The "Dark Side" of Medical Education?
It is rare that a medical journal would publish an essay by a physician anonymously which describes the "dark side of medicine" and perhaps including the "dark side" of medical education. The article is in the August 18 2015 issue of the Annals of Internal Medicine
and in an editorial in the same issue, the following:
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.
So this "dark side" can be said to also involves those of us in involved medical education such as myself.. Perhaps medical educators are inadequately inspecting and controlling the content of the "hidden curriculum" being presented to medical students and not facilitating advice and support for those students and doctors who witness "dark behavior" to "speak up" to the perpetrators but also to superiors in administration.
By the way, if you want more, read the article in Better Health
an immediate response to the Annals essay. ..Maurice.
Graphic: From Google Images and modified by me with ArtRage and Picasa3.
posted by Maurice Bernstein, M.D. @ 9:32:00 AM
9 comments
9 Comments:
Maurice,
I am going to start this off, perhaps being as controversial as always…
First let me thank you for sharing some very good articles that admit a dark side of the profession exists.
Perhaps the most disturbing article was "Confronting Scandalous Physician Behavior: The Annals Of Internal Medicine Takes The First Step.” In it, the author states:
I guess you could say that in my medical training, I witnessed a child rape. I don’t think it gets much worse than that… and I don’t know what to do with this horrific memory. I am forever changed.
I recently came across the blog post, "Gentlemen Don't Look up Ladies’ Skirts.” The procedure focused on in this piece are gynocological exams by male physicians. It also supports that humans are sexual beings, hence humans may experience sexual feelings (both doctor and patient from these procedures.
It does reference journal articles (although it does not link directly to them). I too covered this issue in a number of my blog posts, including my most recent, “Patient Dignity: But it is Sexual... Redux.”
I do wan to note that sexual feelings, attractions, and abuse can be perpetrated by either gender AGAINST either gender. It is NOT just men having these feelings about women.
The same can be said of children and adolescents (whose bodies are more mature than their minds). In this society, we are presented with advertising of the ideal beauty being young and thin, resembling that of adolescents. In some state the age of consent is as low as 16 (and may even be lower).
So it is not out the realm of posibility that someone who is not a pedophile may be aroused by a young person. Fodder for many comedians is a parent not recognizing their child’s best friend at first, but viewing them as attractive until they realize who they are and their age.
Even worse are pedophiles who specifically target children in these situations. One of the problems with protecting children is how healthcare (especially the AAP) try to sell the false reality that genital exams are “routine.” Just as "Gentlemen Don't Look up Ladies’ Skirts” does not buy into the notion that the exams are “professional,” neither should we accept them as “routine” either.
That is not to say that they are sometimes medically necessary, but do not try to sell them as being the same as examining an elbow. Perhaps the problem is that routine is not to comfort the patient as much as to comfort the physician (as the term “professional” does).
Another problem is that when medicine became “professional,” and that was used to justify undressing a patient, women and children had no rights. Both were thought of as possessions. Just as the annual pelvic exam was found to be more voodoo ritual than science, I am sure that the same can be said of children’s annual wellness exam.
—Banterings
It has been many years since I have contributed to this blog. As a 'professional patient' (my slightly sardonic description of my 'role' as a life long patient with complex, chronic conditions) I had the luxury of being largely out of the system for a few years. However, I am currently active within the public system and find myself again as I was back then; frustrated, irritable and feeling trapped. And so I find myself back here, seeking an opportunity to understand and contribute.
I am groping somewhat with what to write regarding this post. As a patient, I can say with certainty that sexual reactions, however fleeting, do occur from physicians. I would believe patients can have the same in return. And yes, inappropriate behaviour in pelvic examinations also occurs. I have experienced it.
It is serendipitous that I chose to revisit this blog tonight, as I have just applied to be a Simulated Patient at a leading University. I ticked 'no' for the Women's Health program primarily because I knew I would not have sufficient disassociation from the task; I also would physiologically be ineligible.
But I wonder, is there scope for detection of potential 'assholes' before they graduate, or is this subject just so taboo that it will continue to be pushed under the rug, with potentially devastating consequences to future patients AND co-workers.
MC,
Welcome back. I hope that despite not posting that you have been following the blog. If not, you should go back and read. You will also notice that in Patient Modesty: Volume 68 there has been a change in tone, that these situations that patients have described are not anomalies, but the status quo.
One of the problems in healthcare is the “denial of the obvious.” For example physicians are taught and patients are told a genital exam is NOT sexual, yet both can not deny the physical sensations that their bodies feel. I address this issue on my blog most recently in the post; Patient Dignity: But it is Sexual... Redux.
All these things, such as the denials and the excessive undressing of patients are solely for the convenience of the providers. One of the greatest abuses was urinary catheter use. The staff found it much easer to catheterize or leave catheterized patients than helping them hobble to the bathroom or provide a urinal.
The abuse became so widespread and problematic, that the Federal Government (via Medicare/Medicaid) had to intervene. Simply making a law or policy would NOT change the situation (it was too easy to use the excuse “thought medically necessary at the time”). The solution was to impose monetary penalties based on outcomes.
That leads me to your comment about the “assholes.” If providers will NOT report “bad providers" that they witness first hand, how can you expect them to screen candidates? (See: The M.D.: Silence on bad doctors and Why Doctors Stay Mum About Mistakes Their Colleagues Make. ) Even having a chaperone does not protect patients: Patient Chaperones: A Practice that is Useless and Abusive. I have a Maurice posted on Volume 73 of this blog some examples of (sexual) abuse. I believe that part of the problem that lends itself for the lack or reporting is because providers are told this is NOT sexual. So even when they witness sexual abuse, they deny it because they were taught medical procedures are not sexual. Still, they realize that it was sexual abuse and the disconnect prevents action.
—Banterings
Hello Banterings, thank you for the welcome.
No, I have not been following the blog in my absence (no offence, Maurice!). When I'm able to be out of the medical system, or rather, exist on its peripheral edge, I prefer to turn my back completely on it and pursue as 'normal' a life as possible, knowing full well that the day will come when I will be thrust back in the thick of it.
I have a lot of catch-up to do.
I started with the original link Maurice posted, and also 'Gentlemen Don't Look Up Ladies Skirts', and later began to wade through the latest Patient Modesty volume.
Tonight I read your blog post on patient dignity being sexual, with mixed emotions. I have long been aware of multiple journal articles on the trauma reported by patients that undergo internal examinations as children; the association with rape/abuse, the 'long-term emotional consequences' as you wrote and resultant dissociation as a coping mechanism. Finding these journal articles was one part of a larger personal quest, beginning in my early 20's, to understand my own dissociative issues that developed as a child within the health system.
I had the same mixed emotions regarding what you wrote on urinary catheters, a protocol I have long questioned. Whilst they are obviously necessary in certain situations, I have challenged their usage in situations where I can see no purpose for them. As a patient, this 'non compliance' does not make you popular. It was nice, in a strangely disheartened way, to read your blog, and heartily wish I could drag you around to many of my appointments as an advocate!
I agree with your assertion that 'bad providers' may often go unreported for sexual misconduct due to the belief that the procedures are not sexual. I will add that fear is another reason for not reporting a colleague, especially one that is higher up the medical hierarchy. Having briefly dated a surgical registrar (I'm in Australia) who was attempting to get onto a surgical program, I became aware of how many hoops, many of which had no relation to surgical skill or competence, younger physicians had to jump through in order to secure themselves a place in such a competitive and coveted program.
Who would be willing to risk their potential career by reporting colleagues and/or superiors for behaviour that can so easily be dismissed as well within the bounds of medically necessary and legitimate?
-MC
Banterings, as soon as I submitted the above post I returned to your blog and, of course, your most recent post was about the negative impact on the career of an nurse who reported a surgeon for misconduct.
A patient, what hope do I and billions more like me have? Patients are the bottom of the medical food chain, with 'patients rights' frequently being nothing more than a colourful brochure in a waiting room.
The scenario mentioned in the essay and the response in Better Health is appalling and criminal. If we (healthcare employees) do not stand up for our patient then who will? Isn't that why we chose this field to begin with? The incidents mentioned are not isolated and will continue to grow in frequency if they are not addressed and prosecuted/punished.
Should ethicists also stand up for the patient population? Take a look at this view of the "side" of physician behavior as written by a well-known ethicist in today's issue of Michigan State University Bioethics.
..Maurice.
Pertinent to this subject and the article in the above linked Michigan State University Bioethics website, Ray, a visitor to my Patient Modesty: Volume 73 thread who discussed at length in a series of 8 postings a great discussion about this controversial behavior of healthcare providers. Go to the above link and read what he wrote, return here and write your own comments. ..Maurice.
Dark side of medical education surely also includes what is being taught as a medical fact and which doctors must follow when it is only assumptions that aid in profiteering for the pharmaceutical companies. Doctors are taught for instance that cancer cells are normally killed by the immune system but there is stark evidence that cancer cells are aided by the immune system. For instance, in metastasis cancer cells need to get through epithelium tissues and other tissues, through the walls of blood and lymphatic vessels and other epithelium tissues etc both leaving the primary site and in the destination site which is typically another organ. They can’t do that on their own, they need help, they need for the tissues to become permeable. The only known way that tissues become permeable is by immune cell products like histamine. This is clear evidence that the immune system is involved in cancer proliferation at least, if not in cancer formation and growth as well, which I believe is the case. How can such information reach the public? Doctors are not to blame as they are taught and as doctors must follow guidelines or lose their license. But if enough doctors speak up then this sort of bad education and the bad consequences it has on patients can be addressed.
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