A prominent medical journal has published an anonymous account of doctors behaving badly. The piece in The Annals of Internal Medicine tells of a medical educator’s bizarre experience, recalled upon hearing a student’s tale. An accompanying editorial, by three editors including my former colleague in residency, Dr. Christine Laine,* reflects on the decision to publish the essay.
The article is important, first because the stories are entirely plausible. They serve as parables. By discussing these kinds of episodes, now formally published in a medical journal, doctors might learn and improve the moral environment in which they work and constantly perform risky, life-altering tasks. As things stand, complaining about senior physicians and those in charge, however egregious their behavior, can be very problematic for a young or mid-career doctor, or even an older one.
I don't mind the anonymity, because the greater point is not about one physician. Why I value the article is that I don’t think the fullest solution rests in calling out individual doctors for wrong-doing, although in some instances that may be appropriate or necessary. Rather, it involves nurturing ethical practices and better leadership in medicine, so that bad behavior would be nipped, early, by peer pressure among physicians.
In Our Family Secrets, the author describes leading a class in “medical humanities.” The day’s topic was forgiveness. A fourth-year medical student reported being in an operating room, scrubbed in for a hysterectomy. The senior physician displayed lewd behavior toward his anesthetized patient: “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.”
The student felt powerless. He challenged the classroom teacher, asking if the predicament was familiar. Had he or she had ever found himself going along – if not outright chiming in – with a senior physician’s offensive behavior? The answer, of course, was yes.
The teacher, in turn, recalled an incident in the third year of medical school, after he delivered the baby girl of “Mrs. Lopez.” Blood began gushing from the mother’s vagina. The obstetrician first tried to stop the hemorrhage by medication, and then by physically manipulating her womb. The student and a peer held her legs apart, each by clasping one of her knees, as instructed. The doctor put his fisted left hand into the woman’s vagina, and placed his right hand on her belly. He massaged her uterus, from inside and out, until the bleeding stopped.
And then the obstetrician began to sing: “La Cucaracha, la cucaracha, dada, dada, dada-daaa.” With his left hand still immersed in Mrs. Lopez’s vagina, he began to dance, stomped his feet, twisted his body and waved his right arm. When he looked at the student, the student began to shuffle his feet, hum and sway along with the music. An anesthesiologist walked in to the delivery room, putting a kibosh on the wildness.
Now, a reader here might be shocked by such disrespectful, sexist and racist words and gestures displayed by physicians while treating unconscious, naked, vulnerable patients. That would be an understandable, and perhaps most appropriate, reaction.
Maybe I’m jaded (I hope I’m not), but when I read this piece, my first reaction was: “I’ve seen doctors do much worse.” Neither story surprised me.
The Annals is right to publish the essay, because it will promote discussion among physicians about professionalism, and how doctors and physicians-in-training might handle these sorts of episodes in the future. If a student considers – before it happens, such as in a first-year class – how to cope with situations such as those described in the essay, he or she will be more prepared to respond appropriately and maybe, even, have the nerve to say “No, don’t do that. Stop,” without fear of retaliation.
Doctors need to “own” their behavior, and this is a step in that direction. The very act of raising awareness – and writing, talking openly about physicians’ unprofessional and abusive conduct – will render all but the most defiant among obnoxious doctors afraid of continuing their disparaging ways. The few, most obstinate and persistently bad actors, if they are made to feel sufficiently uncomfortable in the medical community, would stop, volitionally or otherwise.
If I had to pick an issue with the article, it’s that both tales are in the area of obstetrics and gynecology, or maybe family medicine. Specialties attract distinct personalities. But in each field, surely there are some characters who could use some counseling. Or time off. No doctor, or field, field is perfectly immune.
It’d be easy to respond – as an advocate or patient, hospital administrator or amateur medical ethicist – to this article with outrage, and state that these doctors – and others like them – should be punished, fined, fired, put through courses in moral remediation, humiliated and have their licenses revoked. Such non-professional behavior cannot be tolerated, of course.
Others might suggest we need more humanities majors in medical school. But those “types” of medical school applicants, while valuable, do not necessarily make for better doctors. The historians and writers I know are not all saints. Many of the biology and chemistry majors, engineers I’ve known are really nice people.
It’s tempting to invoke or “blame” the pressure that doctors are under – long hours, increased scrutiny, heavy life-and-death responsibilities, etc. – as causal factors. And while it may be true that stress contributes to the problem of doctors behaving badly, it’s no excuse. Doctors are accountable for what they say and do in their chosen profession.
I considered, also, the harsh timing of the Annals story. Doctors are feeling vulnerable these days, after ProPublica released its Surgeon Scorecard and, days ago, cut a deal with Yelp for reviewing doctors. Whether those enterprises are good or bad, right or wrong, they place physicians under even more scrutiny, add pressure to their days, and might cause them to feel vulnerable to humiliation. I worry that if that’s how doctors are treated – with less respect, in the public realm – they may respond by taking less pride in their work and in their professionalism.
It takes a lot of effort – and time, skill, dedication, ambition – to become a doctor. And it’s a huge responsibility to care for patients who are really sick. Not everyone is capable of handling all that. A recent survey showed that a high proportion of medical school grads from top schools are leaving the profession, feeling disaffected. Most doctors deserve credit, and respect.
Imagine, a non-Amazonian culture of kindness in the hospital workplace. If 99 out of 100 doctors were, by their nature and habits, the sort of people who would not abuse a patient, or behave so awfully, the 1 percent can be squelched – by peer pressure.
It’d be like herd immunity, but applied in the moral sphere. Medicine needs this. Patients would benefit. And doctors would find themselves working in happier, healthier, humane work environments, where they might thrive and be most productive.
Fortunately, the episode described in the obstetrics suite is less likely to happen now, in part due to doctors’ awareness in many places (not all) that they may be working under a camera. And because, in general, younger U.S. doctors are a more diversified lot. Frank racism, misogyny and other forms of bigotry are less likely to be revealed on rounds, or in the O.R., than they were a generation ago.
Ultimately, establishing a medical workplace where crass and harmful behavior is out-of-the-norm, so that the perpetrator is made to feel uncomfortable, and not the observer, will take the profession to a better place.
***
*Dr. Laine is a former colleague from residency and friend with whom I have not yet discussed the published essay or editorial.
"Doctor and Mrs Syntax, with a party of friends, experimenting with laughing gas." Coloured aquatint... [+]
