Sunday, August 23, 2015

To my Fellow Medical Students: Beware before Judging your Residents, for you may Easily Become them

A recent paper in the Annals of Internal Medicine has sparked a large news media response.

In it, two incidents are described: in one, a male obstetrician-gynecologist is prepping a patient's vaginal area for surgery, which involves running a brush soaked in betadine or chloraprep solution over the labia, mons pubis, perineum, and inner thighs when the patient is already put to sleep by anesthesia.  He makes an appalling joke, "I bet she is enjoying this".

In the second, another male obstetrician-gynecology resident runs into a room with a patient bleeding to death from her vagina.  He controls the bleeding with manual pressure, putting his hand into the woman's vagina.  And then, when the crisis is over, he starts dancing and singing, while his hand is still in the woman's vagina, keeping the woman from bleeding again.

Many comments, especially from other medicals students, are condemning the behavior of these doctors and likening it to sexual assault.

I make no excuses for this behavior.  But while it is easy for us as medical students to judge, the reality is that residency will put us all at risk of becoming these doctors.  The lesson here should not be "what monsters!", but rather "I must make sure I never become them".


This stems in large part from the overwhelming pressure that doctors face, and the desensitization that is an inevitable and necessary part of residency training.

Consider the second incident, where the ob/gyn resident danced. That woman could have died in the next 5 minutes. If the resident didn't find and exert pressure on her uterus in the right way and give the right sequence of medications, she would have bled out then and there- a newborn baby would have been left motherless, a new father widowed, and a young woman would have lost many, many years of her life with her children. There was no time to call an attending over. No time to ask for help- it was that resident doing the right thing or nothing.

Residency and medical training is a process whereby we learn to balance being close to our patients and being able to distance ourselves to act decisively and effectively when necessary- to run sprinting to a room and see not a young mother about to die, but a uterus that needs to be found and put under heavy manual pressure.

Then, you have to start a pitocin drip, followed by methergine (methylergonovine)- UNLESS they have hypertension, in which it could kill them with a stroke.  Next?  Hemabate (Prostin/PGF2), UNLESS they have asthma, in which case they can die of an asthma attack (hope you memorized that H+P), followed by rectal Misoprostal. If that fails, what's next? A D&C. Then? What's the bleeding rate? Too high? Interventional radiology. Wait, is IR around at this time? Are they in the middle of a pelvic trauma case? Then it's open pelvic vessel ligation. Can you find the vessels and clamp them? Did it work? If not, hysterectomy- and this women will never have any more children.

Can you think through that algorithm and decision points as your patient, a young mother is dying in front of you? Can you remember the dosing on those medications as you think of the newborn baby and the joy when the new mother held him for the first time? Or remember the anatomy of the pelvic region as you ponder the dad standing outside the room, terrified?  How can anyone possibly function in that situation if they thought of the patient as a human being?  No one can.  Part of becoming a doctor is learning to not see people as people, but as systems of organs.

Once the situation was over, and the adrenaline rush starts to die down, there is a natural urge to celebrate.  Consider this thought experiment: do you think the resident ob/gyn derived any sexual gratification from what he did? The woman may have felt profoundly violated, but I doubt the resident meant what he did in a sexual manner- he was probably just so happy at having saved the woman's life (and so completely desensitized to having a hand in a woman's vagina), that he celebrated in a profoundly inappropriate way.

I saw this video linked to in a comment discussing this article.  In it, a popular TV doctor who shall remain un-named is dancing with her hand in someone's abdomen, having controlled their patient's bleeding. How was this incident received, relative to the one described here? Did/does it strike you as being nearly inappropriate as the one described in the piece?  The only difference is that the doctor in this piece had his hand in the woman's vagina- and his dancing would likely have been taken by the patient as a profound violation of her dignity and body, if not as sexual assault.  While for the resident ob/gyn who has probably delivered hundreds of babies and performed thousands of pelvic exams, having hand in someone's vagina was as normal and typical as eating lunch, and had no sexual implications.

Once again, I am not making excuses for this resident's behavior- my point is that this resident was not a wolf who hid his nature through ten to twelve years of post-high school training.  He was someone once just like us who committed a terrible deed as a result of letting the natural residency process of forging us into doctors go too far.

This is the reality of what will happen to us all as we enter residency. We stop seeing patients as people with hopes, fears, and dreams- people who would probably feel profoundly violated if someone danced with a hand in their vagina.  Instead, we see them as anatomy to be considered, medical history to take into account, as problems that need fixing.  The resident did not see the woman as a person- all he saw was a problem which he had just fixed.  Why not celebrate his good work with a little dance?  What not spike the football?

Some of that desensitization is necessary for all medical trainees. Too much, and we become the doctors in this piece.  It is easy to condemn other doctors as being terrible deviants and aberrations upon the profession. It is harder to face the truth that we will all move a little closer to being what they are during residency. For the sake of our patients, careers, and souls, we must remember to not go too far in that direction, and remember that our patients are people first, and problems second.