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Hello, everyone. Thank you very much for braving the western wind and weather to be here. Very honored and privileged to have new with, with us. Welcome. Also to those of you who are joining us online from the women in surgery groups around the country and Ireland and also the Edinburgh Student Surgical Society members. Welcome, Carrie is, as those of you who who medical teaching here at Edinburgh will remember we talk about, er, Aristotle and Aristotle's favorite virtue, er, which is courage, the golden mean between coward and reckless bravery. And I think that the authors of this, that this report, which Carrie is going to talk about are certainly very brave at taking on the establishment. But we're going to hear more about how, how this report came about and Carrie's involvement with it now. But first of all, thank you, Carrie for being here this evening. Pleasure. Thank you, sit down. Thank you David for your kind invite to speak and, and thanks everyone for coming out this evening. So I'm going to talk to you about our journey in terms of breaking the silence on sexual misconduct and surgery and consider some issues on speaking up in health care and how individuals and organizations can be willfully blind. Mm mm So this commentary by two trainees, Simon Fleming and Becky Fisher who are involved with our group was published in September 2021. Um They're both very active on social media and Simon Fleming commented that of over 20 women who had in the past shared with him experiences not a single one was willing to coauthor the paper even on guarantee of anonymity. And then Philippa Jackson, who's a consultant plastic surgeon in Bristol wrote the first named testimony in terms of te telling her story of what happened to her. And there were further other multiple influential contributions. So we formed the working party on sexual misconducting surgery at the beginning of 2022. And we really hit at a time when people were starting to listen about this being potentially a problem. Um And we got support eventually from multiple stakeholders like the Royal Colleges and people like health Education England who were prepared to listen to us and help us in um sending our survey around their email lists which ran from September to December 2022. And then we held a round table at the General Medical Council to which we invited people at the Medical Schools Council, um people from the colleges, the NHS um to talk to them about what we had found so that we could all try and work together in terms of them coming up with some solutions because we're essentially just a bunch of um surgeons who are dipping our toes into politics and don't really have any power apart from having the data. Um Interestingly, in 2019, there had been a survey of people in healthcare professions. So allied healthcare professionals who belonged to unionists and their union um had already come out, but very little notice had been taken of it. So the majority of those who experienced sexual harassment work was by a colleague. Most of them didn't report it and those who did report it. Um Most of them didn't feel that their case had been dealt with appropriately. So this is a sensitive issue and getting to where we are today, we have a lot of hurdles to overcome. Um We were given a lot of pushbacks on these. It was about 2017 when a colleague and I went to the committee on surgical training and asked them to run a survey because we were aware of problems in our own specialty where trainees had been assaulted and raped at our annual conference. Um And there were lots of things that we were told along the, along the way, this is a matter for trust to deal with. Don't have policies. Um We don't get involved in relationships between colleagues. You can't hack a bit of banter. Are you in the right job? Oh, that sounds bad. And then a bit of a tilt of the head, you know what he's like. So there's a lot of moral licensing goes on in things like surgery where people are good at hip replacements, for example. And therefore you're just expected to put up with their behavior and the, the common thing, this is a matter for the police. Um, and it may well be, but we shouldn't be living in a system and having to work in a system whereby we're letting this happen and then suggesting that people have to go to the police about it. And as we know that the, the justice that people get when they've been sexually assaulted or raped from the, from the police system, um leaves much to be desired. Yeah. Um, we were often told it may have happened in the past but it wasn't a current issue. Um People get very worried about vexatious reporting and I'll talk about a little bit later. There was real concern about there being um, legal jeopardy if perpetrators are named, if you ask people about things before, want to tell you who they are. And then what do you do with that information? Particularly if you're on the GMC register, you know, what's your duty then in terms of knowing who people are and who will take legal responsibility if a pattern emerges. So we did this research in conjunction with the University of Exeter, which went through all their ethics committees and they kept all the data and effectively cleaned any names or any patterns out of it for us because that wasn't the purpose of the survey. So our paper and accompanying report came out on the 12th of September this year and note the subtitle here of how men and women are living different realities. And that's quite an important thing in terms of the message as to how we help to deal with this. There's everybody's problem to deal with, but men and women are seeing it very differently. We then, um, published a report on the same day. Um and that really look at the wider issues in health care and came up with some recommendations that were a result of the round table that we've held with, um, some of the stakeholders, um because they're the people who got the power to make a difference. Um, the traffic to the British Journal of Surgery for the following week was described by them as unusual, which was really interesting. You know, we, we thought that it would make some waves that we weren't quite expecting that the, um, the website would have trouble coping with the traffic. Um, the paper received a huge amount of attention. So it's currently in the top 5% of all research outputs on optometric, which was quite astonishing. Um, it was on the front page of the Times and we spent a day doing very peculiar things for surgeons being on the tele and being on the radio and being completely terrified. Um GB News kept in getting in touch with us through all sorts of mechanisms wanting us to talk to them and we told them that we weren't going to, which was really enjoyable, but this had a huge amount of coverage and it ended up, you know, all over the world and translation of lots of different languages. And I think largely because um sex in the story is always gonna, you know, hit the news big time, but people are genuinely worried about this in terms of it being a patient safety issue. Um because the the ramifications for this in terms of patient safety are quite significant. Uh So I have three sons. Um You, most of you here won't have Children, but there is a time in your life when you move on from trying to impress your parents and make them proud of you to hoping that your Children will think you've done, done something reasonable in life. One of my sons was responsible for our website and at seven minutes past midnight on the 12th of September, when he posted all the stuff up, he said everything was so proud of you. I'm so proud to be your son. You'll be great on the radio. You're the expert, you'll be amazing, which was really wonderful. Um My, we ended up in the British Medical Journal, um some snapshots of us and a story about it, which we weren't actually expecting. Um, and second son quite rightly commented that a casual observer who doesn't read the small print might assume you're one of said sexual offenders in a line up of sorts. So, um, you've gotta love your kids. Um, we collected many stories from people, so I'm just gonna share a few experiences with you here. Lots of stories about people being aware of what was going on. One assumes and looking away, um, repeated harassment by seniors, people commenting things like I began to dread going to work for fear of repeats of these unwanted advances. All the female doctors are warned about him. There's no way I would ever name him. He's a senior consultant with friends across the country. He's known as inappropriate with female trainees. He told they'll get good operating numbers if they go into his theater, if they can cope with his behavior, he's never been sanctioned, although everyone knows about it. So moral licensing and willful blindness being rife. I asked more than five different victims of this man, if they were prepared to give written statements, they didn't feel they could. The perpetrator remains in the organization. So a fear of speaking up and a lot of continuing harm. You know, a lot of the stories that we heard, people felt incredibly guilty that they hadn't spoken up about it. You know, they wanted to protect their own careers, they hadn't spoken up about it and they were aware that people coming behind them were also being damaged by the same people. And that compounded the damage which had happened to them so damaged if they do speak up and damaged internally, if they don't speak up. But also the normalization of an abusive system. We had lots of comments. We had over 50% of the respondents were men to our survey, many of whom were very supportive of it needing to be looked at. But quite a lot of comments that effectively normalize an abusive system, you know, women use this to their advantage. I'm unsure if it can be regarded as harassment when the women get something out of it, which is career um progression, but significant patient safety issue when I needed senior support, this was refused because they thought I'd reported a perpetrator. Um a lot of stories like that. So this is a significant patient safety issue. You know, if you look, if you're a patient and you're looked after by a dysfunctional team, if you were to talk, don't speak up about one thing, they're not gonna speak about clinical things going wrong. So, um some of the figures, um we asked people if they had been targets of sexual harassment. So significantly different between women and men. Two thirds of women in the last five years had um been subject to sexual harassment in around a quarter of men. A third of women said they had been sexually assaulted. So we gave people legal definitions of these things. So they knew exactly what items it was that they were being asked about. Um and rape happens and more rapes were reported to us that had happened outside the workplace. But by colleagues, so at things like work related events, particularly conferences, they said boundaries being blurred, they're being alcohol involved. Um and, and seniors being in a position where they felt they could take advantage of somebody who was um in a, in a vulnerable situation. And in terms of people witnessing, um the vast majority of people had witnessed sexual harassment. A lot of people have witnessed sexual assault and people were aware of rape happening and you'll see between women and men. All these differences are statistically significant and what we're not sure about is do these things happen when the men aren't around or are they simply not seeing it for what it is? And we, or if you're really institutionalized, you know, the longer you've been in a system, whatever that system is, by definition, you, you, you protect yourself by buying into the culture of the place and you normalize it in order for you to be able to um go to work every day or go to do what you do. So we think there's a lot of normalization of the abnormal. And one of the things that we need to do is increase awareness of what it is that's actually happening and what people are seeing So we have, um, one in three women being sexually assaulted and one in 15 men. Um, what about the perpetrators? So they, they are different, what is happening. Um One of our, our team called Roslyn, who's a professor, professor of organizational psychology at Glasgow has done a lot of work with the professional standards authority. The professional standards authority effectively regulate the regulators. So there are nine healthcare regulators and they're all under the jurisdiction of Professional Standards Authority and where there were cases of proven misconduct that had been through things like the GMC or the Nursing and Re Council, the Healthcare Professions Council. Um the people who were found guilty of sexual misconduct had to undergo a psychological assessment as part of that outcome. Um and in terms of medicine, um most of the perpetrators were men in a position of power and GPS and surgeons were significantly overrepresented where females are found guilty of sexual misconduct. They, that was more common amongst nursing staff. There are more, more women who are um nurses, but they tended to have a single target who they repeatedly um approached and um made unwanted the sexual advances towards. So they're completely different patterns. And you have these senior male perpetrators who basically wait for the next set of students or the next trainees to come along and that's their modus operandi. Um But doctors um tended to be treated far less harshly by their regulator and also far less harshly if the person who was targeted was a colleague than if it was a patient, which is, you know, morally, somewhat dubious. Uh um We had specific, um, details of these incidents, nearly 1000 of them, which we haven't reported yet. But it's important to note that less than 16% of these were formally reported so that the vast majority of people didn't formally report these at all. It was more likely if it was more severe sexual violence, but nobody reported their rapes and the reasons for not reporting really related to cultural issues within within healthcare. So fear of not being believed, fear that they would be damaged, knowledge that the perpetrator was often a powerful person within the organization. Um and that they didn't feel the reporting systems were adequate. Mhm. Um We also asked people how well they thought accountable organizations were dealing with this issue and 15% of women thought that the GMC were doing an adequate job. Um and only slightly more thought that the NHS were doing an adequate job and amongst the men, still less than half thought that there was an adequate job being done. But significant differences between um genders and the only group sort of thought to be doing a reasonable job were the Royal colleges a and predominantly by men who we, who we spoke to. So we came up with a series of recommendations and currently there is pretty much no data about this, you know, this happens in a trust and people very often don't do anything about it. They certainly don't publicize it because it's bad for their reputation. Um, and they often try to close it down. So, um, we've asked for the Department of Health to have an international implementation panel to make sure that these recommendations go through. Um And it's been really interesting this popping up in front of important people and saying, we think you should do this and if you have numbers and you have people backing you, then all of a sudden people say, well, do you know what we think we could do that? And then we all look at each other and go bloody hell. I can't believe that we've got away with that. Um The big thing that we've been asking for is for there to be independent investigation and reporting processes of these. There's no point asking people to speak up if they're still having to speak up to a untrusted system where they're going to get damaged. So the importance of having external independent fit for purpose, um investigations into this is key. Um The good news is that um um I and a couple of members of our group have been asked to join this group who are a statutory body who work for the Department of Health and Social Care, trying to sort out the gender pay gap in medicine and they have powers to ask health care organizations to give them their data, um, including the regulators. Um, and so we have sort of, um, piggybacked onto them and managed to get quite a lot of teeth on the basis of that because we can ask people for their figures and, um, work out whether they are following our recommendations. So that's been, um, an, an exceptionally unhelpful thing to find. Mhm. Only one in 10 NHS Trusts has got any form of policy on this whatsoever. Um Interestingly, and policies really need to be enacted. There's no point in having a policy and nobody does anything about it. Um, but the NHS have come up with a, um sexual safety, um, organizational charter. About half of NHS Trusts in the country have now have now signed up to this. But others haven't, whether they think they haven't got a problem or whether, um, there's a, there's a, uh, any relationship between people who have policies and actually enact them or they do the right thing and haven't got a policy is, you know, is, is research that hasn't been done as yet. Uh, um I won't go through all the recommendations. One of the things we talk about is um active bystander training there. So encouraging people to stand up when things are going wrong. There's a deanery um not to be named in the country who's stopped active bystander training, um consequent to this. Um because people have been speaking up about this and they have the ones that have had the negative consequences, they have been damaged. And so the Deanery has taken an active decision to pause active bystander training until there are appropriate reporting mechanisms and investigation processes in place. So, you know, we come up with these things and you don't think that you've got to get them in place in order, but, you know, unforeseen consequences that you haven't, we haven't necessarily expected. And we've asked um the regulators. So the regulators in the NHS had this data before it went public and we did that very collaboratively with them because they wanted to have a chance to try and get the house in order. So as the way with these things work with the spin of organizations, they all came out a couple of weeks before they knew our paper was coming out. But the GMC, you may be aware, came up with some alterations to good medical practice to include sexual behavior towards colleagues. For you, you have to put into your professional standards um for you to adhere to that you must not assault or rape. Your trainee is really jaw-dropping. But you know, these organizations, unless you have transgressed a written standard, then they say, well, they haven't got anything to act on, particularly if it hasn't gone through the police and, and many people don't want to go to the police with these things. Um We also have managed to get into the NHS survey which staff fill out in hospitals, questions on sexual misconduct. So, um have you been the target of unwanted behavior of a sexual nature um from patients and also from, from staff and colleagues? So that is really powerful because that um filters into how well a trust and a hospital does in terms of their rating by people like the C QC or um you know, there's a Scottish equivalent to that, but um, hospitals protect that very carefully. So that would be quite a powerful thing. And the GMC have a survey that they send out to trainees every year and they have now included questions on this, but less than half the people responded to that question this year, people are really wary of, of being identified in these things. And you, I think it's telling that only half of the trainees actually answered these questions because they must have answers to them even if it's no, I have not been subject to this behavior. So, um, I think there needs to be much more capacity for anonymity in these things. Mhm. But data are really key to this. There's a medical school in New Zealand. I've been speaking to recently have a thing called hotspots. And at least 15 people in each placement get the capacity to go into an anonymous reporting system and they get asked about good things and bad things including, you know, did you feel sexually safe in a placement? Um, and I think there's a lot of good practice like that around the world. And since we came up with this philosophy of been getting in touch and saying, oh, you'll need to talk to them. So there's a huge amount of work to be done on this still. Um, I don't know if you're aware that, um, there was a, a letter in the paper after, uh, things in the times from a retired anesthetist talking about the snowflake generation of young doctors. Um and that it was stressful and if they want to make, make a success of this rewarding career, then perhaps they should toughen up. Um That was um gob smacking response but entirely unsurprising I have to say. Um And when he was tackled on this, he doubled down and said, well, I've spoken to all my mates and they all agree with me. Um So there was, it was, it was um lots of people got in touch and said, I can't believe that, you know, the Times have printed this and actually the Times very robustly defended it and said we printed it because we thought it was absolutely part of the story. And I have to say we agreed with them. But the Health and Social Care Committee are now going to look into the issue, which is um good. So there are lots of politicians um interested in this turns out if you email a politician about something that's been in the news, they very often get back to you and want to chat to you about it. So, you know, they're just people, um, and they have a job to do and it's fine to contact them because they might respond to you. Um, you might be aware, um, of this man. Um, so interestingly, I think the latest news on him is that there have been five people who've come forward now and so they've been assaulted by him. Um the police um unit that was set up to ask people to come forward after Jimmy s um popped up and said that they were um they wanted to hear people's um stories of accusations against Russell brand. Um and that they would investigate them, you know, accurately and independently and sensitively. And it's really interesting, isn't it how a, how the media moves on? But also, you know, here's a man who's a comedian who's potentially assaulted lots of people, but five people have spoken up, you know, we've got over 1000 testimonies of people who've been um subject to sexual violence and health care and we have no improvement in the reporting system and no police units popping up and saying this is really important come to us with your story. So it's um yeah, go figure um really interesting to think about um the perpetrators who these people are. So, in Ross's work that she did, she asked, um you know, did psychological assessments of them and they very almost universally denied that anything bad had happened. Um Despite having shown insight in their hearing, um they denied any harm would come to people. They blamed the victim. They reconstructed things to make themselves um not a villain. They're very often narcissists with difficulties with empathy, often intelligent and high functioning, but in lack of capacity to pick up on clues with a and a wry moral compass. And you have to consider what the, what the impact is in terms of their interaction with patients. And would you want these people looking after you or somebody who you love? Yeah. And it's really important that we have a safe workforce and that patients are safe and, and the education around this isn't just to do with the workforce. It, it largely relates also to the people who are accountable, like people in the NHS trust with position of responsibilities and people in the regulators who are patently not seen by the workforce as adequately doing their job. Um Something that happens to people if they um are able to come forward and speak up and many people can't and don't, many people don't do it for many years. Um One of the things that we've asked the regulators to do is to remove the five year limit on, on investigating incidents because there are a lot of people who are now wanting to come forward because they realize they're not the only one. many people haven't spoken about it before, but the idea that somebody would have to go through a trust investigation process and tell their story. They'd have to then do the same with the police and they'd then have to do the same at GMC hearings. For example, if somebody is almost unthinkable when you've already suffered so much trauma, usually. Um, so there is a real argument for people being able to record their testimony, not being subject to the adversarial nature of having, um, somebody's KC um, tearing into you and questioning your own personal sexual history and your morals in the way that we know these things happen. Um But the, the people who are targeted at very often are the ones who get more investigated than the person who did it in the first place. So here are um, 400 rapists in this infographic. Um, two people will have been falsely accused. Most people don't get reported. Most people don't face trial and very few people end up being jailed. So, you know, we often get asked about vexatious reporting and you can't legislate against it. It will happen. But the people who are really impacted by this are the people who have been raped or sexually assaulted and their perpetrator remains hiding in plain sight. Yeah. Um, so I think it's, you know, it's quite complicated what's gonna happen in the future, I think where we have more people coming forward or people who have been asked to speak up and we've said only speak up if you feel it's the right time for you because we're not sure that the system has changed enough for you to be able to be safe. We really hope there won't be a reduction in numbers of women who want to come into surgery. Um, many people have said it strengthened their resolve that they definitely want to do it because they know there are good people around trying to sort out the problems but some older women surgeons who I know who said it's all very well for me. But actually, I don't think I'd want my daughter to do it. So, you know, there are influencers out with us. We have wondered if there would be some earlier than expected retirements. You know, if you've been doing this for a long time and you've got away with, it might just be the right time to take your pension. Um, I feel slightly sorry for people who feel that it's the right time for them to retire and don't wanna be, um, targeted with that potential description and they might wanna put it off for a bit. Um, interesting. The London ambulance service instigated independent reporting investigation systems. They have a real problem in the ambulance service with this, um, another area where there are women, you know, significantly underrepresented. So most people who work in the ambulance service are men. You may be aware that only 15% of consultant surgeons are women still. So this is much more of a common in areas where there's a significant sort of hierarchy and a significant gender mismatch, but they had a five fold increase in reports and there were multiple dismissals. Um but they've all ended up in an employment tribunal. So, real jeopardy for people who do sack people because then they end up in the legal process. Do current new consultants and trainees have a set of different standards and the culture will change anyway to an extent by evolution. Well, that might be one thing but it, that's not going to be, that's not gonna be enough. So I think the lessons we've learned from this, if you have numbers, then it's really powerful. But stories are also influential and people by stand at all levels were all really institutionalized. Um And there's the idea of not just people speaking up and doing the right thing, but actually people listening as well and, and taking the right action. Um and you won't convince everyone but you might shut some of them up. Um And I think it's really important for us to all remember that the standard that you walk past is the standard that you accept. So um a lot of willful blindness around this, so willful blindness is, you know, it's a, it's a, it's a self protective thing and people get tribes and they want to protect their organization. But you can think of it as a state of strategic ignorance um going from it is not a problem. Nothing to see here. So maybe we should look at that. Oh look, everyone knew all along. And I think that's where we are with this story and such conduct. So definitely in an institutional failure, um and perpetrators are continuing still to abuse with impunity. And I II think the final thing to say is that um it's a problem for all of health care, including patients and we need everybody to help to solve it. And there are a lot of good people in, in health care. Um And the vast majority of men are decent people, but we all need to speak up and listen up and people in positions of authority need to take the appropriate action when things have gone wrong. So thank you very much. It. So the opportunity for you to carry some questions we have come in online as well. Hi. Thank you so much for that talk. Should, should we hear the questions on the phone? So it goes through the system or it goes through either or we wouldn't like to cover that what's going on? Yeah. Yes, that's great. This is more for the people online, isn't it? Than for ourselves? Uh No, just a huge. Thank you for the talk. And it um I wanted to ask specifically about the surveys that you've managed to convince people to add those questions to, have you, have you managed to do it in such a way that they're obliged to release that data or are they gonna sweep it under the rug? Um It's a good question and yes, they can't sweep that data under the rug. Um, because it's, it is, people don't have to respond to them. So, you know, you've got response rate issues and people being concerned about their own safety if they do respond. But the NHS survey, um, is, um, are the results of th those are, are openly um published for hospitals and other healthcare organizations. In fact, um, and they are available to the, the healthcare regulators like the C QC or the others in, in the devolved nations. So, um, no, they can't sweep that under the rug. Good. She's good. Absolutely. Because it will be in their interests to do so. But, um, um, they're not gonna be able to do that and the GMC report their, um, their findings and they've already reported those and interestingly, um, in that people who did respond to surgery, um, pe people who are working in surgery, um, answered much more positively to that question. So they have a much higher incidence of, of being um, affected by poor sexual behavior. Good, I suppose, relating to that as well was just a lot of the way that we're looking at the trust is that they're there as a passive stakeholder sort of thing. And my concern with that is that actually they, they, I mean, they should be smartening up because they are surely obliged to provide a safe working environment and that is not what's happening. And they should be the ones that really are doing this proactively rather than having you come along saying by the way, you've got a problem and then they go in some instances like that dignity that you were saying, you know, actually, and actually just stopping processes from happening, that should be happening. Yeah, I mean, I think if you look at the who this is happening to, it's largely happening to trainees. Um and there's a, there's been a bit of, I don't know if you came across the um case of um there's AAA junior doctor called Christopher Day has um um had been in, in significant um has been an incredibly brave individual, but essentially he whistle blew about conditions in, in intensive care. He was working in um he um was told by the trust that he wasn't their employee. So he therefore wasn't subject to whistleblowing protections in, in employment or legislation, health education, England also turned around and said, um you're not our employee either to which he said, well, somebody employs me, but nobody wanted to own up to employing trainees. So um there's been, that's been all the way up to various, you know, court of appeal and things. And um it has been designated now that um I think the health education bodies are responsible but they do well, and that trainees do have rights as, um, employees under whistleblowing legislation. Um, yeah. What was the start you went on that? Yeah. No, I suppose the way I was thinking it back was, you know, it's a, it's an obligation surely of the trusts to provide a safe working environment. But then they will then say these aren't our employees. So we don't have to, we don't have to provide a safe working environment for them. That's one issue. And they are very conflicted because they have reputations to manage. I mean, it's always worse, isn't it to cover something up? And then you've got the bad thing that happened to begin with and then you've got the cover up to have to explain as well, but people still do it and they do it all the time. Um So that's one issue. Um And they have, you know, expensive, highly productive, often very powerful people in their organizations who would be a great loss to them because they do a whole load of hip replacements and the trainees are expendable and will be moving on. So, you know, they're not the right people to be investigating these things anyway. And if they were smart about it, yeah, unless they would get the house in order and make sure that they had a happy working environment because, you know, happy staff means good outcomes for patients and people wanting to come and work down patients wanting to come and be treated there. But, you know, as we know, um, people hunker down when they're under attack and they don't always respond in the right way. Thanks so much, I guess. Then on a similar note, you're talking about the fact that it's, there's currently a five year limit on reporting you as if you part of the potential if you remove that is that if these people that were trainees will be more comfortable reporting these retrospectively in 10 or 15 years when they've got the security of having a consultant position. Yes, absolutely. And we found that um we were, we had um, more women else our survey than, than there are in work, you know, proportionately more women than there are in the surgical workforce and, and a lot of women consultants answered. So more women consultants and trainees answered. So they were talking about what has happened to them in the last five years. Some of them, some of which will be while they've been consultants even. But, um, you're quite right that and, and there's been a lot happened, hasn't there across the world in other areas where when they've removed the statu of limitations on people coming forward with, with sexual crimes, like in Hollywood, for example, when, um it isn't that how um Donald Trump was um um found guilty with the um EJ Carroll case that it was, you know, that the, the time was removed, that you had to and you could go into anything historic. So I think, um, certainly the professional standards authority were very interested in that as a, as a concept that in this area where all the evidence is that people can't speak up for lots of reasons and they don't speak up and it takes them a long time to feel that they can speak up either because they've, you know, they've, they've, they're in a psychologically better place from having been damaged, but also sometimes simply that they've got their consultant post and they don't feel vulnerable anymore and that will take AAA varying length of time. So I think that's really key that it may take 1015 years or so. But those people, the people who, you know, assaulted them or raped them are so often in, in post, you know, these people are serial offenders. Um, interestingly, I II won't name the specialty, but I was told recently that at a national conference, there were people openly standing behind people in, in coffee queues and things and going and saying what, which is fantastic. You know, that the, the, the power of the, the sort of, um you know, this disinfectant power of sunlight on something is, and the, the collective um kinship there is between people who think this is wrong and that something needs to be sorted out has been really, um it, it sort of restores your faith in humanity to an extent when you've heard all these harrowing stories and, you know, how bad things can be. Sometimes in, in, in people's operating filters for all sorts of reasons. Surgeons can often behave very badly if nobody checks them and they frequently do. Mm. I guess also, do you think that there's any sort of, oh, you go ahead, finish up. Um, sorry, I see. Um, do you think there's gonna be a changing of the guard of like, the fact that we're the newer trainees and the newer, um, stuff that coming in, like, generally we're in a culture where like sexual harassment and sexual assault is much less, much more spoken about and much more normalized to speak up. Do you have you, is there notice of any changing or, um, I don't think we have the data to, to know that really? I mean, I think I ii wonder whether, you know, there's a, there's a cohort to us sort of, um, coming through at the moment who won't have had the upbringing that some of the younger people have, you know, in terms of the massive exposure to pornography that everybody has at a very young age now. And, and also, you know, a lot of the sort of toxic masculinity type stuff, you know, the Andrew tape type stuff that none of us will been exposed to any of that as youngsters. So I think, you know, that it then it may be a sort of AAA thing that's doing that, that, that has been bad and it might get a bit better. But then there will be people who've been damaged as youngsters coming into medical school. And II think there's, there's lots of conversations going on in terms of um, whether people, you know, so, you know, situational judgment tests and, and all those sorts of things that people have to do to, um get into um med school these days. How do you, how do you test for somebody who's got bad values towards other human beings if they're smart people and they know how to answer the questions smartly. It's quite, it's quite um tricky. There's an interesting thing which some of you may have heard of, but you should, could and should look it up called the um um I think it's called the innate attitudes test. If you look up. I at Harvard, I don't know if you've come across it, it gets you to um um compare different things and how quickly you put different things in different boxes, actually tells you whether you inherently associate, you know, men with being leaders and women with looking after the house kind of thing. And you feel that you have your own senses on these. And, you know, um I personally, I was pretty good at thinking that women was good at science, but I slightly favored men as being leaders when I did it and I, you know, I, I've done quite a lot in my life that I would think as being quite leader and I really support women but turns out, you know, I was, I was, um, sort of so sociologically, um, damaged in terms of, of what I think people should be doing. And, um, so that's, I think, and that, and that's one of the things we've suggested that something like that, that you can't actually be smart about and answer the, the right answer. That's the very obvious thing that a right thinking person would do, even if that's not you. So things like that, I think it will be important to be able to bring the right people into medicine because um you've got to start somewhere and if you bring people in who, who, who got bad attitudes to begin with across all, you know, values and behaviors really. But I think that would be quite a useful thing to do, you know. Uh Thanks for uh a very illuminating talk. Uh I wanted to ask, have you spoken to international colleagues and whether they see similarities in their professions in other um countries and whether agencies in other nations or maybe addressing this better or maybe worse or is there anything from other countries? Yes. Um A lot of work was done in Australia um previously. Um possibly because it, you know, it, it's quite a, there's quite a lot of toxicity towards women and very few women surgeons in Australia. So they did a big study on it which showed, um, pretty similar, um, figures to ours. Um, and they, um, you know, introduced lots of teaching for people, um, lots of, um, interventions which ranged from what they call a cup of coffee that somebody would take somebody aside and, you know, have a little chat with them and say, you know, you might not wanna, um, pinch the nurses bums when they're scrubbing kind of thing. Um Two, you know, people, um being disciplined out of being a surgeon and some people going to prison in Australia, for example. So there's been quite wide ranging there. One of the backlashes to that has been that in several specialties, there have been fewer women appointed to higher training posts. Absolutely. You know, who is it a result of, of that? Most people who I've spoken to in Australian surgical circles seem to think that there's a whole load of men that have said, well, if they're gonna complain about a bit of banter or are gonna complain about a bit of a slap on the arse. Let's just stick with the blokes. So, you know, there are interesting consequences to I think, um there are very few areas, um, certainly in surgery where there's anything like gender parity in across the world. So and the more stark that is the worse the problem seems to be that may be, um, you know, cause and effect, who knows? Um, people don't wanna come into it because they don't wanna be subject to sort of misogyny and they don't wanna be subject to harassment equally. Um, there may be, you know, it may be a way of, of keeping women out of it. Um, who knows? Um, but certainly it's, it is a worldwide problem and there is a worldwide problem across society anyway, isn't it? You know? But particularly in areas where there's a big power imbalance and particularly in areas where, um, women are underrepresented in, in, in a profession or in positions of leadership in a profession. So, yeah. So it's society. What's to blame? And we just need to sort them out and it'll all be fine. Yeah. Um, yes, thank you very much. Such an interesting talk. Um, II just wondered somebody had actually put it up there and they've deleted it. But you've, obviously your stuff is relating to surgery. I'm an anesthetist. So I've seen fair amount of bad surgical behavior over the years. But, um, I just wondered, do you think there is something about the surgery environment or would you expect to see the same results reproduced in all of medicine or all across society? Yeah. I think surgery is worse. I'm sure it's worse. Um, there is evidence that medical students who are more verbally aggressive are more likely to become surgeons. There's some, um, slightly dodgy research done by surgeons suggesting that surgeons are better looking than the other people in medicine. Um, well, in my hospital but, you know, people who are, and there is, you know, evidence isn't there that the sort of player type of person. Um, so, you know, there are quite a lot of, there are quite a lot of people in surgery who have all the, you know, the personality traits and the power that makes this, um, much more likely to, um, be for them to be able to get away with it. And it's partly not checking things. There's a, there's a theory that, um, you know, the sort of low level, um, sexual humor that people introduce into places is kind of testing the water and seeing whether they've got allies and seeing whether anybody's gonna say anything about it and when that doesn't happen, a lot of people laugh and other people join in and people either look away but they don't, they're not checked, then they escalate that behavior. So there's a lot of evidence that people have done in, you know, fly on the wall type stuff that, that the behavior then escalates. So, you know, the Sarah Everard case, for example, you know, his sort of, um, a lot of the stuff that he did that wasn't checked, you know, the sort of, um, flashing and things that were, were known about and weren't actually followed up, but, you know, sexual violence tends to start low level and if you get away with it, then you escalate it and I'm sure that happens in, in theaters and, you know, you will know what I presumably everybody here has been in operating theaters and they are absolutely w there's such a range of, of, sort of calm, respectful, um scenarios in theaters where the patients are the focus and everybody is trusting of each other and can say anything that they think is concerning and that leadership really comes from the, you know, the top I think, and, you know, surgeons are in a huge amount of power in a theater. You can pretty much, you know, say, or do a lot of stuff and people won't check you and, and, and that's bad. But that's because we're all institutionalized and, um, people don't wanna put their head above the parapet and they don't want to be the one who's speaking up yet. If you ask people afterwards, they often all thought. Oh, yeah, I wasn't that dreadful but, you know, nobody doesn't think about it. So, yeah, I think surgeons are definitely worse. Do you think that, I mean, this is no way Napoleon's comment at all. But do you think that the fact that it's a stressful job and stress invariably brings out the worst of people because, you know, you do see a lot of bad behavior because people are stressed. I'm not sure how relevant it is to sexual misconduct, but I certainly seen bad behavior because of stress. And I just wonder, I, is there something about that because this culture is just happening across so many surgical departments and how much of that could be a factor? Do we just need more surgeons to be working less, hard, to not be so grumpy? Um, possibly. Um, but I think in some ways it's, it's that, you know, poor parenting by the system, isn't it? You know, these people behave like toddlers quite often. Um, you know, and it shouldn't, it shouldn't be countenance, but they've seen people, they've modeled themselves on other people who they thought they needed to be like and maybe slightly wanted to be like as well. So, but I think there is, there is certainly, um you know, proper evidence that the more stressful um a situation is the more likely you are to not behave properly. Um But maybe we should be having people who actually calm, you know, calm down and become collaborative when things are, are stressful, that's much safer for safer for the patients and somebody um going off on one and nobody being prepared to um tackle them. But yeah, sorry. It's going to seem like a forum of anesthetist here, but just for decoration. I'm a consultant. A well, you're great observers, aren't you? You know, that lead me directly into my question, I guess just a very practical point. We witness a lot. Um I am in a relative position of power as a consultant. Aist in the direct theater environment that I work in. So there's wonderful work has been done at very high level. The Department of Health, um the GMC, et cetera, et cetera. Have you done any direct collaborative work with, say the Royal College of Anesthetists, the Association of Anesthetists, their trainee committee because they're very active. Yes. Yes, they've been really supportive in fact. So we have, we have a member of our group called Sarah Thornton who, um, is part of our working party. And I think about 10% of our respondents were anesthetists. So we heard a lot from anesthetists, um, who, you know, have and, and women are quite well represented in, in, um, anesthetic professions as well, aren't they? So, um, yes. So, I think they, um, we haven't drilled down in terms of, um, who witnesses most, but it's entirely likely, isn't it? That there's a lot of anesthetists will have, um, seen it all and we kind of rest on our Laurels. We haven't asked these questions. So we don't know if it's a problem in our specialty, but I suspect it is because it's a problem in society. Yes, I feel that needs to be said as well. Yes. Yeah. Yes. It's certainly not restricted to surgeons and, and I think the theater environment, you know, allows people to, um, they just on occasions be appalling. No. Yeah. Any final questions. Uh, 11 more. Thank you. Very interesting talk. Thanks. For that. Um But I just wanted to ask, is there any data following on from kind of what you've said earlier about um stress and how stress impacts it? I would be curious as to if there's any data regarding what, how these people act within their general lives, like nonprofessional lives. Um because it seems to me that a lot of the time people who act unprofessionally or more unprofessionally who act aly in the workplace, um, often do have a greater propensity to act abusively in a situation outside of the workplace. And I wonder if any research has been done to that end? Yeah. Um, I don't know, in terms of, I mean, most of these people don't ever get sanctioned for it. So it's difficult to, you know, we do know if you look at the cases of misconduct that go through, they frequently um don't just abuse colleagues but also patients. Um and um, ros who I mentioned earlier again is doing some work looking at um the sort of um the, the likelihood that people who behave badly in one area of their life also behave badly in, in many other areas of their life. So, you know, they're more likely to have property issues. They're more likely to be a bit financially dodgy, you know, overcharge the private patients fee committed to um making a lot of money, you know, all the, um, so she is working on that theory at the moment and trying to prove it in terms of the data that she can get out from fitness to practice cases. But they are really the, you know, the tip of an ice tip of the iceberg. Um, only 10% of cases that go to the regulator end up actually going through a fitness practice process. And the people who make those decisions are probably really, um, badly educated in terms of the myths around these things, you know. So, um a lot of these cases don't end up progressing. So the whole, there's a whole load of stuff that isn't known because a people don't report it and then b if they do report it, it generally gets shut down either by the trust or with the GMC. So, um, yeah, there's a lot that we don't know about it anecdotally. I think there's a people, you know, somebody who's dodgy in one way or dodgy in lots of ways and, and, and quite a lot of them, the surgeons sounds like. Yeah, but there are a lot of good that I have to say, you know, there are a lot of decent people in medicine. Um But there's a, there's a theory that this isn't just some bad apples. Um Somebody's come up with the phrase, this isn't bad apples, um Bad barrels, it's bad sellers and that the whole of health care is a, is a seller in which this is absolutely, you know, right to um keep fermenting and that and if you can't do this in isolation, they have to be allowed to get away with it. You know, by the, by the people around them or by the, you know, all the different levels, you know, the within the theater, within the hospital or within, um, you know, the police and the regulators, none of these things are working currently. Um, and people are being allowed to get away with it and it's damaging, hugely damaging. Good. Well, uh, once again, Carrie, thank you very, very much for coming all the way from Surrey, first of all, er, on this, er, you know, winter's night and, uh, thank you all for coming as well and for those who have joined online, uh, very interesting. Um, is that, that's not a question, is it? Thanks for ging also for organizing the online access through med. And, uh, yeah, we hope to see you again carrier. Actually, it would be good to hear from you in a, in a year or so and see if, if actually anything, anything has changed, if the report has had any impact. Yes. And also to hear that 25% of surgeons are women and so on and six and seven come to my. Yeah. No, I think that's a, that's a good suggestion, isn't it? Anyway, ple please hang around and, and you know, chat so we can carry on, carry on talking, but we'll close the Um.