The following dialogue occurs in the clinic, between a male physician and his patient (male or female):

Patient: Doctor, do you have a family, children?

Doctor: Yes, I do. Three children.

Patient (shocked): Three children! Doctor, how do you do it all?

Doctor: Well, not all by myself of course. My wife gave up her career to be the stay-at-home-parent in our family.

Patient: (incredulous) Your wife stays home with the kids? You're so lucky she's willing to do that, and let you work!

Are you, the reader, incredulous yet? If so, re-read the dialogue above, but switch the gender of the doctor and the spouse. Make the physician a woman and the stay-at-home spouse a man. Do you still think it sounds unrealistic and ridiculous? I'm going to go out on a limb and guess not.

I can tell you that, as a female physician, married with children, with a spouse who for the past few years has opted to be a stay-at-home-Dad, I have had this or similar conversations with my patients, more times than I can count.

And I am weary of it. Of being referred to as "lucky" to be the working parent while my husband is the stay-at-home-parent. Of the insinuations that my husband "lets" me go to work. In the year 2018.

I wonder, are male physicians who are parents subjected to this line of questioning by patients — just who exactly takes care of the children while he is at work?

Do their patients make the same thinly veiled comments about just what, exactly, they think of their physician for choosing to go to work and be the breadwinner — while his wife stays home? And judgment of his wife for, gasp, staying home with the kids and not working outside the home?

Don't get me wrong, I am appreciative of the support of my husband in my career. As I imagine married male physicians with families are appreciative of the support of their wives. (At least, I hope they are). But that's not "lucky." I shouldn't have to describe myself as "lucky" that my husband has an equal-minded attitude as to roles and responsibilities with the kids and the home. Any more than a male physician would say it about his wife. It is the fault of society, not mine, that in the case of a physician-parent with a stay-at-home spouse, a woman is called "lucky," while for a man, it's taken for granted as the status quo.

So I've decided for myself, to stop letting patients get away with these comments. Yes, many of them are elderly. Yes, many of them are of a different generation. But that doesn't excuse gender bias any more than it would any other form of bias.

To female physicians, these kinds of insults from patients, overt or disguised, constitute gender bias. And gender bias is a form of sexual harassment.

Dr. Esther Choo and colleagues recently published in NEJM a powerful piece on the need to end sexual harassment in medicine — Time's Up for Medicine? Only Time Will Tell.

The authors state that the National Academies of Science, Engineering, and Medicine (NASEM) report showed that, "sexual harassment is common across scientific fields, has not abated, and remains a particular problem in medicine, where potential sources of harassment include not just colleagues and supervisors, but also patients and their families." (emphasis added).

Dr. Choo has also brought national attention to patient prejudice and bigotry in the ER, in a tweet that received widespread attention in 2017.

It has been eighteen years since I graduated from medical school. I had hoped, and believed, that things had improved for the next generation. But the NASEM report shows that nothing has changed. Reading about this, writing and researching for this piece, and reflecting on my own experiences, brought back a flood of memories from my training, of what forms the gender bias and harassment by patients and families can take:

Here are just a few varied examples from my personal experience:

The time as a resident when the family member of a patient with altered mental status wouldn't get off the phone to answer my questions about the patient's medical history. He stared me in the eyes, the phone to his ear, ignoring my questions, continuing his phone conversation, as if I didn't exist. Deaf to my explanations that I was the doctor, the senior resident on the team, there to help and treat his family member. Until I, humiliated, had to let the male intern take over the history questioning. Lucky for that patient and his family I was there to teach the intern how to do the LP.

The innumerable times that, even after introducing myself and my title, patients referred to me as the nurse, social worker, fill-in-the-blank with a non-physician role…. And the innumerable times I was told by my patients that I didn't "look like" a doctor…As if that made their comments okay…

The time in my first year of practice, when I entered the exam room, to have an older male patient scold me, as if I were a child, tapping his watch and scowling at me, raising his voice to a threatening tone, "Where have you been, young lady?" Having to start and complete the visit after being put in this position of humiliation.

The time I was stalked by two men, "friends" of a patient, during a late-night ER shift as a 4th-year medical student on an away rotation, so that I had to ask for security to escort me to my housing at the end of my shift. The sleepless night of staring at the flimsy locks on the windows in the student housing.

Another time as a 4th-year medical student, being physically cornered by a patient in a deserted hallway. The visceral memory of his fist pressing in my side, trapping me against the wall, hateful words whispered in my ear. Then the double trauma of being subjected to the embarrassed looks of the residents and attending when I fled to the team (comprised of men and women) for help. Being made to feel silly and weak. Like I was exaggerating what happened. Being told, "Don't worry, he's being released tomorrow." The solution being decided simply that I didn't have to be part of his care any longer. As if that solved the problem.

I realize now this was a completely inappropriate response by my supervisors, but at the time I didn't take any further action. Why would I, when the message I received loud and clear from my team was that this wasn't something one complained about? As if, it was somehow my fault it happened at all. In a companion perspective article in NEJM, Ending Sexual Harassment in Academic Medicine, Drs. Dzau and Johnson wrote an explanation:

"Adding to the power differential is a culture that accepts some degree of suffering as a matter of course. Medical education and training is notoriously grueling and competitive, with long hours, extensive workloads, and unrelenting pressure to perform. Often, human lives are on the line. It's hard to find the time to sleep or eat, let alone file a harassment complaint… In a profession that often eschews any perception of weakness or vulnerability, women don't want the negative attention a complaint will bring."

My examples may seem so disparate that one has nothing to do with the other. But I would argue the opposite, they are all related. The minimization by my supervisors of the trauma of my experience at the hands of that patient exists in a continuum with the dismissals we make on a daily basis of the offhand belittling and marginalizing comments made by patients and families in the exam room.

Is one potentially more harmful than the other? No doubt, physically, yes. But as Dr. Choo and her colleagues wrote: "… sexual harassment encompasses an array of verbal and nonverbal behaviors that 'convey hostility, objectification, exclusion, or second-class status about members of one gender.' Since all forms of harassment have negative effects on women's careers and on their physical and psychological health, there is no clear rationale for ignoring the full range of behavior that falls under this umbrella. Failure to take into account the vast majority of incidents of sexual harassment compromises our response to the problem." (emphasis added)

Another insightful perspective from earlier this year, JAMA Internal Medicine March 2018, in which the editor's note sums it up well: "The impact of a cascade of small injustices that women physicians deal with every day undermines our daily work and collectively sends a demeaning message about our worth in the workplace."

Drs. Dzau and Johnson, write that they "…are calling on our fellow leaders in academic medicine to commit to a systemwide change in culture and climate aimed at stopping sexual harassment before it occurs."

But I think those of us in practice can evoke a culture change as well. For those of us in clinical practice, let's all, women and men, commit to zero tolerance for gender bias from our patients. There's no such thing as an 'innocent' comment when it comes to gender bias.

And there's no such thing as a female physician, in academia or outside of it, who got her position by being "lucky." We all put in the work. We all survived the trenches. The NASEM report reminds us the work isn't done.

Do you have a story of harassment and gender bias from a patient or their family? Let's start a conversation. Please comment.

Dr. Jennifer Lycette, MD is a medical oncologist in community practice for 11 years. She works and resides on the North Oregon Coast, where she lives with her husband and 3 children. Her personal blog, The Hopeful Cancer Doc, includes her writings on practicing oncology, maintaining hope in medicine, work-life balance, and various other musings. She is a 2018-2019 Doximity Author.