With all due respect to surgeons

Back in the murky mists of the 1990s, I did my surgery rotation.  When I first got to medical school, for some reason I thought I wanted to be a surgeon.  I do not know where on earth I got that idea, which at this point in my life seems roughly as sensible as thinking I might take the podium after the Olympic decathlon.  By the time I actually got to learn the rudiments of real-life surgery, I had abandoned the idea of doing it professionally.  Indeed, since I was unmistakably terrible at surgery, it was for the best that I had given up the dream well before the rotation started.

[Aside:  Seriously, I was terrible at surgery.  I once broke the needle when suturing a patient shut.  The next day I was suturing another patient shut when the resident said “Be careful with your technique.  Yesterday one of the students broke a needle trying to close the patient.”  To which I replied, “Um… that was me.”  And then proceeded the break the needle again.  It was maybe not my very best moment.  (I got better at suturing eventually.)]

Anyhow, I remember reading the first chapter of the text that we were supposed to read during the rotation.  I don’t really remember much of the content, but one bit stands out in my memory.  It was, in a nutshell, a little section about how to deal with being yelled at during one’s surgery rotation.  So common was the phenomenon of being yelled at by surgeons that the authors felt compelled to include a little guide to the experience in the textbook.  (I recall no such sections in the texts for any other rotation.)  Suffice it to say that I found that… telling.

To be fair, I found my surgery rotation to be pretty benign on balance.  Though my only experience of overt homophobia came from a surgeon, almost all of them were easy enough to get along with.  I recall that the residents during my OB/GYN rotation were pricklier on the whole, and there was always at least one attending physician per rotation with a reputation for being awful.  (The internal medicine attending at my school with the nastiest rep had earned the charming nickname “The Screaming Teratoma,” which never fails to make me chuckle nostalgically when I remember her.)  It was a matter of course that on a semi-regular basis you could be made to look stupid if you rubbed the wrong resident or attending the wrong way.  You were expected to put up with it.  (I did not put up with the homophobic comment, but fat lot of good came from my complaining.)

All of this is my rather lengthy introduction to this piece about bullying culture in medical education:

For 30 years, medical educators have known that becoming a doctor requires more than an endless array of standardized exams, long hours on the wards and years spent in training. For many medical students, verbal and physical harassment and intimidation are part of the exhausting process, too.

It was a pediatrician, a pioneer in work with abused children, who first noted the problem. And early studies found that abuse of medical students was most pronounced in the third year of medical school, when students began working one on one or in small teams with senior physicians and residents in the hospital. The first surveys found that as many as 85 percent of students felt they had been abused during their third year. They described mistreatment that ranged from being yelled at and told they were “worthless” or “the stupidest medical student,” to being threatened with bad grades or a ruined career and even getting hit, pushed or made the target of a thrown medical tool.

Of course it was a pediatrician who first noted the problem.  Pediatricians are awesome.

The term for being made to feel stupid is “pimp,” which stands for put in my place.  The team rounds on the patients, and at some random point the attending singles you out and asks you how many of Ranson’s criteria the patient has, or to define Fitz-Hugh-Curtis syndrome.  (I selected those two examples because I could never remember the former, but totally nailed the latter this one deeply awesome time.)  It’s often done if you make the mistake of looking like you weren’t paying attention.  (When I’ve seen it done during teaching conferences at Children’s, it tends to be relatively good-natured and mainly when someone is foolish enough to glance at their iPhone.)  While I heard stories of thrown clipboards or pens, I never actually saw it.

Obviously this kind of malignant behavior is mean-spirited and pointless.  I was particularly troubled to read how pervasive actual physical menace apparently is, and it’s vaguely horrifying to consider that our finest institutes of medical education cannot either stamp it out or create an environment wherein students feel confident enough the report it and expect an appropriate response.  And it was also discouraging but not entirely surprising to read that the efforts at the medical school at UCLA to mitigate the problem were not particularly successful.

To be honest, I’ve given far more thought to the brutal grind of the long hours worked during residency than to the casual and accepted psychological bullying (or worse, it seems) that pervades medical education.  (Members of other professions and vocations should chime in with their own experiences if it’s not just medical schools that have this problem.)  One very positive change I’ve seen as a medical provider is that nurses are far more likely to stand up to aggressive and inappropriate doctors, so it’s not like the culture within the medical realm is totally impervious to change if it’s demanded strongly enough.  But seeing how easily I just accepted it, along with my classmates, makes me think it’s tacitly accepted by the majority of doctors as just something to live with until you’re done, and nothing will change before that attitude does.

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.

23 Comments

  1. So common was the phenomenon of being yelled at by surgeons that the authors felt compelled to include a little guide to the experience in the textbook.

    What did the guide say?

    I’ll ask Clancy. She’s never mentioned anything of the sort, and the school really wanted her to stick around for residency so may have been particularly nice to her.

    Among the worst harassment she got in residency actually came from OB nurses. It was actually so bad that one of her colleagues dropped out of the OB portion of the residency immediately after getting the minimum required deliveries.

    • The single nastiest nurse I’ve ever encountered was when I was a medical student during my OB rotation.

      And my hazy recollection of the text is that is boiled down to “Um… so this kind of happens a lot, and you shouldn’t take it personally. Best to just let it slide, really.”

  2. Russell, I rather like the recent bent of your medical-related posts. Real change – as TVD, Mark T, and myself would all agree – is at root cultural. The most effective way for culture to change is when participants in that culture begin to question the assumed norms and practices. And this

    But seeing how easily I just accepted it, along with my classmates, makes me think it’s tacitly accepted by the majority of doctors as just something to live with until you’re done, and nothing will change before that attitude does.

    is a nice summary of how resistant culture is to changing ridiculous norms and customs that have little to no justification. Well, other than tradition, unchallenged convention wisdom, and preserving the advantages (sadistic, in this case) of privilege.

    • Well, there’s no denying that medicine is a culture, holding tightly to its norms as long as possible.

      I suspect the attitude that undergirds this kind of behavior is that it toughens students as they prepare for a career that can be very hard and heartbreaking. I happen to think that’s malarkey, and that creating a culture that supports providers if they are struggling with some aspect of their work would be a much more effective and humane approach, but I imagine that’s how the jerks justify themselves.

      • it might be more like “be pissed at me. direct your anger elsewhere, not at yourself. Develop a Spine. or at least, if you must, channel your rage.”

        … but I got that from a different field. may be less applicable to doctors than writers, who tend to get depressed at the drop of a hat.

  3. While present in medical school and residency — internal medicine — the degree of bullying was nothing of the routine psychic damage I experienced in graduate school. My PI was so bad he didn’t get tenure, even with a multimillion R 1 grant.

  4. surgeons have always seemed to either be genuinely nice guys or complete raving maniacs. like, jump-up-on-a-table-and-have-a-hissy-fit-in-the-middle-of-a-meeting-with-15-other-people-watching-style maniacs. (had i not seen this with my own two eyes, i would not have believed it)

      • if by drugs you mean the dept chair, then yes, he was on drugs.

        • seriously, that sounds like more than just “too much caffeine”…

    • Where I went to med school there was one surgeon who would throw scalpels and syringes with needles at residents while in the OR. The residents called this “getting harpooned.”

      • The residents called this “getting harpooned.”

        I think the legal system calls it “assault.”

        • he ended up losing privileges in all of the hospitals in the city and moved to the East coast. He was always nice to medical students.

  5. I wonder if one of the excuses for that behavior are patients?

    I mean let’s face it — just like cops tend to deal with criminals all day (not the nicest fellows), doctors and surgeons fill their days with talking to the sick. People who tend to not be at their best. Miserable, often in pain — enough to make even the best of humans a tad grumpy.

    Still don’t think it’s valid. Much better to simply hold classes on recognized methods of dealing with combative personalities, and give them experience with mock setups before letting them deal with patients — rather than have a superior be a combative jerkwad.

    • “I wonder if one of the excuses for that behavior are patients?”

      Maybe, but I thought one of the (quite probably false conventional wisdom) cliches of surgeons is that they don’t ‘deal’ with patients, they just deal with the problems – i.e. cutting them up like bags of meat.

      • That’s the stereotype. The truism for surgery is “a chance to cut is a chance to cure.”

        (For the record, the surgeon who took care of one of my close family members recently was really fantastic, and couldn’t have been more attentive and encouraging to us. And I have every expectation that the friends I had from medical school who went into surgery are much kinder than the stereotype would indicate.)

        • About half a year ago, I had my own bout with a hospital and doctors and worst of all hospital staff who were collectively behaving not very far from the emotionally disinterested stereotype towards a patient I care about deeply. Being treated like a piece of meat had a bad effect on the patient despite what seemed to be the right clinical decisions being made. I had to assume the role of the patient’s advocate, and play the “lawyer card” on behalf of the patient, before behavior improved. It worked out well in that particular case — but as bothered me then and still bothers me now, a patient ought not to need to have to associate a lawyer in order to be treated with dignity and respect.

          • Once upon a time, we had to see a doctor who had an absolutely dreadful personality (the guy actually seemed disappointed when it turned out there was no cancer). It was explained that he was not really a caregiver but more like a soldier, with cancer as his enemy. I guess if you have cancer that might not be a bad person to have on your side, but we were just kind of thinking “Well, it’s a good thing for him that he is legendarily good at his job…”

        • “(For the record, the surgeon who took care of one of my close family members recently was really fantastic, and couldn’t have been more attentive and encouraging to us. And I have every expectation that the friends I had from medical school who went into surgery are much kinder than the stereotype would indicate.)”

          My girlfriend had her gallbladder out a few months ago (non-emergency) and we found the surgeon–indeed, the whole staff–to be very nice and solicitous of our concerns. Granted, this is probably a result of her having good insurance, perhaps the luck of the draw, and also perhaps the fact that it’s a fairly common, routine, and more or less non-invasive type of surgery. Still, we appreciated everyone’s attitude.

  6. According to my parents, the pediatrician who treated my brother and me during the ’50s and ’60s had a terrible personality. But since he was competent, we stuck with him.

    Barbara

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