Heavy Overtones of Sexual Assault in the OR

[meltoine]

www.washingtonpost.com/news/to-your-health/wp/2015/08/18/anonymous-medical-journal-essay-heavy-overtones-of-sexual-assault-in-operating-rooms/

If you were freaked out by the news in June that an anesthesiologist had talked trash about her patient while he was unconscious on the table in front of her, you'd better brace yourself. There's more and it's worse. So much worse.

In an anonymous essay published in the Annals of Internal Medicine this week, one physician describes — in graphic detail — what happened to two women when they were asleep in operating rooms. The stories are horrifying.

"I bet she's enjoying this," one doctor reportedly said while prepping a woman for a vaginal hysterectomy. In another case, an obstetrician performed an obscene dance after saving the life of a woman who was bleeding out after having a baby. 

The article is an unusual one for the the journal, which was established in 1927 by the American College of Physicians and typically publishes technical articles about disease management and medical research.

In a letter accompanying the essay, the editorial team agonized over whether to publish the piece. They said everyone agreed that the piece was "disgusting and scandalous" and could damage the profession's reputation. But some argued that this was why they shouldn't publish it while others felt that was why they should publish it.

"The discussion was so impassioned and opinions so disparate that we needed a 'time-out,' " editor-in-chief Christine Laine and her deputies wrote in a letter accompanying the essay.

In the end they said they decided to do so in order to "expose medicine's dark underbelly." They said the first incident "reeked of misogyny and disrespect — the second reeked of all that plus heavy overtones of sexual assault and racism."

"It is our hope that the essay will gnaw on the consciences of readers who may recall any 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," they wrote.


The editors said the author — identified as a practicing physician who is affiliated with a medical school — originally submitted the narrative essay with his name but the journal decided to publish it anonymously in order to protect any people who might be identified, most importantly the patients. Annals of Internal Medicine said the piece was peer-reviewed before publication.

The author said he learned of the first incident when teaching a medical humanities course 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?"

A student he called David said he was observing the surgery when an attending physician made the lewd comments while cleansing and scrubbing the patient. David commented, "Man, I was just standing there trying to learn. The guy was a dirtball. It still pisses me off."

The author says the student turned the discussion around by asking him the same question. He said he "felt my face flush" and before he knew it, he told the class about the second incident, which occurred in his third year of medical school while he was on an OB/GYN rotation. He said that he ended up laughing and joining in on the doctor's disrespectful dance until the anesthesiologist in the room yelled "Knock it off" and swore at them.

In the one-page narrative essay, the author doesn't offer any judgement or opinion about the incidents but says that the discussion in the class made him realize "this is my silence to break."

The journal's editors said that they hope that medical educators and others will use the essay as a "jumping-off point for discussions that explore the reasons why physicians sometimes behave badly."

"If the essay squelches such behavior even once, then it was well worth publishing," they wrote.

Deborah Hall, president of the American Medical Student Association, told U.S. News and World Report that medical students might be reluctant to express their objection even though they know they should because they are at the bottom of the pecking order in an operating theater filled with doctors, nurses and technicians.

[Patients press the ‘record’

"Students feel incredibly vulnerable," Hall told the publication. "It's incredibly difficult to speak up."


Harlan M. Krumholz, a cardiology and social and policy professor at Yale, told MedPage Today that "there needs to be a mechanism where such behavior can be reported — and then the issue needs to be investigated by an ombudsperson and handled appropriately.

"We want to avoid false accusations or misunderstandings — but also, some of these actions are downright criminal — and so need to be addressed immediately," Krumholz said.

[meltoine]

And the essay from the journal: annals.org/article.aspx?articleid=2427613

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 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 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, 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.

[decemberwedding07]

Ho.ly. Shit. That's all I have right now. This is horrifying!

[shanbrite2]

Yuck. No words.

[underwaterrhymes]

Oh my fucking God.

[Pom]

There are some disgusting fucks out there.

I hope the medical team I had for my hysterectomy had more humanity. If not, I'm glad I don't know.

[aurora]

I kinda wish I hadn't read this.

[ESF]

Props to the Journal for publishing this piece. This was a bold move and I hope it will encourage witnesses to these kinds of sexual assaults to come forward.

It also makes you wonder what deep dark secrets other medical specialities and other professional associations are keeping about themselves.

[YeahSure]

Omg

[jln]

I'm glad people havr come forward and I hope more continue to do so.

This was my biggest fear when I went into my D&C. I was terrified that something like this would happen in the OR to me. The anesthesiologist was a complete asshole to me and said something really shitty to me just before he started the IV so I went into the OR really scared.

[LadySusan]

Wow. To do crappy stuff like that in full view in a room full of people is crazy.

[nsuhomer]

I'm sick over this.

I experienced birth trauma with the birth of my second daughter (nothing near this extreme), and it took over 2 years to handle the PTSD. Damn. This is fucked up.

[secretlyevil]

Apparently you can't trust anyone. Gah, I'm with aurora, I really wish I hadn't read these.

[Michelle]

In Texas it is especially fun to manage because hospitals cannot employ physicians. Physicians can be owners of a hospital and practice it, and physicians can be employed by an affiliated organization, but there is a texas code that says hospitals cannot be the employer. So when you have assholes do this kind of thing, you have the RN, tech, etc. employed by the hospital, residents in training and employed by the medical school/hospital, physician who has privileges that he can and will threaten to take elsewhere which means all the patients go and he can say whatever he wants about his reason for leaving (hospital care declined, etc. instead of 'they don't want me there because I'm an asshole') and often in Houston the anesthesiologists are employed by a 3rd party contract that doesn't change much, but all this means one super asshole action means multiple HR depts from different employers, medical staff governing body, etc. all have to get involved and manage competing stakeholder interests in dealing with these douchebags instead of saying, "you know what - do that again and you are fired you creep" and moving on with everyone knowing it will not be tolerated again. They don't know. And contracts/business/patient perceptions are all hanging on the line, which makes the least powerful (the nurses, techs, residents) afraid to speak up.

[IIOY]

Aug 22, 2015 16:49:53 GMT -5 Michelle said:

And contracts/business/patient perceptions are all hanging on the line, which makes the least powerful (the nurses, techs, residents) afraid to speak up.

I was going to say, in many instances it's not just students who have no power and are afraid to speak up.

Perhaps it's my professional experience or hearing my mother's stories from her HR work in a hospital, or maybe I've seen too many terrible TV shows, but the OP just didn't shock me. To be perfectly honest, the biggest surprise to me is that we don't hear more stories like this, but then, see my first paragraph.

[NewOrleans]

Disgusting.

Where is that twit who informed us about compassion fatigue?

[Michelle]

Aug 22, 2015 17:23:08 GMT -5 IIOY said:

Aug 22, 2015 16:49:53 GMT -5 Michelle said:

And contracts/business/patient perceptions are all hanging on the line, which makes the least powerful (the nurses, techs, residents) afraid to speak up.

I was going to say, in many instances it's not just students who have no power and are afraid to speak up.

Perhaps it's my professional experience or hearing my mother's stories from her HR work in a hospital, or maybe I've seen too many terrible TV shows, but the OP just didn't shock me. To be perfectly honest, the biggest surprise to me is that we don't hear more stories like this, but then, see my first paragraph.

I don't think I've ever known that your mom worked in HR in a hospital. So you can probably really picture what I may vent about here occasionally, lol.

Except for the sexualization part, it is true that I have done employee relations investigations into so much worse than what is posted here. I have to say that we have had certain executives who have been able to get in and talk some sense with many physicians and curb the behavior or flat out get rid of them. As demands for nurses continue to increase they have stronger power in the workplace to take their skills somewhere where they don't have to take the hostile work environment. But when the physician is part of your advertising campaign because of their special patented surgical technique and what not, even top execs are afraid to do things sometimes.


There is almost always a way to address it though. If you have strength of character. 

[twohearted]

I worry about stuff like this too because I've always assumed it went on.

Was the patient in the second example unconscious? I had that issue after my second delivery, but I was fully awake through the procedure. Does ketamine knock you out?

[Michelle]

Aug 22, 2015 18:37:40 GMT -5 twohearted said:

I worry about stuff like this too because I've always assumed it went on.

Was the patient in the second example unconscious? I had that issue after my second delivery, but I was fully awake through the procedure. Does ketamine knock you out?

If Ms. Lopez was aware of that kukaracha shit she should have sued the fuck out of that hospital!

[meltoine]

Aug 22, 2015 18:37:40 GMT -5 twohearted said:

I worry about stuff like this too because I've always assumed it went on.

Was the patient in the second example unconscious? I had that issue after my second delivery, but I was fully awake through the procedure. Does ketamine knock you out?

Ketamine is a pretty powerful sedative. I'm assuming she was out. 

[twohearted]

Aug 22, 2015 18:40:16 GMT -5 Michelle said:

Aug 22, 2015 18:37:40 GMT -5 twohearted said:

I worry about stuff like this too because I've always assumed it went on.

Was the patient in the second example unconscious? I had that issue after my second delivery, but I was fully awake through the procedure. Does ketamine knock you out?

If Ms. Lopez was aware of that kukaracha shit she should have sued the fuck out of that hospital!

Yeah, you're right. I was hoping she wasn't just a vulnerable patient who didn't feel like she could speak up or something.

[Deleted]

Damn, how sad.

This does surprise me. I'm glad I've never experienced anything like this or felt like I couldn't speak up because of inappropriate behavior in the OR towards a patient.

[LeggsBenedict]

oh god, this (david's story) reminds me of something that happened to a family member. but she was awake.

jesus.

[gpw]

Aug 22, 2015 19:02:24 GMT -5 @wandering said:

Damn, how sad.

This does surprise me. I'm glad I've never experienced anything like this or felt like I couldn't speak up because of inappropriate behavior in the OR towards a patient.

You know what?  I am glad it surprises you.  Because at least it means it's not everywhere.  

This is really fucking depressing.  

[Michelle]

Aug 22, 2015 19:02:24 GMT -5 @wandering said:

Damn, how sad.

This does surprise me. I'm glad I've never experienced anything like this or felt like I couldn't speak up because of inappropriate behavior in the OR towards a patient.

TBH I was encompassing behavior toward staff as much if not more than patients. Just basically some pretty assholish behavior that happens. But I am very glad you haven't seen that kind of stuff!

[twohearted]

Aug 22, 2015 19:10:24 GMT -5 @viv said:

Aug 22, 2015 19:02:24 GMT -5 @wandering said:

Damn, how sad.

This does surprise me. I'm glad I've never experienced anything like this or felt like I couldn't speak up because of inappropriate behavior in the OR towards a patient.

Yeah, I've definitely never witnessed anything like this. These examples are outright sexual assault. 

I can understand students feeling like they can't speak up about inappropriate behavior. The culture/hierarchy in some teaching hospitals is...something else...

But in the one story the doctor was actually the resident, wasn't he? Would med students really fear reporting a resident's unethical behavior? I think the anesthesiologist certainly should have.

[Deleted]

Aug 22, 2015 20:06:04 GMT -5 twohearted said:

Aug 22, 2015 19:10:24 GMT -5 @viv said:

Yeah, I've definitely never witnessed anything like this. These examples are outright sexual assault. 

I can understand students feeling like they can't speak up about inappropriate behavior. The culture/hierarchy in some teaching hospitals is...something else...

But in the one story the doctor was actually the resident, wasn't he? Would med students really fear reporting a resident's unethical behavior? I think the anesthesiologist certainly should have.

Yes I would be worried. Especially if it were at a place with a residency programs. In many instances medical students don't work very directly with the attending and spend 90% of their time with residents who will determine if you will get in that residency program.

I mean obviously in an ideal world reporting unethical behavior would be a no brainier but residents do have a lot of say in a med students grade and/or ranking in a program if they are trying to get in to that program. So yes it would make sense for a med student would be somewhat fearful about any repercussions it may have on their career.

[nikki25]

Aug 22, 2015 19:30:25 GMT -5 @32flavors said:

Aug 22, 2015 19:10:24 GMT -5 @viv said:

Yeah, I've definitely never witnessed anything like this. These examples are outright sexual assault. 

I can understand students feeling like they can't speak up about inappropriate behavior. The culture/hierarchy in some teaching hospitals is...something else...

They are gross examples of human behavior, but sexual assault? The physical contact that occurred in both stories was necessary and approiate. They comments were disgusting and should be addressed. But I have a hard time seeing a lifesaving procedure as assault, even if I think the physician performing it should be banned for his disrespect.

I agree that this is not a sexual assault  and labeling  it as such could be a dangerously  slippery  slope. Was their verbal conduct  appropriate? Absolutely  not, but if physical   conduct was in-house  the course of a medical procedure  being douche bag doesn't  make them assailants . And, the resident with the singing I have to imagine  he kept his hand in there to ensure  the uterus stayed contrated not because  he enjoyed  it. Listen he was an ass for acting like a fucking inappropriate  fool but jumping to sexual  assault  is really  pushing it IMO.

[nikki25]

Aug 22, 2015 20:54:26 GMT -5 kevin arnold said:

Compassion fatigue! No big deal. We just don't understand because we're not doctors.

If that was towards me, no, fuck no. There is no excuse for their behavior it is fucking inappropriate but I am extremely hesitant to label is as a sexual assault, I am based upon these two examples.

[Deleted]

Aug 22, 2015 20:54:26 GMT -5 kevin arnold said:

Compassion fatigue! No big deal. We just don't understand because we're not doctors.

Who is this in reference to? :/

I hope not me. I think the behavior was totally inappropriate and hope that came across in my post.