Scene I, in which I defend my profession

Our Scibling PhysioProf has launched the opening salvo in what may turn out to be a rather bloody flame war. In the interest of actually gaining something from this other than venting my own anger and frustration, I will beg your indulgence here as I explain why my colleague is so utterly misguided.

PhysioProf (hereafter referred to as “PP”) is a researcher at a medical school, and teaches medical students (no secrets here…I’m not outing anyone, just re-stating facts already in evidence). According to my sources who know such things, both PP, and his/her blog partner DrugMonkey, write excellent material on the process of grant writing and surviving scientific academia. I take that as a given, as it is far outside my expertise.

Where neither of them seems to have a clue is the world of clinical medicine.

PP, who we’ll focus on here, wrote about a horrible incident in which a surgeon essentially assaulted a patient (he put washable tattoos on her during surgery). I would be surprised if this were the first incident, as people who do these type of things tend to be repeat offenders. What led this particular surgeon to this inappropriate act is anyone’s guess, but I don’t see how this particular anecdote can be used to form gross generalizations.

Look, I’m an internist; internists and surgeons stereotypically hold each other in friendly contempt, which has created a whole genre of bad jokes. But at the end of the day, we are colleagues who work together to help people.

For every crappy-surgeon anecdote PP has, I have a dozen good ones. For example, during my surgery rotation in medical school, I worked with a surgeon who was a tyrant in the OR; for 2 months my name was “pull, goddamn you!”. But when talking with patients, well…

One day in his office he was doing a biopsy on an older woman. It was an office procedure done with a local anesthetic, but was still rather painful, and since it involved cancer, the patient was scared. As she stared to cry, the young medical student (me) reached out to grab her hand, but then pulled back, unsure of my boundaries. The surgeon said, “NO! It is never wrong to hold a hand and comfort a patient. It’s the most important thing. Please continue so I can finish my biopsy.”

But anecdote wars can continue all day, so are rather pointless. More important are some of PP’s other points.

As someone who spends a substantial portion of his professional time teaching medical students, I can tell you that this kind of attitude-that physicians are gods, not mere mortals, and wield power over other human beings that no one dare question-is inculcated in them from the very beginning of medical training. It is an ugly secret of our medical training system. And the more prestigious the institutions where physicians receive their training, the more overweening is this attitude.

Now admittedly, I haven’t been affiliated with every medical school in the country, but I’ve been doing this a while. I have known arrogant medical students, but I have never seen a systematic inculcation of arrogance and omniscience in medical schools or hospitals. Never. There is no dirty secret. Some doctors are unpleasant, but most are not. In fact, medicine generally attracts people with good communication and interpersonal skills, as that is what they will likely be using for the rest of their careers.

More important, as a professor at a medical school, PP has the opportunity to affect medical students, both positively and negatively. Just because physiology is not generally a clinical class does not mean that lessons about humanity cannot be taught in the way you interact with your colleagues and students. Many of my pre-clinical med school instructors were huge influences on me.

And that brings me to the most important point. PP and the rest of us have the ability to influence young doctors, but that influence does not have to be positive. You can choose to treat them as arrogant pricks who are using you for your knowledge, thereby creating the very behavior you loathe.

If a physioprof at a medical school can’t see the opportunities for real teaching, including the human interaction, and can’t see his or her students as people, rather than med students, perhaps they should spend more time in the lab, and less in the classroom.

Comments

  1. #1 Joe Fredette
    July 24, 2008

    If I may ask- what exactly is meant by “washable” tattoo? Do you mean a non-permanent tattoo, if so, is there ever any reason to even have such a thing? I’m certainly not a doctor or surgeon, but it seems that such a thing would be a bad idea, given that they are probably not very clean things. Maybe I’m being naive.

    It certainly seems plausible that this PP guy is just overgeneralizing, I hope though- that this doesn’t turn out to be a flame war- given that flame wars are generally pointless wastes of time. Much more productive to just get back to doing science or helping patients or students or whatever.

    Maybe I’m just an optimist.

  2. #2 PalMD
    July 24, 2008

    The point is NOT that the tattoo is one of those kinds of things that kids use…it was reportedly a rose…there is no reason to do this that puts the surgeon in a kind light.

    edited to correct typo

  3. #3 Annie
    July 24, 2008

    It was rather unfortunate that PP painted with such a large roller. I commented (#15) on the Feministe post about future self advocacy and the role, especially, of the circulating nurse, during surgical procedures involving the OR and anesthesia.

    Surgery is a team sport, and while the surgeon is the captain, all members of the team are accountable for the patient’s safety and well-being.

    Just as with all professions, members range in behavior and ethics from stellar to stinking, and surgeons are no exception. For stellar, a case in point is to visit Surgeonsblog, written by Sidney Schwab who’s on a blogging hiatus.

  4. #4 Anonymous
    July 24, 2008

    Look, I’m an internist; internists and surgeons stereotypically hold each other in friendly contempt, which has created a whole genre of bad jokes.

    I remember that episode of “Scrubs.”

  5. #5 Barn Owl
    July 24, 2008

    First I’ll say that the surgeon’s self-appointed tattoo artistry was totally inappropriate, unethical, and inexcusable. I think we all agree on that point.

    However, my experiences teaching and interacting with medical students are very different from PP’s. Unlike him or her, I am not a big R01-swinging PI at a “very prestigious private medical school”. My research is funded primarily through collaborations with others, I spend most (70-80%) of my time teaching, and I’m at a very middle-tier state medical school. I have well over 100 contact hours each year with medical students alone, not including help sessions, office hours, student-related committees (admissions, curriculum), grading, or lecture prep time. “Contact hours” means gross anatomy or neuroanatomy lab to me. I have never seen nor heard of any systematic, or indeed random, inculcation of arrogance applied to medical students by any of my teaching colleagues here, whether in clinical or basic sciences. Quite the opposite, in fact.

    One of the things that I discovered from talking with collaborators who *are* big R01-swinging PIs at very prestigious private medical schools is that their medical student classes are not very diverse. Not at all diverse, in fact. Predominantly male, socioeconomically privileged, predominantly white, undergrad degrees from expensive private universities, no MCAT scores below the mid-30s, no GPAs below 3.6 … why would anyone be surprised by the sense of entitlement with which such individuals enter medical school? Jeebus, I can just imagine it – an entire entering medical school class full of arrogant gunners. :-P

  6. #6 PalMD
    July 24, 2008

    Medical students in the U.S. are slightly majority female.

    For example, one prestigious medical school in 04 admitted 59% women. There is plenty of gender disparity in academic medicine, but not usually at the level of medical school admission.

  7. #7 Kevin
    July 24, 2008

    Joe: I’m certainly not a doctor or surgeon, but it seems that such a thing would be a bad idea, given that they are probably not very clean things.

    My kids do these at the fair. It is about as “unclean” as drawing on your skin with a pencil. Goes on in about 10 seconds with a little water to make it stick. Washes off with water, and even when kept dry rubs off in a few days.

    -kevin

  8. #8 Barn Owl
    July 24, 2008

    Yes, the list I saw of medical schools that admit at least 50% female students included several private medical schools (e.g. Stanford and Baylor), but most were state system medical schools. And gender is only one aspect of diversity, obviously, and certainly not one you’d consider when evaluating an applicant’s experiences working with diverse groups of individuals.

  9. #9 PalMD
    July 24, 2008

    Impermanence is irrelevant. Doing something nonmedical and unnecessary to someone is horrid.

  10. #10 Bill
    July 24, 2008

    Pal wrote: “The point is that the tattoo is one of those kinds of things that kids use…it was reportedly a rose…there is no reason to do this that puts the surgeon in a kind light.”

    I know of a transplant surgeon that has a tendency to cut a S-shaped incision that is supposed to be representative of his first name initial. I think there is a legitimate reason for it, but I really don’t know. Maybe he just gets his kicks signing his work. I would be more concerned with what he did after the incision.

    Now, for this incident, was it a successful surgery? Did the person have complications? I think most people might get a chuckle rather than get upset. I would think it was humorous. (Of course, it depends on where it was placed.)

    Also, since this is an anecdote passed down through several hands by now, are we sure that it wasn’t a marker? Rather than mark a limb or a particular body part with a ballpoint pen or a sharpie, did he maybe use a temp. tattoo to verify the proper surgical site?

    Anyone that gets pissed off about a harmless act like this just doesn’t have enough to worry about. They were looking for something to get pissed about to begin with.

  11. #11 Matt Hussein Platte
    July 24, 2008

    Concern trolling, perhaps: After almost 20 years of getting stars and stickers, checkmarks and comments on school reports, I could easily accept the explanation that it’s just another “gold star” — for a good patient in this case. I know that every time I went to the hospital when I was a kid I got some kind of prize or treat to take home with my aching immunization site or my heavy new cast or whatever. Had I been able to go home with a washable pirate tattoo, well….

  12. #12 PalMD
    July 24, 2008

    ARGHHHHH!!!!!

    IT IS NEVER OK TO DO THIS TO A PATIENT. THAT IS NOT THE POINT OF THIS POST!!!11!!

  13. #13 Anonymous
    July 24, 2008

    During my father’s final illness this winter, I dealt with many physicians, from his GP to interns, residents, and faculty at a major teaching hospital. Only one of them was at all arrogant or imperious, and in his case I think it was personality and an approach that focused on the tumor, not the patient. My impression was that the younger physicians were more interested in the patient as a person than those in their 50s and 60s. The ER physician who admitted him after his last crisis and the residents who cared for him in his last day were amazingly competent and compassionate. (They were all women, for what it’s worth.)

    The plural of anecdote is not data, but it sounds like the surgeon in question was in the minority. It is a pretty creepy thing to do, but it’s hardly the basis for a broad generalization.

  14. #14 Anonymous
    July 24, 2008

    Whoops, TypeKey is confused. My post (7/24 @ 10:14 p.m.) was not meant to be anonymous. If TypeKey still doesn’t identify me, follow the link to find out who I am!

  15. #15 Jeb, FCD
    July 24, 2008

    They may not inculcate the god complex, but they don’t discourage it either. And it’s not medical school. It starts in pre-med. Most of those who make it to med school see it as an affirmation.

  16. #16 CSP
    July 24, 2008

    “PhysioProf” has no illusions about this incident having sprung from the way medical students are treated by faculty. He plainly has a hard-on for medical doctors and is using a reprehensible but isolated incident as a springboard to take cheap shots at MDs, no different than someone pointing at physiology professors who have slept with their students and shouting that the whole doctoral candidate-advisor dynamic foments such abuses of power. This tactic is, in a word, horseshit.

    This is spot on:

    You can choose to treat them as arrogant pricks who are using you for your knowledge, thereby creating the very behavior you loathe.

    When I was in medical school, I had an audiologist for two or three lectures (and thankfully no more than that). This man, for whatever reason, couldn’t get enough digs in at doctors, taking every opportunity to emphasize how little most of them knew about the use of an otoscope or the human ear in general. Most of us could barely contain our eye-rolling and guffawing, and I’m sure this led the guy to hate docs even more.

    The bottom line is that some people are, regardless of the amount of knowledge they bring to the table, simply ill-suited for interacting with human beings.

  17. #17 MarkH
    July 25, 2008

    The issue with the temporary tattoo was that it was in an inappropriate place (below the pantyline) and since it was a rose, you have to kind of wonder what kind of creep thinks such a thing was funny.

    There is little question it was an egregious breach of doctor-patient boundaries. If these are indeed the facts of the case he will be punished. I don’t think any of the MD-types here disagree with that, which is what makes PP’s post so stupid. He’s just painting all doctors with the actions of a single creep. I don’t think all PhD’s are shits just because PP is.

  18. #18 Nico
    July 25, 2008

    Augh. So inappropriate, temporary or not. I’d have gone batshit with rage. ( the very idea is creepy as it is.) When you go under anesthesia, you’re trusting people with your zonked meat body to not do pranks reminiscent of a drunken student at a frat house.

    However, I wouldn’t presume it to be a standard symptom of the surgeons as a whole, across the land, but of one surgeon who needs to be smacked a few times with Clue by Four of Appropriateness.

    C

  19. #19 Skeptico
    July 25, 2008

    If you ask me, PP seems to be the one with the God complex, going by his writing style.

  20. #20 Joe Fredette
    July 25, 2008

    With minimal fear of overstating my influence, it seems that my question may have triggered a similar set of questions which are obviously false, applying anything to a patient w/o consent is obviously unethical. I was more trying to ask whether or not those kind of tattoos are used for some kind of real purpose, I could imagine such a use as putting one on to remind the person to– I don’t know, not scratch the stitches, even if they really really itch. From what I understand, this is not that kind of case- It’s obvious that putting a marking of any kind on any part of the body that you aren’t supposed to be near is completely unethical, you’re not there to admire or toy with the patient, you’re there to fix the machine.

    At least- that was my impression.

    /joe

  21. #21 PhysioProf
    July 25, 2008

    I care very deeply for my medical students, and spend a lot of time and effort on effective teaching. I also have great affection for them, and wish them only the best in their future medical careers. It is unfortunate that you have failed to recognize that pointing out a weakness in the medical profession and its system of training is wholly consistent with this.

    The unhinged responses I have received from physician/surgeons to my pointed criticism is, perhaps, relevant to the question at hand.

  22. #22 Erik
    July 25, 2008

    PhysioProf,

    I honestly can’t think of any other way to characterize what you wrote than as an unjustified rant and a severely myopic stereotype (if not outright bigoted) indictment of all physicians. Your brush was entirely too broad. Not only the substance but also the tone of your piece was downright insulting to the vast majority of physicians who would undoubtedly find the behavior of the surgeon in question AT LEAST as offensive as you do. Of course you are taking some flames over it. If you can’t understand why that is then you, too, must suffer from the sort of poor interpersonal skills that result in an inability to form empathic relationships with others that likely is part of the personality of the surgeon in the incident. Perhaps this is why you have such a poor opinion of your students: reflection is a real interpersonal dynamic.

    But let me give you the benefit of the doubt. If indeed you are the sort of professor that desires to help medical students to retain and even enhance their sense of humanity through the grueling medical training process, and the invective in your original post was merely a byproduct of your great disgust for the entirely unethical behavior of this particular surgeon that you let your emotion overwhelm you, and the students you interact with are actually a bunch of nascent narcissists likely to treat patients poorly, and the other professors are enablers or instigators of such behavior, perhaps you should consider affiliating with a different medical school that better embodies the philosophies you would see inculcated in your students. If your CV and energy for teaching is as impressive as you make it out to be surely there would be any number of prestigious schools that would be excited to have you on the faculty. Or consider a less prestigious school, or an Osteopathic school. Perhaps those students would not have the sense of entitlement that you find with your current elite students. I seriously think you should consider these options. The amount of stress your students seem to engender in you can’t make for a healthy or satisfying work environment. You might be pleasantly surprised by a move.

  23. #23 Martin
    July 25, 2008

    Oh what a shock, that’s three blogs now that PP has copy-pasted the same comment to. So here’s my reply again:

    @PhysioProf: Don’t play the innocent victim. You made a statement calculated to get peoples’ backs up, and now you’re complaining that the responses are “unhinged”?

    If I published a post on my blog saying that, “given the way firemen are trained to believe they are gods who function on a practical and ethical plane that is above mere mortals, this kind of shit doesn’t surprise me one bit”, then I would be pilloried for it, and rightly so.

    And don’t pretend that you were “pointing out a weakness”. If you were genuinely interested in doing that you would have published a much more considered, contemplative post, looking at whether incidents like the above were common place, and talking about the case for perhaps improving training. That would have been constructive… but given this and some of the other incidents I’ve see on your blog, somehow I get the impression constructive isn’t your strong point.

    Nothing annoys me more than people who flame a whole bunch of people, then whine when they exercise their right to be pissed off.

  24. #24 "GrrlScientist"
    July 25, 2008

    anyone who finds inappropriate markings on their body after a surgery has been assaulted and has every right to pursue legal action against the perpetrator, and indeed, should do so. such markings represent a clear and flagrant violation of a patient’s trust when that person was absolutely vulnerable to whatever abuses the surgeon and his team decided to indulge in. further, just as the kid who tortures flies by pulling their wings off, who knows to what levels such bad behavior will escalate to?

  25. #25 PalMD
    July 25, 2008

    this kind of violence is an indicator of possible escalation to worse, I would certainly agree. I put out another post to clarify for folks, given that some commenters don’t seem to understand the gravity of this violation.

  26. #26 CSP
    July 25, 2008

    One thing I’m not seeing pointed out is that PhysioProf’s using this tattooing thing as an excuse to spit on the way doctors are educated is a complete non sequitur. Even if medical students were encouraged to be arrogant as hell, this wouldn’t lead to behavior like this orthopod’s in people without pe-existing personality problems, and every profession has these.

    PhysioProf was merely being the blogging equivalent of an opportunistic infection, using a story he knew would piss a lot of people off (who wouldn’t find the tattoo thing unnerving?) as a cloddish means of kicking and thrashing away at something entirely unrelated, tweaks his balls even more, and also resonates with everyday folk (Who hasn’t met a doctor who seemed incompetent or uncaring?).

    As for his claim that some of the responses from people within the profession to his over-the-top raving were “unhinged,” I bring you this:

    Where the fuck do you get the cockamamie idea that this has anything whatsoever to do with ‘sexual appeal’? The entire fucking idea is that physicians/surgeons should just do their ‘job’, ‘nothing more’, and – like every other member of society – refrain from committing battery.

    What scares people is that sick motherfuckers like you see the world through the lens of a depraved ‘excite/bore’ dichotomy. Nice projection of your sick-fuck sexualized perversions on the rest of humanity, though.

    This is how he responded to a measured commenter who disagreed with him. Sound like someone capable of engaging in serious student-teacher, or for that matter colleague-colleague, dialogue?

    PhysioProf a hypocrite, an asshole for the sake of being one, and not worth taking the east bit seriously, and got exactly what he hoped for in doing what he did. And in trying to defend him, his blog-buddy looks like the Pope trying to “clarify” the “harmony” between Church doctrine and evolution. Fortunately, their blog makes their self-parodic, ignorant, bad-attempt-at-Carlinesque oratory clear within a few sentences of any given post, so sensible people never need to waver when it comes to bookmarking decisions.

  27. #27 --bill
    July 25, 2008

    one thing that i’m curious about–this surgeon, he puts the tattoo on this woman while she’s still under…didn’t anybody else see him doing this? Aren’t OR’s full of other people? At least the anaesthologist?
    And no one reported him; the patient had to do it.
    No one in that operating room thought this tattoo was a problem, or, at least, no one in that operating room thought this was enough of a problem to actually report it.

  28. #28 Barn Owl
    July 25, 2008

    If you can’t understand why that is then you, too, must suffer from the sort of poor interpersonal skills that result in an inability to form empathic relationships with others that likely is part of the personality of the surgeon in the incident.

    There are PhDs at very prestigious medical schools who have poor interpersonal skills? Get OUT!!11!!

    Next you’ll expect me to believe that there are science bloggers who are attention whores. Oh NOES!!11!

  29. #29 RBH
    July 25, 2008

    My all-time favorite GP, now regrettably retired, had a plaque on his desk that read “M.D. does not stand for Minor Deity.”

  30. #30 PalMD
    July 25, 2008

    Minor???? Puh-leez!

  31. #31 MarkH
    July 27, 2008

    @–bill
    I concur, as I commented over on Chris’ post on the subject the OR is a hard place to do something privately. There are always at least 4 people present. Surgeon, scrub nurse, circulating nurse, anesthesiologist. Additionally there are frequently medical students, PAs, other doctors, various technicians etc. This was a failure of multiple levels of control. Granted, the surgeon is the boss of the room and ultimately responsible for everything that happens. And it is difficult and risky to criticize a superior. But if I had witnessed such foolishness I would like to think I would have found a way to put a stop to it. This was a failure of several humans to exercise good judgment and protect this woman’s trust.

  32. #32 James Stein
    July 28, 2008

    The one thing I haven’t heard about at all in this fracas is “where was the rest of the OR team?” I know surgeons are head honchos in the OR but weren’t there at least a half-dozen other people in the room when this occured? Why are we not condemning the nurses, anesthesiologists, PAs, et al.?

    No, this has nothing to do with just spewing vitriol at surgeons, reallllly.

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