is stirring controversy by pulling back the operating room curtain and exposing questionable behavior by surgeons, but it is doing so under the banner of anonymity.
This week a regular Annals' feature with the prosaic running title, "On Being a Doctor," presents an anonymous essay called "Our Family Secrets." The essay recounts two disturbing scenarios involving patients -- both of them women -- under general anesthesia.
The accounts, which were termed "appalling" by one retired surgeon and possibly "criminal" by a leading cardiologist, raise a number of questions, including a very basic one: is this true or hyperbole?
鶹ý asked Annals about the vetting of the anonymous essayist and received this response, which was attributed to the journal's editor-in-chief:
"We believe that inappropriate behavior is a problem that occurs in all medical specialties and across provider types. Annals of Internal Medicine's aim in publishing the essay is to generate discussion to prevent such behavior. Like all Annals' 'On Being a Doctor' essays, the essay was subject to peer review.
"We know the author's identity but chose to publish this piece only if the author agreed to do so anonymously so as to prevent the identification of others in the story, most importantly the patients involved. The author agreed with anonymous publication and is indeed a physician involved in both patient care and teaching. Authors who submit fictional essays are required to identify them as such and in the many years since this section of the journal began, the overwhelming majority of submitted essays, including this one, are not identified as fiction."
Victimless Hijinks or Sexual Abuse?
Here is an excerpt from the first scenario, which the anonymous author attributed to a fourth-year medical student:
"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."
The student, identified as "David" admitted that he joined in the laughter and his reasoning was, in essence, "What was I supposed to do?"
The second incident involved the anonymous author who said it occurred when he -- or she -- was a third-year student on an ob/gyn rotation. A woman identified as Mrs. Lopez had just delivered a healthy baby girl, when she began to hemorrhage. The resident on duty, Dr. Canby, was alerted, ketamine was started and Canby inserted his left hand into the woman's vagina, placed his right hand on her abdomen and began uterine massage.
Here is what happened next:
"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."
The Ring of Truth
"Why would anyone write this? And why would a respectable journal such as Annals of Internal Medicine publish it? Are they looking for clicks?" asked a retired surgeon who blogs as. "Unfortunately, the stories are quite credible."
He added that the ideal response when witnessing such actions would be to report them to the department chief, but he said that can be a daunting choice for junior personnel who might fear repercussions if they spoke up.
"Some hospitals have initiated anonymous hotlines so that unethical behavior can be reported. However, as a former surgical department chairman, I can tell you that it is difficult to discipline any physician unless witnesses are willing to come forward and testify at a hospital executive committee or medical board hearing," Skeptical Scalpel told 鶹ý.
, who holds dual professorships in cardiology and social and policy studies at Yale, said, "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, which will depend on the circumstances. We want to avoid false accusations or misunderstandings – but also, some of these actions are downright criminal – and so need to be addressed immediately."
Roy D. Clark, Jr., MD, a Bainbridge Island, Wash., psychiatrist who specialized in addiction medicine, wondered how the scenes described in the essay could truly remain "Family Secrets" noting that in his experience such events would not escape "quick and decisive administrative actions."
"I wondered if the attending and resident involved would want their mothers, sisters, wives, or daughters treated in the same manner," Clark wrote.
"As a resident for 5 years and a surgeon for 41 years I thought I had heard most everything. but the vulgarity of the surgeon described by David is inexcusable," wrote John O'Connor, MD, a retired colorectal surgeon from Washington, D.C.
Endangering Patients' Trust
"Based on personal experience in high-risk settings such as the ER and Intensive Care Units, this account rings true," wrote Tracy Poling, RN, JD. Poling, Clark, and O'Connor were asked by 鶹ý to respond to the essay.
Poling, who lives in Georgia and works full time tending to the "medical, legal, and educational needs" of her severely disabled daughter, said how one responds to such scenes has a lot to do with experience. "Today, as a woman and female nurse, I would not tolerate the attending's behavior in David's story. I would likely warn the attending first that if he planned continuing to practice operating on women, he would not continue to speak in that manner. If that did not stop the behavior, I would go up the chain of command until I was satisfied."
She was, however, more forgiving of Dr. Canby, the resident described in the second scenario, noting that he was faced with an extremely stressful, life-and-death situation. As such, I would give more leeway to the comments and actions and not immediately see them as intentionally disrespectful. Instead, it was likely a poor attempt at humor after the life-threatening emergency had passed."
"Skeptical Scalpel" said the stories reminded him "of the recent case of an anesthesiologist . The anesthesiologist did not know that the patient had accidentally left his cell phone on in record mode.
And there is who slapped patients' buttocks when they were asleep.
Krumholz summed up his reaction this way: "Patients trust us – and we need to be worthy of that trust at all times."