A safe workplace is essential to employee satisfaction and well-being. Workplace abuse and harassment diminishes safety, and eradication of harassment has become a top policy goal in the United States.¹ Policymakers have worked to reduce workplace abuse and harassment by various means, including workplace training programs and legal frameworks such as Title VII of the Civil Right Act of 1964.² Workplace abuse and harassment is particularly prevalent in the health care field and can manifest through physical, verbal, psychological, sexual, or racial/ethnic abuses.^1,3,4 A meta-analysis found that a third of nurses were exposed to physical violence, a third experienced injury, a quarter experienced sexual harassment, and two-thirds experienced nonphysical violence.³ In a report release by Medscape in 2018, 7% of physicians reported experiencing sexual harassment perpetrated by clinicians, medical personnel, or administrators, while 27% were sexually harassed by patients.⁵ A 2021 survey found that 49.5% of urologists reported patient-perpetrated sexual harassment, with higher rates associated with female gender, resident or fellow training status, and age less than 41 years.⁶ These statistics likely understate the prevalence of medical workplace harassment, as it is often not reported due to embarrassment, perceived helplessness, fear of retaliation, or unclear reporting policies.⁵ Experiencing and witnessing harassment and discrimination in the workplace can result in negative psychological consequences such as anxiety, post-traumatic stress disorder, detrimental organizational impact such as low morale and productivity, and may damage patient-provider relationships.⁷

While multiple health care harassment studies have found patients among the most common offenders,^3,4,7 the prevalence of these inappropriate interactions has not been thoroughly studied in urology. Additionally, a body of literature describes rates of sexual harassment by patients toward physician providers, and clinicians,^5,6,8-10 but these studies do not address troublesome interactions with other medical employees, such as nurses, medical assistants, schedulers, or those who triage patient calls. Nonphysician staff may be more vulnerable to these abuses, as there is a higher prevalence of women and people of color in those roles.⁶ Further, the urology office is a unique environment with frequent patient interactions involving discussion of sexual topics and intimate details, routine examinations of genitalia, and inspection of photography of genitalia.⁶ In that environment, increased awareness and vigilance is required to actively promote a safe work environment free of harassment and abuse.

The goal of our study was to categorize and quantify the prevalence of inappropriate patient interactions in our outpatient urology offices among all employees who interacted with patients, both in person and over the phone. Additionally, we sought to determine if certain groups of employees, based on gender, race/ethnicity, role in the office, etc, were more or less likely to experience these abuses, and if there were perceived barriers to reporting. We developed an anonymous electronic survey which was administered to all staff in our department who interact with patients, including physicians, nurse practitioners, physician assistants, nurses, medical assistants, schedulers, and phone operators. We had a 69.6% response rate, with 71 responses of 103 surveys distributed. Responders included 21 physicians (29.6%), 18 nurses (25.3%), 8 medical assistants (11.3%), 7 nurse practitioners or physicians’ assistants (9.9%), and 17 other employees (23.9%; see Table).

Among respondents, 83.1% of employees reported verbal abuse by patients, 74.6% witnessed abusive interactions towards others, 59.2% reported sexual harassment, and 14.1% reported racial/ethnic abuse (see Figure). Non-White employees were more likely to experience racial/ethnic discrimination, and less likely to experience sexual harassment compared to White employees (p < 0.05). Interestingly, there were no significant differences observed between male and female employees, or between physicians and nonphysicians. Two-thirds of respondents who reported an abusive encounter (66.7%) did not report the encounter, most commonly because “it was not a big deal” (35.2%) or fear of “damaging the patient-provider relationship” (15.5%).

Figure. Employee responses to questions assessing prevalence of different types of abusive patient behavior.

Armed with this preliminary data, we aim for further discussion and policy regarding best practices for minimizing these negative encounters, improving ease of reporting, and providing resources for victims of abuse. However, this early study yields more questions than answers; how prevalent is this problem elsewhere in the region? Elsewhere in the country? In practices where patient abuse of staff is a less prevalent issue, what factors contribute? Our data form a starting point towards better understanding this underreported phenomenon, and we hope that future multicenter collaboration will move the needle towards a safer work environment for urologists and nonphysician employees alike.