others will act for the good of the team—helps create psychological safety.¹⁰ Leaders can build trust by making expectations clear, being consistent, being inclusive, and modeling behaviors they wish to encourage.⁶ Predictability reduces anxiety and promotes psychological safety.⁹ Defining goals and expectations helps people relax, ask questions, and focus on learning.¹⁴ In times of crisis, leaders can tell teams what changes to expect, spell out new priorities, and assign specific tasks to give people a way to contribute.¹⁵

Activities that create connection also build trust, enhancing the team’s sense of psychological safety. Shared experiences foster connections.² Leaders can encourage team bonding by setting aside time to share stories and coping strategies.¹⁰ Chief residents in the early days of the pandemic found defining social distancing only as physical separation and focusing on emotional bonds helped maintain a sense of community. Debriefing about emotional patient encounters and discussing interesting clinical cases during video calls were ways to implement this strategy.¹⁰ Team members feel connected to each other and dedicated to their work if they focus on the meaning of the work to them, as well as its impact on society.² This shared belief that what they are doing matters to their community helps bond them.² Currently, the shared experience of treating a novel illness during the COVID-19 pandemic and the common goal of patient well-being unites healthcare providers across the globe. Leaders can create solidarity by emphasizing the shared identity of fighting COVID-19 and reminding teams of the impact of their work. Leaders can say, “Remember, we are here to improve patients’ health and form emotional bonds with people and their families.” These reminders have been shown to promote psychological safety and connection.¹⁶

Make Team Members Feel Valued

As many healthcare providers work harder or in unfamiliar environments during this pandemic, recognition of their efforts by leaders can be especially motivating and meaningful. When individuals on a team feel their work is valued, it helps create a sense of psychological safety.¹⁷ Employees feel valued when they believe their leaders care, they are in socially supportive environments, and are given resources for professional growth.¹⁷ Diversity and inclusion are also associated with feeling valued.¹⁷ During the height of the initial COVID-19 surge at our hospital, the chief of the Department of Medicine regularly sent messages and photographs of trainees and faculty, showing teams coming together during these unprecedented times. This boosted morale and created comradery and is an excellent example of a leader modeling inclusion.

Gratitude strengthens relationships and motivates people, especially when its expression is thoughtful and unique to individuals.¹⁸ Sincere compliments, acknowledgement of hard work, inclusiveness, and gratitude all contribute to team members feeling at ease and are key to leading, especially in times of crisis.¹⁷ Leaders can provide motivation by affirming the team’s ability to work together. Leaders can say, “I believe in each and every one of your capabilities—and I believe even more so in our joint capabilities. We can do this together.”¹⁹

Psychological safety is a powerful predictor of team performance, increased engagement, and satisfaction. It is critical for creating teams that can deal with uncertainty in high-risk situations, promoting a culture that is safe to acknowledge mistakes and take chances, which is important for optimal team functioning. Crises like the COVID-19 pandemic emphasize the need for psychologically safe team climates to promote learning, safe patient care, and team support. Hospitalists often care for patients when they are at their most vulnerable. Respecting and connecting with patients, through good and efficient teamwork, is important to providing effective care. The strategies suggested in this article strive to help hospitalists create a respectful culture to strengthen relationships with patients and colleagues in order to create an inclusive environment in times of crisis.