The Annals essay, Our Family Secrets, describes the disrespectful, and repugnant, behavior of some physicians toward patients. Moreover, it challenges us to ask ourselves to consider truthfully whether we have ever silently observed inappropriate behavior or even joined in. Read the editorial or listen to the audio recording of why the Annals editors decided to publish this essay.
Consider the following:
- Have you ever been in situations where you felt you should stop colleagues from behaving inappropriately? Did you? Was it easy? What is the right thing to do? These are lessons we've all heard since childhood. Are they different here?
- Why do physicians sometimes behave badly? How can we prevent it? How can we stop it when it happens? What should be done after such an event has been stopped?
- Imagine you are an editor of a medical journal. Would you have published this essay? Why or why not? Do you object, or agree, with the decision to publish this piece anonymously? Why or why not?
Back to September 2015 Issue of IMpact
Imagine this scene:
A female patient under general anesthesia is being prepped for a vaginal hysterectomy. As the attending doctor washes and scrubs her labia and inner thighs, he turns to a medical student and says: "I bet she's enjoying this." Then he winks and laughs.
No, this account doesn't come from a racy British tabloid. It was published this week in a reputable medical journal, Annals of Internal Medicine.
The account, written by an anonymous doctor and titled "Our Family Secrets," also describes an incident involving an obstetric patient, Mrs. Lopez, who experienced hemorrhaging and other complications after childbirth. To stop the bleeding and ultimately save the patient, her doctor performs what is called an "internal bimanual uterine massage," which means he must get his entire hand inside her vagina. From the piece:
“...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, assholes!' And we stop.”
Dr. Christine Laine, editor in chief of Annals of Internal Medicine, said this is the first time in her tenure that such a profanity has been printed in the journal. But, she said in an interview, it seemed appropriate in this case. When she first read the essay she says it made her "stomach churn," and it made her angry.
"Angry for the patients ... angry for the younger physicians who encountered this behavior, angry at myself and others who have witnessed colleagues being disrespectful to patients but were too timid to speak out," Laine said.
In an accompanying editorial condemning the behavior described in the essay, Laine and her colleagues wrote: "The first incident reeked of misogyny and disrespect — the second reeked of all that plus heavy overtones of sexual assault and racism."
So how did this series of unfortunate medical events unfold?
Here's the backstory: The anonymous author of the essay (the journal decided to keep the doctor's identity a secret) was leading a course on medical humanities for senior medical students. The topic was "the virtue of forgiveness." At one point the doctor put a question to the class: “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?”
Did You Laugh Too?
After the question was posed, the room went silent. Finally, a student named David spoke out: “Something unforgivable happened to me.”
David then recounted the story we started this post with. Here's the full account from the piece:
“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 you ever 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 looked up at David. “Yes, I have.”
“So, what happened?” David asked.
The instructor then recounted his own story, from when he was a third year medical school working in obstetrics/gynecology. The patient, Mrs. Lopez, delivered her baby but then started hemorrhaging. That's when Dr. Canby takes charge.
From the essay:
"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, assholes!' 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.
So, the doctor saves Mrs. Lopez's life. And she likely knows nothing of the event. But the entire essay begs the question: How many of us are being mocked and crudely taunted when we're at our most vulnerable — exposed, under anesthesia or not watching what the doctor is doing?
The answer: Who knows?
The essay brings to mind the recent case of a man who inadvertently recorded his own colonoscopy and discovered the anesthesiologist and other doctors mocked and insulted him while he was sedated: among other things, doctors made fun of certain body parts and noted on his chart that he had hemorrhoids, which was untrue, according to reports.
Laine, the journal editor who is also a general internist at Jefferson Medical College in Philadelphia, said that while the awful behavior outlined in the essay is extreme, doctors show disrespect toward patients all too often.
"The incidents described in the essay are clearly abhorrent and at the far end of the spectrum," she said. "But do these things happen? They do on occasion happen, and even if they happen rarely, that's too often. And there are far less extreme examples, and those shouldn't happen either."
She added that for physicians who witness such behavior, there are three options: to play along, to be quiet, "and the third is to call them [the offensive doctors] out and try to stop it ... We need more physicians willing to tell people to knock it off."
In some medical circles, efforts are underway to address such "emotional harm" in a more systematic manner.
At Beth Israel Deaconess Medical Center in Boston, for instance, emotional harm is beginning to be addressed with "the same rigor that we’ve traditionally applied to physical harms -- such as falls, infections or wrong site procedures," Dr. Lauge Sokol-Hessner wrote in an email. Sokol-Hessner is the associate director of inpatient quality at Beth Israel and lead author of a recent article published in the journal BMJ Quality and Safety, titled "Emotional Harm from Disrespect: The Neglected Preventable Harm."
Ken Sands, a co-author of the emotional harm paper and chief quality officer at Beth Israel Deaconess, added in an email:
Currently most hospitals are rigorous about tracking physical harm events. There are definitions to refer to, methods for counting, models for doing root cause analysis, and reporting on findings and corrective actions. Emotional harm lacks the same rigor, often goes unreported (as the Annals paper illustrates) and if it is reported, there is likely to be anxiety, handwringing, and perhaps individual follow-up but nothing resembling formal cause analysis, reporting, and corrective action. We have put systems in place to 1) encourage our staff to consider these as adverse events that need to be reported; 2) come up with definitions and a classification scheme so that we can track events; 3) subject serious events to analysis and corrective action planning; 4) formally report on occurrences to hospital leaders and the Board.
And Laine says that by publishing the essay, she hopes to spark more discussion about how to prevent such behavior and change the culture from which it stems.
Here's more from the editorial that was published alongside the essay:
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...
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 should publish 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 “assholes” when that label is appropriate. We owe it to ourselves, to our profession, and especially to our patients.