Thank you so very much. Something to read, someone sent it to me from another forum:
On Being a Doctor: Shining a Light on the Dark Side
Christine Laine, MD, MPH; Darren B. Taichman, MD, PhD; and Michael A. LaCombe, MD
Ann Intern Med. 2015;163(4):320. doi:10.7326/M15-1144
This issue includes an On Being a Doctor essay, titled “Our Family Secrets,” that we think, and hope, will make readers' stomachs churn (1). In this essay, the author describes teaching a medical humanities course to senior medical students and asking, “Do any of you have someone to forgive from your clinical experiences? Did anything ever happen that you need to forgive or perhaps still can't forgive?” One of the students—clearly distraught—recounts lacking the courage to object to a surgeon's highly disrespectful behavior to a patient under general anesthesia for a vaginal hysterectomy. The author then recounts how he was an accomplice to the harrowing behavior of an obstetrician during a delivery complicated by uterine atony and hemorrhage. The first incident reeked of misogyny and disrespect—the second reeked of all that plus heavy overtones of sexual assault and racism.
Many On Being a Doctor essays highlight positive aspects of our profession and are uplifting and inspirational. Why did we choose to publish something that exposes medicine's dark underbelly? If you haven't read the essay, we urge you to read it now before continuing here.
Although we wish it were otherwise, most physicians at some point find themselves in the midst of situations where a colleague acts in a manner that is disrespectful to a patient. There are various ways that we might react when witnessing such behavior. When the perpetrator is a superior, we may feel pressure to join in, as the author and his student did. After all, it was just a joke and the patient was unaware, right? Alternatively, we might simply remain silent. Saying nothing robs the perpetrator of an audience and, hopefully, extinguishes the incentive to continue the behavior. Or we might be the anesthesiologist in the essay and demand an end to the behavior and even chastise the perpetrators. Although we know of no empirical evidence about which response is most common, we speculate that it is silence and that there are too few “anesthesiologists” among us. If the essay gives just one physician the courage to act like the anesthesiologist in this story, then it will be well worth publishing.
It is our hope that the essay will gnaw on the consciences of readers who may recall an instance of their own repugnant behavior. The story is an opportunity to see what this behavior looks like to others and starkly shows that it is anything but funny. After finishing it, readers guilty of previous offense will hopefully think twice before acting in a manner that demeans patients and makes trainees and colleagues squirm. Again, if the essay squelches such behavior even once, then it was well worth publishing.
Ambiguity magnifies the power of the essay. Is the author struggling to forgive the surgeon for his poor treatment of Mrs. Lopez, or is he struggling to forgive himself for joining in the antics or for not acting more like the anesthesiologist? Is it right to be appalled by the surgeon when, despite his oafish behavior, he really did save the patient's life? Saving a patient's life seems like a pretty good demonstration of respect, doesn't it?
Multiple interpretations of the piece are valid and lend insight. They were reflected in the lengthy and heated discussion that occurred among our editorial team when considering whether to publish the story. The discussion was so impassioned and opinions so disparate that we needed a “time-out” and came back to it a week later after we had ample time to contemplate the issues raised. We all agreed that the piece was disgusting and scandalous and could damage the profession's reputation. Some believed that this was reason not to publish the story. Others believed that it was precisely why we
shouldpublish it.
When we finally decided to publish the essay, we did so under the condition that the author would remain anonymous. We have done this in only one other instance. Then, as now, we did so to protect the identity of any person who might be identified, most importantly the patients.
We hope that medical educators and others will use this essay as a jumping-off point for discussions that explore the reasons why physicians sometimes behave badly and brainstorm strategies for handling these ugly situations in real time. By shining a light on this dark side of the profession, we emphasize to physicians young and old that this behavior is unacceptable—we should not only refrain from personally acting in such a manner but also call out our colleagues who do. We all need the strength to act like the anesthesiologist in this story and call our colleagues “dinguses” when that label is appropriate. We owe it to ourselves, to our profession, and especially to our patients.
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Our Family Secrets
Ann Intern Med. 2015;163(4):321. doi:10.7326/M14-2168
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One day in January, I was facilitating a fourth-year elective course with eight medical students. It was a medical humanities class, and the topic that afternoon was the virtue of forgiveness. A student named David led the discussion, and I listened as they exchanged ideas. When their energy waned, I asked, “Do any of you have someone to forgive from your clinical experiences? Did anything ever happen that you need to forgive or perhaps still can't forgive?”
I waited for an answer, but no one said a word. When a classroom becomes that quiet in response to a question, I sometimes have the strength to sit with the silence. So, I looked out the window and waited. I leaned back in my chair and waited. Finally, David said, “Something unforgiveable happened to me.”
“What happened?” I asked him.
“I was scrubbed into a vaginal hysterectomy. The patient was under general anesthesia. My attending was prepping the patient's vagina. He picked up a clamp holding sterile cotton balls and dipped them into Betadine. While he was cleansing and scrubbing her labia and inner thighs, he looked at me and said, ‘I bet she's enjoying this.' My attending winked at me and laughed.”
Someone gasped. I stared at David. He shifted in his seat and crossed his arms on his chest. A splotchy red rash appeared on his neck. Staring down at the table, he murmured, “Man, I was just standing there trying to learn. The guy was a dirtball. It still pisses me off.”
David glanced at me. I asked, “When your attending said that and laughed, did you laugh, too?”
My question touched a nerve; perhaps my tone was accusatory. David snapped back, “Yeah, I laughed, but what was I supposed to do? Have
youever been in a situation like that?”
I looked down at the table in front of me and saw my black ballpoint pen. I focused on its gold clip for a moment. I placed my index finger and thumb beside the pen and spun it in place. It twirled and clicked as it spun around and around. I stared at the rotating pen and remembered. I felt my face flush. The spinning pen slowed, and then the clicking stopped. I looked up at David. “Yes, I have.”
“So, what happened?” David asked.
“It's my third year of medical school and I'm on Ob/Gyn. I deliver a baby girl and put her in the mother's arms. I can still remember the mom's name—Mrs. Lopez. I deliver the placenta, put it in a pan, and inspect it. It's intact. Then, I turn back to Mrs. Lopez. I see blood gushing from her vagina. It comes in waves. I've never seen anything like it. I yell to my resident—the guy's name is Dr. Canby—'Hey, something's wrong. She's really bleeding over here.' He shoulders me out of the way and checks her perineum for a laceration. There is none. He puts his hand on her abdomen and aggressively massages her uterus. She keeps bleeding. Then Dr. Canby says, ‘She's got uterine atony. Start oxytocin and call anesthesia.' A nurse lifts the baby off the patient's chest.”
“A few moments later, the anesthesiologist walks in the room and asks, ‘What do you got?' Dr. Canby says, ‘Vaginal delivery. Uterine atony. External massage failed. Give her some ketamine.'”
“Anyway, so I hear the anesthesiologist say, ‘Ketamine is in.' I look at Mrs. Lopez—her eyes are half-closed and vacant. Dr. Canby instructs me to hold her knee. A fellow medical student holds her other knee. Our job is to keep her legs spread. Canby then performs an internal bimanual uterine massage. He places his left hand inside her vagina, makes a fist, and presses it against her uterus. I look down and see only his wrist; his entire hand is inside her. Canby puts his right hand on her abdomen and then massages her uterus between his hands. After a few minutes, he feels the uterus contract and harden. He says something like, ‘Atta girl. That's what I like. A nice, tight uterus.' And the bleeding stops. The guy saved her life. I was blown away.”
“But then something happened that I'll never forget. Dr. Canby raises his right hand into the air. He starts to sing ‘La Cucaracha.' He sings, ‘La Cucaracha, la cucaracha, dada, dada, dada-daaa.' It looks like he is dancing with her. He stomps his feet, twists his body, and waves his right arm above his head. All the while, he holds her, his whole hand still inside her vagina. He starts laughing. He keeps dancing. And then he looks at me. I begin to sway to his beat. My feet shuffle. I hum and laugh along with him. Moments later, the anesthesiologist yells, ‘Knock it off, dinguses!' And we stop.”
After I finish my story, I glance at the students; some gaze down at the table in front of them, while a few others look at me with blank stares. They are all quiet.
I know this is my silence to break.
Note:All names in this essay are pseudonyms
