0:02

This is Thinking About OB-GYN

0:04

with your hosts Antonia Roberts

0:06

and Howard Harrell .

0:17

Antonia .

0:18

Howard .

0:19

What are we thinking about on today's episode ?

0:21

Well , we're going to talk about mistreatment

0:24

of residents and medical students and

0:26

about its consequences , and

0:28

we'll also try to answer a listener

0:30

question that we didn't get to in the last

0:32

episode . But first we've got four

0:34

tips for the management of uterine

0:36

inversion . So this is a very

0:38

rare but scary obstetric emergency

0:41

where the fundus of the uterus

0:43

inverts inside out

0:45

, often during attempts

0:47

to deliver the placenta , or perhaps

0:50

right after the placenta delivers , and

0:52

it just it's exactly how it

0:54

sounds it inverts into the cavity

0:56

of the uterus and maybe

0:58

all the way out through the cervix and even past

1:01

the introitus , completely inside

1:03

out . This can happen outside

1:06

of that immediate placental delivery setting

1:08

, it can happen later , but most

1:10

of the time , if it's going to happen , it happens right

1:13

then and there , during the third stage of labor , and

1:15

the incidence is about one in every

1:18

3,500 births .

1:20

Yes , it can be very scary because significant

1:23

postpartum hemorrhage can occur , as the

1:25

uterus may not be able to contract down

1:27

correctly when it's turned inside out . So

1:29

there's a fairly high rate of blood transfusion

1:31

and shock and emergency surgery

1:34

even associated when a uterine inversion occurs

1:36

, and then , of course , a significantly higher

1:38

risk of maternal death that goes along with all

1:40

those things .

1:41

Okay , so we have four tips for management

1:43

of acute uterine inversion and

1:46

, like in a lot of other four

1:48

tips and emergencies that we've discussed

1:50

before , the first tip is prevention

1:53

.

1:53

Yeah , it's always easier to not have an emergency

1:55

than to deal with an emergency . So , understanding

1:58

what we can do to prevent uterine inversion

2:00

, or what we might do that causes

2:02

it , and avoid those things , well , that's difficult

2:05

because it's still a relatively rare condition

2:07

. So it's hard to study this and

2:09

hard to control for many confounding factors

2:11

. One obvious risk factor , and maybe

2:14

the greatest risk factor that we know

2:16

of , is abnormal placentation , and

2:18

there's nothing we can specifically do about that

2:20

, except perhaps have an awareness that

2:22

if the third stage of labor is prolonged

2:25

, then you should consider that the placenta

2:27

might be inappropriately attached , and

2:29

I'm fond of having an ultrasound at the

2:31

bedside whenever I have a prolonged

2:33

third stage of labor so that I can see

2:35

what I'm doing and just understand where

2:37

the placenta is located . But risk factors

2:39

that we have the most control over include

2:42

how we manage the third stage of labor . One

2:44

management decision that's often criticized

2:47

is umbilical cord traction in

2:49

terms of are we pulling it out and causing

2:51

the inversion ? But newer studies really don't

2:53

show that this is associated with

2:55

an increased risk of uterine inversion . The cord

2:57

may break if you have excessive traction

3:00

, but you're not likely to increase the risk of uterine

3:02

inversion . So a couple of things that still remain

3:05

as risk factors that we might be able to

3:07

control is manual extraction of

3:09

the placenta . If this is done , perhaps

3:11

it indicates that there is some abnormal

3:13

placentation and therefore the risk was

3:15

increased anyway , but it also just

3:17

might be born out of impatience . So don't

3:19

do manual extraction unless you really need to

3:21

, and then be prepared for uterine inversion

3:24

as a possible consequence . But the

3:26

one technique we can probably do without is

3:28

putting a hand on top of the uterus and massaging

3:30

the uterus before the placenta is delivered

3:33

, or even really just having the mother

3:35

bear down with delivery of the placenta

3:37

. We don't need to increase the pressure

3:39

on the top of the fundus , either with

3:41

our hand or with that maternal

3:43

valsalva effort , while we're at the

3:45

same time pulling down on the placenta . So

3:48

that's the one thing that probably really shouldn't

3:50

occur in modern obstetrics .

3:52

Yeah , I've been in a lot of deliveries

3:54

where somebody whether it's a nurse

3:57

or my senior colleague

3:59

or junior colleague asks the mother

4:01

to push while we're

4:03

waiting on the placenta , and sometimes the patients

4:06

themselves will either just

4:08

start pushing or they'll ask like , are you

4:10

ready for me to push for

4:12

this part yet ? But the

4:14

maternal valsalva efforts are

4:17

not contributing to the placenta separating

4:19

from the uterus , and neither is

4:21

the cord traction , by the way , and

4:23

the maternal valsalva really isn't

4:26

doing much after the placenta is separated

4:28

to expel the placenta out

4:30

through the vagina . That's the part

4:32

that the cord traction works on

4:34

, just so it's not sitting there

4:36

in the birth canal . What's getting the placenta

4:39

to separate is the uterus contracting

4:41

and the placenta not being

4:43

morbidly adherent . So

4:46

it is at least theoretically possible

4:48

, if you think about the physics of it , that if

4:51

the mother is pushing really hard , her

4:54

intra-abdominal pressure could push down

4:56

on that big floppy

4:58

part of the fundus inwards into

5:01

the cavity and invert it . And

5:03

you can also do that unwittingly

5:05

yourself if your hand is up at the fundus

5:07

and you're pushing , pushing downwards as the placenta

5:09

is coming out . I've visually seen

5:11

this once during a cesarean

5:14

, but at least at that

5:16

time we were able to see it and immediately flip

5:18

it back . But it was pretty clear

5:20

how , before the placenta comes out , sometimes that

5:22

uterus is floppy and it can easily turn

5:24

inside out like a little sock . So don't

5:26

get tricked into doing that , because

5:29

you might really regret it . So , okay , we're

5:31

going to summarize the additional

5:33

tips for actually managing it

5:35

. But obviously the first step is

5:37

prevent it by not doing

5:39

things that will cause the uterus to flip

5:41

inside out . But let's say that it has anyway

5:44

. Maybe the mom pushed even

5:46

when you didn't ask her to , or maybe

5:48

you know , maybe the placenta is stuck and

5:51

now it's inside out . So the

5:53

next tip is you have this inverted

5:55

uterus , the placenta is stuck . Do not

5:57

try to remove the placenta

5:59

.

6:00

Right , at least not immediately . So your best

6:02

opportunity to restore the fundus

6:04

and revert the uterus is as soon

6:07

as you see that this is happening and if you remove

6:09

the placenta that's still attached . But also

6:11

, during this time , prepare

6:13

for the emergency . So

6:25

start a second IV , request a type and

6:27

cross or even unmatched blood

6:29

if that's what you need . Get fluid boluses

6:32

started , call for help , get an OR team

6:34

, call for an anesthesiologist while

6:36

you're attempting to replace the fundus . Now

6:38

it may be that you can't replace

6:40

it because of the size of the placenta and

6:42

that's why it's tempting to people to take it off . And

6:44

if you're going to try to take it off and replace

6:47

the fundus after you've removed it , that's

6:49

fine . But take advantage of the time

6:51

that the placenta is still attached to

6:53

prepare for this impending emergency

6:55

if you don't get it back in .

6:57

Right , you can wait to

6:59

remove the placenta . Remember that there's

7:01

some cases , there's some case theories

7:04

where with placenta accreta , they

7:06

actually successfully just never remove

7:08

it . They just leave it there and of course there's

7:10

morbidities and stuff with that . But it's

7:12

not an emergency to leave the placenta on

7:15

if it's not coming off . So , either

7:17

way , the first thing you're trying to do is

7:19

replace the uterus , re

7:21

, flip it back back to right

7:24

side out , and while

7:26

you're doing this , you're getting a second IV

7:28

and everything available you need . So

7:31

the third tip is , while

7:34

you're doing this , you are probably going to need to use

7:36

a uterine relaxant .

7:38

Right , you don't have to do this with your first

7:40

attempt and obviously you can ask for this

7:42

while you're attempting . But you can

7:44

give the patient 100 micrograms of nitroglycerin

7:47

to relax the muscle of the uterus and

7:49

this may significantly help your efforts . Remember

7:51

that also for Zavanelli's . We talked about that before

7:54

in our emergencies episodes . But

7:56

be prepared for the fact that now the uterus is going

7:58

to be relaxed when you get it replaced

8:00

and you may have subsequent hemorrhage . So

8:02

using something like a Bakri balloon afterwards

8:05

or our acne protocols may

8:07

become very necessary . So you want those things ready

8:09

too .

8:10

Yeah , so essentially you're going to hold

8:12

the inverted fundus in your hand

8:14

and you can use

8:16

your fingers to try to dilate the cervix

8:19

and the lower uterine segment in

8:21

order to accommodate the fundus

8:23

, push it back with as

8:25

much of your hand as you can and hold it back

8:28

up in the pelvis and if you can successfully

8:30

un-invert it or revert it

8:32

, then you probably want to keep

8:34

your hand in there for at least a few

8:36

minutes , firstly to help squeeze

8:39

the uterus with a bimanual while the other

8:41

uterotonics are working , and also

8:43

just in case you need a Bacri

8:46

. You have your hand already there and you

8:48

can start feeding it in a Bacri or I don't

8:50

know if places are . Some places

8:52

are already using Jada's now , but you know

8:54

some kind of device and doubtful

8:57

that the uterus would re-invert

8:59

, but if your hand's there , then you

9:01

can . You know you can catch it .

9:03

It might if you take your fist off and immediately start

9:05

doing fundal massage to try to yeah , yeah

9:07

exactly .

9:08

Yeah , OK . The fourth tip is

9:11

prepare for operative interventions

9:13

.

9:14

Right . So if you've done all those things and

9:16

you still don't have it corrected

9:18

, then you may need to do surgery , and we don't have

9:20

to describe all those techniques right now . But

9:23

I think the important part is that early on

9:25

you're preparing for that . So

9:27

you have to call up front

9:29

for an operating room to be made available

9:32

, call for anesthesia to come to the bedside you

9:34

may need them with your hemorrhage

9:36

efforts anyway and now if

9:38

you've not been able to get it at the bedside , you're going

9:40

to need to go to the operating room and prepare for surgical

9:42

intervention . So usually if you're not able

9:44

to restore the uterus , it's because of a contraction

9:47

of the cervical-uterine junction In

9:49

an unstable bleeding patient . In this situation

9:52

you want to make an abdominal incision , like

9:54

you would for a cesarean , and grab the fundus

9:56

with a pair of Alice clamps , pull the fundus

9:58

back up through this inverted tunnel

10:00

. That's what's called a Huntington

10:03

procedure . And

10:11

if the cervical vaginal junction is too constricted to allow you to do that , then you

10:13

can do a Haltane procedure , where you cut the constriction band with a vertical incision , usually

10:15

on the posterior side , to avoid the bladder , and then pull

10:17

it up through .

10:18

Like all emergencies , early recognition and a

10:20

team approach is going to be key

10:23

. So if you have an acute uterine

10:25

inversion , do not feel bad for calling

10:27

for all these things that you anticipate

10:29

you could need in the worst case scenario . Even

10:32

if then , 20 seconds later , you reverted

10:34

it and everything is fine and you can

10:36

call them all off , that is a good outcome

10:39

. No one should be upset with you for making

10:41

that call only to have them turn back

10:43

around and walk away . That is so much

10:45

better than the opposite , where you're

10:47

afraid to call . You actually need them

10:49

. The mom's about to go into shock and you still

10:51

haven't even called .

10:53

Yeah , absolutely .

10:54

Yeah , better to call up front and remember , if

10:56

she's like really pouring out blood

10:58

, someone can hold

11:01

pressure against the aorta . You can actually

11:03

push back through just

11:05

the abdominal wall and if a patient's

11:08

open then you

11:10

can even call in a surgeon

11:12

to cross clamp it if you're in

11:14

that bad of a spot .

11:15

Yeah , better to be prepared and not need

11:17

things than the opposite , for sure

11:19

. So well , folks should definitely read about

11:21

these surgical procedures and look at pictures

11:23

and understand how to do them before they might

11:26

ever need to in real life . This is another

11:28

type of emergency where simulation

11:30

can be very beneficial . It doesn't mean that you

11:33

have to simulate the actual procedures and

11:35

need some fancy mannequins or anything

11:37

, but simulating the readiness

11:39

and preparedness of your team is useful

11:41

. Preparedness

11:45

of your team is useful . For example , you might find that if you do an in situ simulation , that no one

11:47

knows where the nitroglycerin is or where the dose is , or how it's administered

11:49

or just things like that . So in situ

11:52

simulation can help prepare for some

11:54

of these rare emergencies .

11:56

Yeah , I've found it's always nice to

11:58

have a run through of how long does it take someone

12:00

to get to the blood bank and back , for the emergency

12:02

release is usually that needs

12:04

a little polishing . Anyway , let's

12:07

move on to our topic .

12:09

Well , this is the last episode

12:11

of this season and our

12:13

, I think , 91st episode overall .

12:15

And we're going right into another season , just

12:17

in case anyone's worried . But

12:19

that's pretty exciting . So at this point it

12:22

would take someone about four days of

12:24

like straight listening to the podcast

12:26

and nothing else to get through all our episodes

12:29

.

12:29

Well , this episode comes out on

12:31

Wednesday June 26 . So if there

12:34

are any new interns out there who start residency

12:36

on Monday July 1st , well , you

12:38

have exactly four days in between to

12:40

listen to every episode and be ready for

12:42

work bright and early Monday morning .

12:44

four days in between to listen to every episode and be ready for work bright and

12:46

early Monday morning Perfect timing . I think that would also prepare them for sleep

12:48

deprivation , because that would be four days

12:50

with no sleep and then going

12:53

straight into work on Monday morning , first

12:55

day on the new job .

12:56

Okay , so maybe they don't have time to listen to every episode

12:59

with the new work hour restrictions

13:01

and all , but they could still get through two

13:03

thirds of them , or they could listen to them at 150%

13:05

speed and have time for sleep , and

13:08

then , if they have any leftover , they can get

13:10

to those in the evenings after their work

13:12

is caught up .

13:13

Well , I think probably a less

13:16

fanatical idea

13:18

or less crazy idea would be to spend the

13:21

next four days in their happy place , get

13:24

lots of sunshine and fresh air . Definitely

13:26

be aware of our podcast . Maybe over the next four

13:29

years you'll have gotten through all our episodes

13:31

. That would be fine and you'll probably

13:33

want to like stand in front of the mirror

13:35

and practice your power poses and just

13:37

really psych yourself up . I know we're about

13:39

to go into a discussion about

13:41

this , so at a minimum , there's

13:43

going to be a lot of humbling experiences , but

13:46

even the first day intern is going

13:48

to be a hugely important role . It's

13:50

easy to joke that you think that you're nothing

13:52

and you're just a baby intern , but they're

13:54

all already really depending on you to

13:57

carry the team and any little

13:59

bit of enthusiasm , curiosity

14:01

and zeal you can bring is going to lift the

14:03

whole team up and it's going to be very

14:05

defining . So really get

14:07

excited , go into it positively

14:10

.

14:11

And everybody makes jokes about July

14:13

1st being the worst day to be in the hospital

14:15

, but actually it's one of the safest

14:17

all year .

14:18

Yeah .

14:19

The . There's a lot of attention , a lot of people

14:21

on their toes , a lot of people looking , a lot

14:23

of double checking , and so

14:25

I would have no problem being taken care

14:27

of by an intern on . July

14:30

1st in a hospital in the United States . Well

14:32

, speaking of new residents starting on

14:34

July 1st , there is a study

14:37

that was published in May in

14:39

JAMA Network Open Access that made

14:41

a few waves At least . This

14:43

was called sexual harassment , abuse

14:45

and discrimination in obstetrics and gynecology

14:48

a systematic review . So this was a review

14:50

of studies that had already been performed

14:52

and published , which included data

14:54

from nearly 9,000 participants

14:56

students , residents and also attendings and

14:58

fellows . They have data from both

15:00

trainees and , as I said

15:03

, those already out in practice . Some of the studies

15:05

were done with gynecologic

15:07

oncologists , but a lot of

15:09

it was from trainees . So some

15:11

of the highlights about 70%

15:13

of OB-GYN trainees

15:15

reported some harassment , which included

15:18

gender harassment , unwanted sexual

15:20

attention and sexual coercion . A

15:22

quarter of students on OB-GYN rotations

15:24

reported some mistreatment during their rotation

15:26

and about 30% of that came from physicians

15:29

, while smaller amounts came from other

15:31

trainees or operating room staff

15:33

or things like that .

15:35

Well , that's pretty terrible and disgusting

15:37

because of course , this

15:40

lifestyle , especially this training

15:42

, is already hard enough . Lifestyle

15:46

, especially this training , is already hard enough , even when everyone around

15:48

is behaving in the most appropriate collegial way possible . So

15:51

obviously those numbers should

15:53

they should be zero . This shouldn't be happening

15:55

at all and it's indefensible

15:57

. So I guess the only good thing I

15:59

can personally say is that I

16:02

had no idea it was this prevalent , because I really

16:04

hadn't encountered this myself in my career

16:06

, so maybe I've been blind to it being so

16:08

common . But yeah , in this

16:10

review , among the trainee responses

16:13

, only about a third reported

16:15

their harassment . But of

16:17

those , almost three

16:19

quarters of those that did report it reported

16:22

it to another trainee . So

16:24

that essentially means the vast majority

16:26

of harassment is going unreported

16:29

to anyone that would have the authority to do anything

16:31

about it . And 40%

16:33

of the trainees in these studies said they

16:36

didn't report because they feared retaliation

16:38

.

16:39

Well , when I read this article , one of the things that I thought

16:41

about at this time of year , as new

16:44

interns and residents and students are

16:46

starting their rotations , wasn't so much

16:48

the overt sexual harassment

16:50

or things like that , but some of the microaggressions

16:53

and bullying that accompanies

16:56

new students and new residents in particular . There's

16:58

this culture of hazing and bullying

17:01

that often accompanies new trainees

17:03

, and some of it's from other residents or

17:05

senior residents , some of it's from attendings

17:08

, some of it's from nursing staff and operating

17:10

room staff who are just establishing

17:12

their primacy over the new trainees

17:14

. But they do this through abuse

17:17

and things that don't quite rise to the

17:19

level , maybe , of reporting , and these sorts

17:21

of things have often been called microaggressions

17:23

, and they do also include some

17:25

data about that in the study as well .

17:28

Yeah , I think it's really informative . Like

17:30

it's good that they captured that as well

17:32

, because often it can be the

17:34

small things that add

17:37

up day to day and month

17:39

to month that can just crush someone's morale

17:42

, and it can be sometimes so small that maybe

17:44

the target even doubts themselves

17:46

about it . Like , did

17:49

that nurse really mean to upset

17:51

me and make me embarrassed , or am I just being

17:54

overly sensitive ? But usually if you're asking

17:56

yourself that me embarrassed or am I just being overly sensitive

17:58

? But usually if you're asking yourself that there usually was some kind of malice

18:00

underlying or at least some insensitivity

18:03

. So some of the microaggressions

18:05

they listed here are more

18:07

explicitly in terms of bias

18:09

, usually gender bias , and that

18:11

could include female physicians

18:14

being referred to as a nurse

18:16

by include

18:19

female physicians being referred to as a nurse by well , whether it's patients

18:21

or other medical professionals or that . This kind of stereotypical

18:24

being told to smile more , being

18:26

told to dress prettier , being told to act

18:28

more feminine , maybe being

18:30

criticized , either overtly or covertly

18:32

, about decisions with family

18:35

planning , taking off too much

18:37

time for maternity or child care or just

18:39

breastfeeding pumping

18:41

. In one study of 18

18:44

OBGYN trainees , 17

18:46

of them said they had been mistaken

18:49

for a non-position , and 16

18:51

of them said that they routinely apologized

18:53

in advance when asking for something from

18:56

either a surgical technician or a nurse . 15

18:58

of them said they routinely

19:00

had to make requests multiple times

19:03

because they would never be addressed

19:05

or acknowledged the first time they asked

19:07

for something , and most of

19:09

the offenders here were in

19:12

the OR setting surgical technicians or circulating

19:15

nurses . They also cited

19:17

a study where nearly half of OBGYN

19:19

clinicians reported burnout directly

19:21

related to these sorts of microaggressions

19:24

.

19:25

Yeah , it has to be frustrating to feel not respected

19:27

or not listened to in your role on

19:30

a daily basis and have to deal with that , and

19:32

it's also important to note that these sort of gendered

19:34

microaggressions although not

19:37

all of those are specifically gendered , but most of the studies

19:39

have been on that Well they're not limited , at

19:42

least in our specialty , to males mistreating

19:44

females , and that certainly was

19:46

likely the case many decades ago , but

19:48

most of these scrub techs and circulating nurses

19:50

referred to in these newer studies

19:53

were themselves female , treating female

19:55

trainees in a different way than they

19:57

might treat male trainees , and among male

19:59

trainees , though , they reported less

20:02

workplace discrimination than women did still

20:04

nearly 40% reported discrimination

20:07

, and most of this was gender discrimination

20:09

, which is a paradox of OBGYN

20:11

that doesn't really probably exist in other specialties

20:13

, perhaps because male trainees and male

20:15

physicians have now become the minority

20:17

in a field that's increasingly dominated

20:20

by females , but also obviously because

20:22

the patients are female , and

20:24

we've talked about gender bias before

20:26

on another episode and some data

20:28

about that , but just as a personal

20:31

commentary , I see many

20:33

females treat other women far

20:36

worse than I sometimes see males treat

20:38

women . That could be a bias , but

20:40

it seems true .

20:41

It seems like the overall tolerance

20:44

of discrimination and possibly the

20:46

flavor of it . Who does it target

20:48

the most or what

20:50

direction it flows in . It'll vary

20:53

widely by program and

20:55

I think it'll vary widely by the senior leadership

20:57

, and I think we all know it can go in

20:59

so many different ways and the power

21:01

differential really is the key factor there .

21:03

Right . A lot of these studies focus on abuse

21:06

that's clearly delineated along

21:08

gender or race or sexual orientation

21:10

lines something like that , which generally

21:12

are all supposed to have legal protections at this point

21:15

against such discrimination or mistreatment

21:17

. But the same power differentials

21:19

that would allow these

21:21

protections to be violated can also create

21:24

just malignant and toxic environments

21:26

where mistreatment and harassment runs

21:28

in the form of hazing and verbal abuse

21:30

and petty jokes and mobbing

21:33

of junior trainees or students . They did

21:35

cite literature about medical student

21:37

mistreatment and a quarter of medical students

21:39

reported occasional or frequent mistreatment

21:41

, including verbal abuse and coercion , mostly

21:44

coming from resident physicians . In another

21:46

study , three quarters of medical students reported

21:48

belittlement and a quarter reported

21:51

frank harassment by OB-GYN residents

21:53

, and compared to other clinical core rotations

21:56

, including general surgery , which we might think of

21:58

as a very intense and potentially

22:00

merciless environment , it was actually

22:02

OB-GYN that had the lowest professionalism

22:05

scores . In one older study , four

22:07

out of 16 medical students actually reported

22:09

physical abuse while on their OB-GYN clerkship

22:12

.

22:12

I just don't know what to say about that . I

22:15

keep being surprised

22:17

and shocked , I guess , by this whole

22:19

conversation so far . Who , what kind

22:21

of a preceptor is delivering

22:24

a baby and then turning around and hitting their students

22:26

like that's ?

22:28

And we don't know yeah , and we don't know the nature

22:30

of the physical .

22:31

Yeah , but yeah .

22:32

But I can imagine some things .

22:34

Yeah , that's just like child abuse

22:36

. Honestly , that's really cruel . But I

22:38

could imagine if that is happening and

22:41

then there's a student that has nerves

22:43

of steel enough to still want to go into

22:45

OBGYN despite being treated that

22:47

badly , they're going to become a resident

22:50

who maybe they still get belittled

22:52

and harassed and bullied by their seniors

22:54

for years and years until eventually

22:56

they're in the position of

22:58

power and they end up doing the same

23:00

thing to their students because that's all

23:02

they know . It's not even conscious anymore

23:04

, and so this whole thing creates a

23:06

vicious cycle that's negative for

23:08

education and for patient care and

23:11

a huge detractor from

23:13

someone good , someone

23:16

that we want being interested in

23:18

pursuing a career in OBGYN , when

23:20

that's the experience they see on

23:22

their core rotations .

23:24

They do also review literature about

23:26

potential interventions for

23:28

these types of behaviors and note from other

23:30

non-OBGYN literature that the rates of

23:32

harassment , in particular of surgical

23:34

trainees of any sort , are very high . In

23:36

fact , so-called academic bullying

23:38

was reported by 32% of general

23:40

surgery trainees , 25%

23:42

of OBGYN trainees and a little less in other

23:45

specialties . And then about a quarter

23:47

of OBGYN trainees also reported

23:49

sexual harassment and this was still

23:51

second to general surgery , which had the highest

23:53

rate of sexual harassment reporting . They

23:55

also found a high tolerance of things

23:57

like tantrums and swearing and humiliation

24:00

and just a cultural acceptance of

24:02

undermining trainees as some

24:04

sort of rite of passage .

24:06

Yeah , I'm pretty thankful that I really don't

24:08

relate to this at all . I

24:10

suppose I've seen and experienced

24:12

my fair share of being nervous presenting something

24:15

at Morning Report . That's probably the extent

24:17

of I don't know if I'd even call

24:19

that academic bullying . But I

24:21

think we we learn enough from

24:24

taking care of patients as a team and

24:26

then reading about or witnessing

24:28

or talking about the complications that we

24:31

want to make sure we minimize and that's it

24:33

. And I think the lessons I've learned most

24:35

strongly have all been in settings where you

24:37

know , maybe that maybe there was a complication , whether

24:40

it was in my hands or my

24:42

colleagues hands , but there was never any

24:44

finger pointing . There was just a really productive

24:47

analysis and discussion

24:50

and a kind of a commitment

24:52

to do better and not any kind

24:55

of name calling or this

24:57

was all your fault kind of thing . But

24:59

I wonder if that does happen to

25:01

someone in their training . Maybe

25:03

those doctors who have been academically

25:06

abused think that it made them

25:08

stronger because they survived it . Maybe

25:11

they think that it made them learn certain principles

25:14

well because they did learn it , even

25:17

though it was maybe even despite

25:19

being yelled at as they were learning that

25:21

stuff , and maybe they are comparing it to

25:23

this idea of military

25:25

boot camp or SEAL training or something

25:27

where the candidates are intentionally

25:30

and strategically torn down so they can

25:32

be built back up . But if that's

25:34

the case , I don't know that I'm really seeing the

25:36

whole intense building back up piece

25:38

in all of these studies .

25:41

Yeah , certainly among general surgery programs

25:43

. A lot of the large academic general

25:45

surgery programs around the country were really

25:47

developed with Korean War trauma

25:49

surgeons as their initial surgeons

25:51

and chairs in this modern age of intensive

25:54

care and surgery , and so a

25:56

lot of the surgery attendings came from

25:58

that . So that's what surgeons talk about . Is this legacy

26:01

of a militaristic kind of thing

26:03

? But that's not the world we live in anymore .

26:05

Yeah , yeah , specialties that

26:07

have high pressure environments , like OBGYN

26:10

general surgery and many , probably

26:12

many other surgical or intensive

26:14

care type environments

26:16

, will have their moments

26:18

where even the well-meaning and otherwise

26:20

very gentle and calm people

26:23

they can get tense and snap

26:25

if there's a life or death situation

26:27

and there's kind of chaos in the room . So

26:30

that can happen much more

26:32

so , obviously , with someone that already has

26:34

baseline anger management issues

26:37

. More so , obviously , with someone

26:39

that already has baseline anger management issues .

26:49

The high stakes environment probably does contribute in some way to this

26:51

kind of mistreatment that we're talking about , than it is

26:53

to address these other things that create

26:55

a toxic environment , like bullying

26:58

and hazing and undermining and demeaning

27:00

language or temper tantrums or verbal

27:02

abuse by physicians , particularly attending

27:05

physicians , who are probably in a stressful

27:07

situation when it occurs , but it's

27:09

just ignored and I think that's

27:11

more likely to be ignored than , frankly

27:14

, outright violations of policy

27:17

. That would include sexual harassment or using

27:19

a racial slur or something like that . Hazing

27:21

and abuse is what new med students

27:23

and new residents are getting ready

27:25

to potentially experience next week

27:27

in large numbers in

27:29

OB-GYN and other specialties , according to this new

27:32

data .

27:32

Yeah , I know that probably now doesn't feel like

27:34

such a great pep talk anymore

27:37

, but hopefully we're going to help

27:39

with awareness and help turn this

27:41

around a little bit . Keeps

27:43

happening down generations

27:45

because it's the children who were abused

27:48

that often grow up to

27:59

parent their own children in

28:01

a more abusive way because they

28:04

don't know what's not normal about it

28:06

. They think it's normal and expected

28:08

and it's just difficult to break

28:10

that cycle . And that certainly

28:12

does exist in surgery and OBGYN

28:15

residencies and probably many other

28:17

type of residencies as well . And

28:19

you might even hear people say things

28:22

like when I was an intern , we had to

28:24

do blah , blah , blah any kind of unpleasant

28:26

thing you can just insert there . And

28:28

interns these days they're soft

28:30

or no work ethic whatever because

28:33

they're not being subject to whatever

28:36

unpleasantries that older person

28:38

was subject to . But somehow there

28:40

is a disconnect there that they

28:42

were being mistreated and maybe

28:44

they shouldn't have had to do that unpleasant

28:47

thing that now they're basically bragging about

28:49

. And just because they

28:51

were mistreated , it doesn't mean that they

28:53

need to pass that mistreatment

28:56

on to others or hold it against others that they need to pass that mistreatment onto others or hold it against

28:58

others that now things are slightly

29:01

better . The only thing I can relate

29:03

to here now that I think about it is when

29:06

a lot of my attendings would talk about their

29:08

work hours that they used to have before the

29:11

ACGME restrictions came into

29:13

place . They were in place when I was

29:15

training . Maybe that qualifies

29:17

as maybe a systemic kind of mistreatment

29:19

in a way , but I remember

29:21

they seemed to have very little sympathy

29:23

for any of us being tired

29:25

after our 80 hour work weeks and

29:28

maybe even if we went a little over that on

29:30

one week and having average five

29:32

to six hours of sleep a night when

29:35

they would always want to bring up . I

29:37

used to work 120 hours each week and I

29:39

would just fall asleep on my drive home .

29:41

Yeah , it's like bragging about driving

29:43

drunk or something . Right , and it's a microaggression

29:46

to make you feel bad about being

29:48

alive in this era where we are

29:50

concerned about safety .

29:52

Yeah , yeah , but I'd say , other than

29:54

that there's occasional someone

29:56

being a little bit snippy or rude here and there , but

29:58

overall I think I

30:00

had a lot of really good role

30:02

models that I still try to emulate

30:04

that were actually very understanding

30:07

and patient and professional . Yeah , so

30:09

it is possible , it already is happening

30:12

. That is not that . That's

30:14

not 100% what

30:16

people are going to go into if they're already starting to

30:18

get scared about us talking .

30:20

It sounds like a lot of other programs should

30:22

be taking notes from your program and we'd

30:24

love to hear listeners' perspectives and

30:26

experiences on this good or bad , or ideas

30:29

about how to make it better or examples

30:31

or things like that and certainly this

30:34

data doesn't represent the majority of programs

30:36

or the majority of academic teachers

30:38

of OBGYN , and so those

30:40

good experiences need to be highlighted . I

30:42

also think this paper got a lot of flack because a

30:44

lot of people were in shock about this is not really

30:46

going on , and sometimes that's because it's not

30:49

at their program and sometimes it's because they just

30:51

have an unawareness of some of

30:53

the things that are happening and don't even view them

30:55

as bad because they don't have the perspective

30:57

of the student or the trainee . But

31:00

we've talked before about how male medical students

31:02

on OBGYN rotations will often

31:04

feel excluded and denied certain educational

31:06

opportunities because of their gender , and

31:08

the residents who are listening to all of our

31:11

episodes in the next four days will run across that one

31:13

at some point . I'm sure we also all have examples

31:15

of mistreatment from our own training and we

31:17

probably have all seen examples of where

31:19

perpetrators of that mistreatment went unpunished

31:22

or , if there were reports made

31:24

, the person who was victimized ends up being

31:26

victimized again because of the power

31:29

differential that exists . So my

31:31

turn for a story . When I was an OB-GYN

31:33

clerk which was not at my medical school

31:35

, by the way On the first or second

31:38

week of my eight-week rotation , I

31:40

was verbally abused and threatened

31:42

by a second-year male

31:44

OB-GYN resident who I just met minutes

31:46

before at 6 am , and this

31:48

happened in front of a chief resident and three

31:50

other residents during a

31:52

period where we were running through

31:55

the list of patients . Now , a lot of people who know me personally

31:57

have heard this story and I won't share all the

31:59

details here . But basically the

32:01

cause of the mistreatment was because

32:03

I had made a comment that not

32:05

all genital herpes is caused by

32:07

HSV-2 , and sometimes and

32:10

actually today now more often than not

32:12

is caused by HSV-1 . But this particular

32:15

resident believed that all cases of genital

32:17

herpes are indeed caused by HSV-2

32:19

. And then he proceeded to

32:22

reenact a scene from the first 15

32:24

minutes of Full Metal Jacket . If you've not seen it

32:26

, watch it . And none of the other people in the

32:28

room said anything during this sort

32:30

of two-minute tirade threatening

32:33

and really just horrible . And none

32:35

of them corrected him or stopped him in any

32:37

way and his abuse and harassment

32:39

continued . And it actually continued for

32:42

years after the rotation

32:44

. I heard stories . Apparently he thought

32:46

it was funny to treat medical students in that way

32:48

and he would tell jokes

32:50

about how he got the better of me , I

32:52

guess , and he never suffered

32:54

a real consequence for it . So he was probably

32:57

emboldened by the lack

32:59

of a consequence and continued

33:01

, maybe to mistreat other students as well .

33:04

Well , that's just really appalling . It sounds

33:06

like he was embarrassing himself the whole time

33:08

and no one really wanted to point it out

33:10

. Maybe they didn't like him , but did

33:13

you report him or how did you

33:15

handle that ?

33:16

Well , of course I'm worried at that

33:18

point about my evaluations , as any student

33:20

is , I suppose , and my grade , and

33:23

as someone who was there , interested in OB-GYN

33:25

and honestly interested in a potential

33:28

residency at that program , one of the reasons why

33:30

I did the rotation there and again , this wasn't

33:32

my home medical school . Well , I wasn't

33:34

sure how to handle it and I had

33:36

never seen anyone have success

33:38

in handling things like this either

33:40

. I did a few things , I talked to people

33:42

in the room and they were reassuring

33:45

and made excuses for him . I

33:47

had lunch with the chairman one day , who

33:49

I think is I still do think is a

33:52

wonderful doctor and a fine person , and

33:54

I felt comfortable in telling him that

33:56

this had happened . And

34:03

I did that primarily to protect myself because I wasn't sure where this was going

34:05

to go or what the resident would do . And there were other episodes of abuse

34:07

beyond that initial day , a couple of

34:09

more episodes and some more overt

34:11

threatening , and I don't know for

34:13

sure . But I do think the chairman said something

34:15

to him because eventually he just

34:18

steered clear of me or was nicer in

34:20

the last month or so , not conciliatory

34:22

but steer clear . But

34:25

by the end of the rotation he produced

34:27

a scathing evaluation full of just

34:29

overt lies that was immediately

34:31

discredited and unbelievable , honestly

34:34

, by the clerkship director because it was

34:36

so inconsistent with other evaluations

34:38

and just also had verifiable

34:40

fallacies in it . But the bad

34:42

talking continued for a couple of years

34:44

, as I said after that , and I knew that

34:46

excluded me from consideration in

34:49

that program , even just for the sake of having to

34:51

work with him as my chief resident for a

34:53

year . By the time I would be there just

34:55

seemed impossible . So that's

34:57

when I first learned about workplace mobbing

34:59

, and unfortunately it wasn't the only time in

35:01

my career where I experienced workplace mobbing

35:03

, which is really a subset of workplace

35:06

violence .

35:07

Why don't you go into that idea a little more

35:09

? The workplace mobbing ?

35:11

Well , the condition in my situation there

35:13

, and for all medical students and many

35:15

other trainees , is that we're there on

35:18

a rotation for a very short time . You

35:20

may only work with a group of people for a few days or

35:22

a week , and even your whole rotation may never

35:24

be longer than a month or two . But the

35:26

longer term faculty and residents and

35:28

nurses and all those other folks they have to

35:30

work together with people for years

35:33

, including such an offensive

35:35

person . And so this offender

35:37

, who may be harassing a student or a trainee

35:40

and around other people , well

35:42

, they're forced to make an uncomfortable choice , and

35:44

so , in my case , the chief resident

35:47

, who was sitting there when it happened , and three other

35:49

witnesses to this behavior . They all made

35:51

a choice to do nothing because they

35:53

would have to continue working with him

35:55

for another two and a half years or whatever

35:57

, but I would be gone in a few weeks and

36:00

they only would interact with me for a few days

36:02

in their entire life , but

36:04

would have to be around him for who knows how

36:06

long .

36:07

Kind of reminds me of that TV show called

36:09

what would you do . It's hosted

36:11

by John . It's

36:15

like a reality show where people are

36:17

put in different situations on hidden

36:19

camera and and the

36:21

vast majority refuse to do anything

36:23

when they personally witness someone

36:25

verbally or physically being

36:28

violent or mistreating another person

36:30

.

36:31

Yeah , and I guess that's human nature . But

36:34

even in that example that

36:36

you mentioned , well , that depicts

36:38

people who don't really have any skin in the game . They're just

36:40

bystanders . They don't know the abuser , they

36:42

don't know the abuser , they don't know the abused . So

36:45

I think it's even worse in workplaces , where

36:47

they may not like this abusive

36:49

person and they don't like his behavior , but

36:51

they stand by and do nothing because

36:53

they have to make a choice about how

36:55

much of this treatment they want to suffer themselves

36:58

or what the repercussions may be for dealing

37:00

with this .

37:01

So they unfortunately tend to

37:03

naturally align themselves with the abuser

37:05

and

37:10

then a whole group does that and it has this sort of inertia about it and

37:12

that's called mobbing . So maybe they think they're just not getting involved or keeping

37:15

the peace , but really they

37:17

and really it's supporting the

37:19

abuse , and they might even go

37:21

as far as supporting the abuser

37:23

in overt ways as

37:25

well .

37:26

Yeah , that's right . Silence is support here

37:28

. The evaluation that

37:30

was made that was negative , that

37:32

I found out about at the end of the rotation . It

37:34

actually wasn't written by the abusive

37:36

person , it was written by an intern

37:38

and a second year resident and

37:40

the second year resident I had never even met . But

37:43

he dictated this evaluation

37:45

to them , didn't put his own name on

37:47

it because he knew that it would be flagged as

37:49

biased or discredited if he did

37:51

it , but he dictated it to them and they

37:53

turned it in .

37:54

Well , that's just so spineless

37:57

and unnecessary and

37:59

I don't know . There must be some kind of pathology

38:02

with that person just psychiatrically

38:04

, because that's a whole lot of effort and thought

38:06

spent by someone who probably had very

38:08

little free time , probably was

38:11

sleep deprived , and could have used that time well

38:13

to better educate themselves on

38:15

HSV-1 and HSV-2 , or

38:17

maybe take a nap or get some anger management

38:20

counseling like something productive

38:22

, anything but what they were

38:24

doing . But yeah , from those

38:26

other residents' perspectives , that second year

38:28

and that intern that even participated

38:30

in this it was maybe it was easier

38:32

to take his word for it if they were never

38:34

there , but they

38:36

probably knew he was embellishing

38:38

things . They

38:46

were probably in survival mode too . They probably were worried about coming under

38:48

the fire of this monster . You know they still had years and years ahead

38:51

of them .

38:51

Yeah , and he was going through some things

38:53

and I'm not going to talk about any of that here . But you're right

38:56

, we all have personal stress and

38:58

things that happen to us , or accumulation

39:00

of things , and then we act

39:02

perhaps differently than we normally would

39:05

. But that doesn't mean it's allowable

39:07

. We don't make excuses for bad

39:09

behavior just because of personal

39:11

stress . We intervene and we help

39:14

the person and help the situation and we

39:16

don't allow vulnerable people to

39:18

be abused just because someone else

39:20

is having a bad run of luck . But

39:22

, interestingly , one of the two residents

39:24

that I mentioned that wrote the

39:26

evaluation on his behalf later , many

39:29

years later , apologized to

39:31

me for her part in the

39:33

whole thing . We were having a couple of

39:35

beers at a meeting and she admitted

39:37

that he had dictated the evaluation to

39:39

her and that she knew the things in it were

39:41

made up , and she apologized for

39:43

going along with that and for not reporting him

39:45

or putting her name to this and not helping

39:47

me . And that's exactly what she said

39:50

that he was a bully to all of them and so

39:52

it was just easier to dump on me . I would be

39:54

gone and probably didn't need to be a resident there

39:56

anyway with him in that picture

39:58

, and it was just easier to do that than to

40:00

suffer further abuse .

40:02

So she actually felt guilty about it .

40:04

Well , of course she did . She's not a bad person at

40:06

all . She's a good

40:08

person and good people go along sometimes

40:10

with this type of overt abuse

40:13

and just bide their time and let

40:15

it pass and don't want to be disruptive and

40:17

don't want to deal with things and everybody's busy

40:20

and have complicated lives and

40:22

it takes a lot of courage to stand up to someone

40:24

viewed as powerful in these situations

40:26

. So they may be desperately beat

40:29

down themselves and in survival mode

40:31

and maybe have clouded judgment in the moment

40:33

and regret it later , even

40:35

if overall it doesn't align with

40:37

their own personal ethics and principles

40:40

to support such abuse .

40:41

It seems like a lot of this stuff , as you said , can

40:44

start with smaller events , like the microaggressions

40:46

, and then build up like

40:48

how ? Now ? I've never done this , but I've

40:51

heard that if you put a cold blooded reptile

40:53

like a frog into a pot of water

40:55

at room temperature and slowly crank the

40:57

heat up , they won't be aware that they're about to

40:59

boil . So it's a slower buildup

41:02

and the abusive person just gets emboldened

41:05

after getting away with the smaller aggressions

41:08

and they become larger and larger over

41:10

time and

41:20

then they just keep getting away with them year in OBGYN . They

41:22

may not have ever had to practice

41:24

dealing with such immature

41:27

people that are both in

41:29

a high stakes environment and have significant

41:32

authority over them , but

41:34

it does seem like the solution here

41:36

actually is to at least mentally

41:38

practice this and prepare this , prepare yourselves

41:41

for this somehow , and get comfortable

41:43

with calling out microaggressions early

41:45

on , nipping it in the bud before it

41:47

gets out of control . So how

41:49

would you do that and do you think ? Do

41:52

you ever think about something you would have said if

41:54

you could go back in time ?

41:55

Well , it's all hard . I do think that getting comfortable

41:57

with calling things out is an important step

42:00

and there's some behavior that all

42:02

of us would respond to and maybe just think

42:04

of it as we need to turn our threshold

42:06

down for response and I've tried

42:08

to do this . I'm not perfect by any means

42:11

, but I have learned something from this lesson and

42:13

I've tried to do these things . I joke around

42:15

as much as anybody , but there's just unacceptable

42:17

things to do . But it's hard , especially when it comes

42:20

from someone you work with all the time and

42:22

how you deal with that . And maybe you do it privately the first

42:24

time , although that's not very supportive

42:26

of the person being victimized . So

42:28

it is difficult . But obviously someone

42:30

who's a bit of a bully and is using this sort

42:32

of language or being abusive to learners doesn't

42:35

believe that they are

42:37

being abusive and they'll probably

42:39

respond negatively to having someone call

42:41

out their microaggressions to them , which

42:44

can make this even more intimidating to

42:46

the victims . But in response to an outright

42:48

insult or threat , I'd start with something

42:50

like I'm not sure I understood that . Could you please

42:53

say that part again , maybe follow up

42:55

with did you mean for that to be hurtful

42:57

, just to make

42:59

him hear himself and say it again , and those

43:01

are effective strategies that you read

43:04

a lot in literature about responding

43:06

to these , and they're similar tips

43:08

to what a guy named Jefferson Fisher

43:10

recommends . He's a lawyer in Texas who does

43:12

personal injury cases not Med

43:14

Mal , but nothing really specific

43:16

about us , so we can like him , but he makes little

43:19

videos on you know , on TikTok and stuff about how to

43:21

deal with difficult people in the workplace that

43:23

have suggestions like that . But these

43:26

are things that you can learn and practice

43:28

and implement . In my case , obviously , we

43:30

didn't have smartphones at the time

43:32

, but I wish I had said something like okay , maybe

43:34

you're right , let's just go look it up and come back

43:36

to this later . Although I wasn't really

43:38

given that opportunity , I did look it up . I was at

43:40

the library that night and carried around the

43:42

papers in my white coat for the next

43:44

two weeks about incidents of HSV

43:47

and genital cultures , but

43:49

that wasn't helpful either . This wasn't about the facts

43:51

, right ?

43:52

Right right .

43:53

I think each institution and department should have examples

43:56

of behaviors that would include

43:58

both overt abuse and these microaggressions

44:01

, and a described policy that these behaviors

44:03

are not tolerated , with defined consequences

44:06

, and then , of course , a system of reporting and

44:08

enforcement of that . So that seems to

44:10

me the easy thing to do , and to

44:12

have required harassment , training for students and

44:14

residents and attendings with these examples

44:16

. But then when the most important

44:18

maternal fetal medicine doctor , or the chairman

44:21

of the department , or the well-respected

44:23

but temperamental ganank or whoever

44:25

that's seemingly really important

44:27

, exhibits this behavior to

44:29

a learner , the question is then

44:32

actually is it going to be enforced

44:34

or the consequence is going to be enforced ? Is it going to be

44:36

dealt with seriously ? Because the moment

44:38

that it's not enforced and people are given

44:40

some special treatment because of their seeming

44:42

importance to the program , well

44:45

, they're emboldened and it goes on and I think that's

44:47

what promotes the cycle of abuse

44:49

.

44:49

Yeah , we really should consider and

44:51

have this perspective of how miserable

44:54

someone must be to be

44:56

treating someone else that abusively

44:58

, and that might not help the

45:01

victim , especially in the moment when they're basically

45:03

being flogged . But you can probably

45:05

guarantee that the abuser has some

45:07

combination of either self-hate or

45:10

unhealthy relationships or maybe

45:12

a traumatic upbringing . That could include their

45:14

professional upbringing , as we've been talking about

45:16

, and their behavior is still completely

45:19

unacceptable regardless of any of that context

45:21

. But maybe it could also be a trigger

45:23

for someone to check

45:25

in on them and say , hey , are you okay

45:28

? Or maybe even to offer

45:30

or mandate like I think you need help

45:32

. You're really being aggressive here . That's

45:35

a bad sign .

45:36

And they could even be narcissistic sociopaths

45:38

. The incidence of mental health problems and

45:40

personality disorders is not different among physicians

45:43

than it is the general public , so those

45:45

people are out there .

45:46

Yeah , and you can't . Yeah , I guess you

45:48

can't really remedy certain things

45:51

, but you know , maybe , yeah , maybe our

45:53

new interns also need to think about what

45:55

are the traits of sociopathic

45:58

narcissists , so that I can just avoid

46:00

them .

46:01

You just smile and nod and avoid it as much as

46:03

you can and just know

46:05

that's that person's pathology and

46:07

yeah , and if the system , if

46:09

the system works as it's supposed to , those folks won't

46:11

be teaching trainees , they'll be right

46:14

, right , exactly A hundred percent

46:16

, yeah .

46:16

They have no , no place teaching . So

46:19

anyway , I think you you

46:21

mentioned briefly , you experienced this in kind

46:23

of a bigger way . Was there anything else that you

46:25

wanted to say about that here ?

46:27

Well , I don't want to talk about those things on

46:29

here , I think , but I think it's the same

46:31

consequence , where things should

46:33

be nipped in the bud early , so to speak

46:35

, to prevent bad habits and

46:38

complex and perverse power

46:40

dynamics from setting in that lead to

46:42

larger systematic abuse .

46:44

Yeah , like there needs to be institutional protection

46:46

from the highest level , but even like , even

46:48

if there isn't even one person

46:51

recognizing it and actually standing up , it

46:53

makes a huge difference . So it

46:55

needs to be all of the above , I agree . So

46:57

a lot of when hazing is

46:59

prevalent . It generally occurs

47:01

right at the beginning of

47:04

a rotation , before people really

47:06

get to know each other , and it could include

47:08

maybe some belittling comments

47:10

or sarcasm and just making

47:12

the new learners feel

47:14

and look stupid in front of others , including

47:17

nursing staff or medical students , and really

47:19

when people do this , it's to try to make

47:21

themselves feel more important and powerful

47:24

by making others look smaller

47:26

. Obviously there's an inferiority complex

47:28

there and like they're trying

47:30

to put the new intern in their place , so

47:32

to speak , and obviously that's very shameful

47:34

and inappropriate and just bad

47:37

, and it takes as much energy , or

47:39

probably less energy to do the opposite

47:42

and instead create a welcoming

47:44

, warm environment for new learners . We want

47:46

an environment that's supportive of asking

47:48

even obvious questions and understanding

47:51

that new interns are going

47:53

to need to learn a lot of rather basic

47:55

stuff , and in fact , you

47:58

want your interns and residents to

48:00

feel comfortable asking you even

48:02

dumb questions and

48:04

not feeling like they're going to be shamed or humiliated

48:07

for asking them . If a bully thinks

48:09

something is obvious , they might just roll

48:11

their eyes and be like how do you not know this

48:13

? Maybe the learner did read the

48:15

material like they were supposed to and they've

48:17

gone ahead and they just couldn't quite grasp

48:19

it the way it was written and they're trying to clarify

48:21

. Or okay , maybe they didn't

48:24

read it , they were supposed to and now they probably

48:26

feel dumb that they didn't read it , so

48:28

you don't have to rub it in their face .

48:30

Yeah , and shaming is not a great motivator

48:32

.

48:33

Right , okay . Well , on this subject

48:35

, I'll confess a little bit that when I've

48:37

been in didactic settings , silently

48:39

, I could get that this was a pet peeve

48:41

of mine , that if we were assigned reading

48:43

I would read it . Sometimes I would

48:45

have a fellow colleague that didn't read

48:48

it and then they would ask a question

48:50

that was very clearly answered in the reading

48:52

and I would feel like we have just an

48:54

hour on this and you're wasting our time . I

48:57

wanted to get to some further questions here

48:59

, and I would sometimes be seething

49:01

, but yeah , is that why they made

49:03

you the academic chief ? I

49:06

guess maybe it wasn't that subtle but probably I tried

49:09

not to be a meanie ever I

49:11

don't think I was . But yeah , probably the

49:13

attendings recognized they needed to keep me

49:15

busy so I'd stop glaring at people

49:17

who didn't study like I did

49:19

whenever they asked the question . But I

49:21

really made it , made a point of never insulting

49:23

anyone , just maybe kind of silent judgments

49:26

.

49:27

Well , people need to do their jobs and

49:29

need to read what they're told to read , and they need to show

49:31

up on time and all that . And there's ways

49:34

of dealing with people who aren't doing those

49:36

things in a constructive and edifying

49:38

way . And so if your only trick as

49:40

a teacher is to humiliate or belittle

49:43

someone or shame them , then

49:45

you're in the wrong job . But I'm glad

49:47

you at least have eased up a little since then

49:49

.

49:50

I think we were all everyone won

49:52

, because then I got to teach and

49:54

shape things a little bit and then the people

49:56

that didn't read , just they

49:59

would just listen to me . So we were all , everyone

50:01

won . We all came out knowing what we

50:03

needed to know and we're all happy . So

50:05

I do remember what it was like being

50:08

an intern , going to those initial events

50:10

even before intern year really started

50:12

and me and my whole class were the outsiders

50:15

coming in . Everyone else had been working

50:17

together for years . They had all their inside

50:19

jokes and they're not

50:21

. I knew they were not necessarily

50:23

excited about having to baby

50:26

us and hold our hands and

50:28

it was like us against the

50:30

world a little bit . And hopefully everyone

50:32

that's going into an intern class will get very

50:34

close with their classmates because you

50:37

know that will really help carry you through . So just

50:39

support each other as much as you can . But

50:41

you go into it having

50:43

to keep up with the seniors and hoping

50:45

that if we can't impress them , at

50:47

least hopefully we're not annoying them too badly

50:50

, because any mistakes or

50:52

misunderstandings or growing

50:54

pains that the learner has can

50:57

either be remedied discreetly with

50:59

understanding or they can be treated

51:01

as an opportunity for a quick laugh in front

51:03

of everyone at the learner's expense and

51:05

maybe even that might be intended and

51:08

just good fun . We're just friendly

51:10

teasing . But if it's taken the wrong

51:12

way by a super nervous brand new

51:14

learner , they may feel humiliated

51:17

and just start learning to fake it till they make

51:19

it . Stop asking questions that could be vital

51:21

and essential questions to ask . So

51:23

for all of you rising interns

51:25

, of course , learn to laugh at yourself

51:28

, but still do keep asking questions

51:30

, because if you don't worry about

51:32

looking smart now , just do your

51:34

best . Don't worry about how it looks . Then you

51:36

will actually help yourself and your whole

51:38

group be more smart by the end of

51:40

this process than if you hold back

51:42

.

51:43

More smart . Oh

51:45

, am I being belittling ? There's

51:49

an example , right , don't do that .

51:51

Yeah , there you go , fine , smarter

51:54

you happy .

51:55

Yeah .

51:55

Okay , well so , and

51:57

to anyone else who's past intern

51:59

year , if you're someone that's in charge of teaching

52:02

interns , just try not to

52:04

shoot them down . It really doesn't

52:06

matter what you think about them , but

52:08

they are looking up to you and they need

52:10

your guidance . So give them something that'll

52:12

inspire them to do

52:14

a great job , and then they're

52:16

actually going to be really helpful to you and

52:18

not an annoyance .

52:20

And we all need different things and we learn in different

52:22

paces and in different ways and

52:24

sometimes we get it immediately and sometimes

52:26

we need iteration and so respect

52:29

, that's just the nature of learning and I

52:31

think all that's a great example of how we can affect

52:33

the learning culture for better or

52:35

for worse . In other critical circumstances those

52:38

things should be debriefed afterwards in a supportive and

52:40

educational way and

52:50

it should be well understood that there's no

52:52

role and no tolerance for

52:54

temper tantrums and shaming and blaming

52:56

and when those sorts of operating

52:58

room or other stressful environments . Well

53:01

, we'll put some links to some literature about this

53:03

, but did you ever watch R

53:05

the show from the beginning ?

53:07

No , I did watch some of them with great

53:09

interest when I was much younger

53:11

, but I probably need to rewatch them . Those are the

53:13

ones with George Clooney right .

53:14

Wow , women always go to George Clooney

53:16

. Yes , well , I'll

53:19

refresh you . So , in , one of the main themes

53:21

in the second season of ER was

53:23

the mistreatment of a surgery intern named

53:25

Dr Gant , who was played by Omar

53:28

Epps .

53:29

You mean Omar Epps from House MD .

53:31

That's Omar Epps . Yeah , before House he

53:33

was on ER , but yeah , well

53:36

, he suffered all the sorts of things

53:38

that we're talking about in that second season

53:40

, except maybe sexual harassment I don't think he

53:42

suffered that , but he had some degree of racial

53:44

discrimination because his character is black . But

53:46

more than that , he suffered abuse from his supervising

53:49

resident , dr Benton , played by

53:51

Eric LaSalle . And then he

53:54

finally stands up for himself and reports

53:56

the abuse to the chief of staff , who was

53:58

another temperamental surgeon who

54:00

was abusive in his own ways . And unfortunately

54:02

the report was not believed , mainly

54:04

because Dr Carter , who had witnessed the

54:07

abuse , but he didn't back him up because

54:09

he was worried about his own problems

54:11

that were going on and the potential ramifications

54:14

for his own career . So shortly

54:16

after all that plays out , that day , dr

54:18

Gant apparently kills himself

54:21

by throwing himself in front of a train

54:23

, and I'll put a link to a YouTube video

54:25

of that pivotal scene where all that happens

54:27

.

54:28

Unfortunately , that really does sound too close

54:30

to reality . We know that physician

54:32

suicide is very real and prevalent

54:35

problem and it's always painful

54:37

to hear those stories and usually

54:39

involves some kind of struggle

54:41

. Everyone's different , but maybe

54:43

there's a professional struggle

54:46

. I know this does happen a lot too

54:48

with malpractice cases or medical

54:50

board complaints academic

54:53

, personal , financial struggles , or

54:55

maybe a combination of those and then some

54:57

kind of either a real or a perceived lack

54:59

of support and then their struggles just

55:02

become unbearable to them .

55:03

Yeah , I'll put a link to a study from a few years ago

55:06

that looked at the causes of death of residents

55:08

in US residency programs over a 14-year

55:11

time period . Residents do have a lower

55:13

risk of death overall compared to other folks

55:15

in their age group , which we would expect , because

55:17

they typically have more resources , better social

55:20

determinants of health , more general health knowledge

55:22

than the general population might . But still

55:24

in that 14 year time period there were

55:26

66 residents who died by suicide

55:28

and another 33 who died by an accidental

55:31

poisoning , and many of those , of course , those

55:33

are their overdoses and they may

55:35

be suicides or they may be accidents

55:37

. But why were they using drugs ? It's still

55:40

the same issue , but the intent's unknown . And

55:42

they actually listed 28 who died by some

55:44

mechanism where the

55:46

intent was unknown . So that

55:48

would be Dr Gant's case , because we

55:50

don't know if he slipped or jumped .

55:52

So the real number of deaths by

55:54

suicide might be twice

55:56

as high as the 66 that

55:58

was officially reported , because we don't . The other

56:01

ones are questionable as to whether they were

56:03

intentional overdoses or

56:05

slips or whatever the other mechanisms were

56:07

, or were they accidents ?

56:09

Yeah , and again , that episode of ER

56:11

where Dr Gant dies really does lean

56:13

into that idea , because again

56:15

he's killed by a train . So did he slip

56:18

or did he fall ? Was it intentional or

56:20

not ?

56:20

That was a cliffhanger , but of course , if you're watching

56:22

the show and have seen what's happened all season , we

56:37

know that he killed himself , but it makes his family

56:39

and everyone else feel better to think that he

56:41

died by accident and it makes the people who

56:43

didn't support him feel they tried to make it look like

56:45

an accident so that their family would get

56:47

the benefit that would not have been paid

56:49

out for suicide or even just so

56:51

it's easier for the family to not

56:53

feel bad or guilty about not

56:55

doing enough . Exactly which ? That

56:57

still doesn't make things any better , but

57:00

, as I just brought up , this

57:02

phenomenon continues beyond

57:04

residency . As I just brought up , this phenomenon

57:06

continues beyond residency . About 400

57:08

physicians die each year by suicide , and a 2020 report found that

57:11

the rates of suicidal ideation

57:13

were as high as one in every

57:15

four physicians , and the vast majority

57:17

were reluctant to seek help for that , even though

57:19

theoretically , they have more access

57:21

than anyone else , but they're

57:24

reluctant because of what it could mean for their career

57:26

. So , in fact , physicians

57:28

have among the highest rates of suicide

57:31

of any occupational group , at least

57:33

in the US .

57:34

Yeah Well , I think the solution to all these

57:36

sorts of issues must start with creating

57:38

a better work environment and ending these

57:40

cycles of mistreatment and abuse that

57:42

exist in medicine . It's enough that

57:44

the job is stressful and high risk

57:46

, but it's too much when our own colleagues

57:49

or the staff that we work with make our lives

57:51

difficult with harassment or belittlement

57:53

or workplace violence or even

57:56

subtle microaggressions , and

57:58

we have to develop a zero tolerance

58:00

for these behaviors in ourselves

58:02

and in others . So this coming Monday

58:04

, when new interns or new medical students

58:06

start , there's no need to jokingly call

58:08

them all fresh meat or make

58:10

any jokes at the expense of something

58:13

you know that they do not know

58:15

, and there's no excuse to do anything

58:17

but be supportive and encouraging . Hierarchy

58:20

in training programs is essential and

58:22

important , but that's different than creating

58:24

a perverse power dynamic . People

58:26

often aren't punished because they're

58:28

viewed as powerful , but they aren't inherently

58:30

powerful . They're empowered by systems

58:33

that fail the victims ultimately .

58:35

So basically treat people the way you want

58:37

to be treated . I think that's what you're trying to say

58:39

.

58:39

Yeah , exactly .

58:41

We will link to a

58:43

website called physiciansupportlinecom

58:46

and their phone number as well

58:48

, which is 888-409-0141

58:52

. They're available for US physicians

58:54

and medical students free , confidentially

58:57

, with no appointments necessary , and

59:00

if you just check the website out , it's

59:02

pretty good . They've got some

59:04

nice little resources on there , nice

59:07

little links to look at . But , yeah , if you're

59:09

in crisis , it's a really easy

59:11

, discreet thing to look at and at

59:14

least get started with some kind of help

59:16

, and there are many other resources that are

59:18

available to people who are struggling .

59:20

And most hospital systems or employers

59:22

have these resources available too , for free .

59:24

Yeah , yeah , all right , do we have

59:26

time for a listener question ?

59:27

We skipped it last time . We've got to pack it in .

59:29

Okay , let's pack it in . Okay , I'm going to read

59:32

it out then Quote I have appreciated

59:34

your book on vaginal hysterectomy and

59:36

your podcast . I have a question that

59:39

was not addressed in the book when closing

59:41

the vaginal cuff , is it beneficial to close

59:43

the anterior peritoneum ? I

59:45

was taught to do so , but I have found

59:47

a small study indicating it's not necessary

59:49

and maybe better not to close it with

59:51

the vaginal cuff . What are your thoughts ? Thanks

59:54

, signed . Piercing Peritoneum

59:57

in Peoria .

59:58

Nice consonants Wow .

1:00:00

Yeah .

1:00:01

Well , there are a surprising number of techniques

1:00:03

employed in all surgeries , including

1:00:05

vaginal hysterectomy , obviously that date back

1:00:08

decades 100 years or

1:00:10

more in some cases that are continually

1:00:12

taught as important based upon principles

1:00:14

that we no longer believe , and

1:00:17

they're done without empiric evidence

1:00:19

from controlled trials with their benefit . There's a lot of

1:00:21

history and just we did a thing

1:00:23

and it worked , and so we kept doing it , but we

1:00:25

didn't know if that was the reason why we had good outcomes

1:00:28

or not , and that's part of the culture of surgery

1:00:30

, I think . So we see this a lot , for example , in the

1:00:32

technique of cesarean delivery , where things

1:00:34

like the creation of a bladder flap or the

1:00:36

closure of parietal and or

1:00:39

visceral peritoneum are still very commonplace

1:00:41

, despite

1:00:46

those practices not really having any scientific evidence

1:00:48

that they're beneficial and some scientific evidence that they're in fact harmful . So

1:00:50

this is the case as well for closure of the peritoneum

1:00:53

at the time of vaginal hysterectomy , and I use

1:00:55

that comparison because the origin of peritoneal

1:00:58

closure for both procedures really has

1:01:00

a common surgical traditional

1:01:02

source .

1:01:03

It's difficult sometimes to separate out what

1:01:05

we do because it's traditional , versus

1:01:07

what is evidence-based , and this is

1:01:09

more difficult when there

1:01:12

just aren't studies for like

1:01:14

a specific technique that we

1:01:16

do .

1:01:17

Yeah , A lot of stuff hasn't been studied , at least in isolation

1:01:19

. It may be studied in combination

1:01:21

with other bundles of techniques . So

1:01:23

it is difficult . But in this case there

1:01:29

is a study which is , I'm assuming , the one that piercing peritoneum and peora actually already found

1:01:31

and this was a case control study back in 2003 , and I'll put a

1:01:33

link to that and they concluded that there was no

1:01:36

difference in the group who had peritoneal

1:01:38

closure compared to the group who didn't , particularly

1:01:40

in things like infection or bleeding or

1:01:42

subsequent problems with the vaginal cuff , and the

1:01:44

group that had peritoneal closure actually

1:01:46

had a higher rate of bowel dysfunction , meaning return

1:01:49

to bowel function , Although I don't

1:01:51

know how clinically significant that finding was

1:01:53

or if it's even related . That might just be a false positive

1:01:56

finding . In any event , they

1:01:58

didn't find any benefit from closing the peritoneum

1:02:01

for these patients .

1:02:01

So why is it even done in the first place ?

1:02:09

Well , in the early days of surgical technique , after , say , the 1880s

1:02:11

, when most of the modern tools of surgery came about , when this modern era began

1:02:13

, there was a big focus on viewing surgery as applied anatomy

1:02:15

. So first you went to the cadaver lab and you did

1:02:17

the surgery there , with a careful dissection

1:02:20

of every anatomic layer , and you identified

1:02:22

them and you treated them very tenderly

1:02:24

and , just as importantly , you closed every

1:02:26

anatomic layer as you finished your surgical

1:02:29

procedure . And this is the cornerstone of what

1:02:31

a lot of people call the Halsteadian technique

1:02:33

, named after William Halstead , the influential

1:02:35

surgeon at Johns Hopkins at the turn of the century

1:02:38

.

1:02:38

Wasn't he the doctor who was addicted

1:02:40

to cocaine and also gave his sister

1:02:43

a blood transfusion when she almost

1:02:45

died after delivery ?

1:02:46

Those things aren't related , but they are both true , yes

1:02:48

, so anyway , I don't think they're related

1:02:50

, but he did emphasize very careful dissection

1:02:53

of every layer and closure of every layer

1:02:55

. And people believe that this was necessary for

1:02:57

good wound healing . So this is one of the reasons

1:03:00

why this technique pervaded early

1:03:02

cesarean and hysterectomy techniques

1:03:04

just all surgeries really

1:03:10

. But over time , each of these individual procedures gained their own

1:03:12

justification for peritoneal closure , and that made sure that we kept

1:03:14

doing this for decades .

1:03:14

So this fake justification that's like that's

1:03:16

called a narrative fallacy .

1:03:18

Exactly , and there's a lot of them out there . So

1:03:20

for vaginal hysterectomy , it was felt that closing

1:03:22

the peritoneum would help isolate infection

1:03:25

from the vagina that would go up into

1:03:27

the peritoneal cavity . And in fact for a long time

1:03:29

many surgeons weren't even closing the vaginal epithelium

1:03:31

, they were just closing the peritoneal edges together

1:03:34

and tying the ligaments together and allowing the

1:03:36

vagina to heal by secondary intention . And

1:03:38

this was a popular thing to do in

1:03:40

the decades before we

1:03:43

had prophylactic antibiotics , so before the mid prophylactic antibiotics

1:03:45

, so before the mid-1950s .

1:03:46

Obviously , that led to more dehiscence

1:03:48

and evisceration .

1:03:50

Right , yeah , but then in the late 90s

1:03:52

we learned that the peritoneum actually

1:03:55

heals on its own very quickly and

1:03:57

putting suture material in it , if anything , delayed

1:03:59

the healing due to the inflammatory response

1:04:02

. So in the late 90s and then early

1:04:04

2000s , where this new study

1:04:06

comes from , you start to see a lot

1:04:08

of data questioning the benefit of peritoneal

1:04:10

closure in a lot of surgeries and for the

1:04:12

most part we haven't closed the peritoneum

1:04:14

, at least with any good scientific backing

1:04:17

at the time of vaginal hysterectomy or cesarean

1:04:19

delivery since about 2004

1:04:21

or so .

1:04:22

Yeah , there's a lot of things that don't work like we

1:04:24

think they do , and just another reminder

1:04:27

yet again that we shouldn't do things without

1:04:29

clinical evidence of benefit .

1:04:31

Well , a lot of these old techniques still hang around

1:04:33

. There's also just the issue that a lot

1:04:35

of older and influential textbooks contain

1:04:38

many of these steps as if they were dogma

1:04:40

, and of course we all read them and it takes a long

1:04:42

time to get that stuff changed . I

1:04:47

recently spoke about vaginal hysterectomy at a conference in Mexico and one of the attendees afterwards

1:04:49

asked me about incorporating the round ligaments into the

1:04:51

peritoneal closure . So she was still doing

1:04:53

that routinely at the time of her vaginal

1:04:55

hysterectomies and at first this was

1:04:57

done because people thought that the round ligaments

1:05:00

would help to support the vaginal cuff and

1:05:02

so they were including them into the peritoneal

1:05:04

closure . And then we learned that the round ligaments

1:05:06

don't really offer any support

1:05:08

. But the habit continued , and by the time

1:05:11

that Dave Nichols and Clyde Randall

1:05:13

wrote about their book about vaginal surgery at

1:05:15

least in the fourth edition that I have in 1996

1:05:18

, they were still recommending incorporation

1:05:20

of the round ligaments into the purse string to

1:05:22

help better peritonealize the pelvis

1:05:24

. Now Nichols also had a habit of trimming

1:05:27

the anterior peritoneum and that technique

1:05:29

became quite popular as well for a while

1:05:31

. But it was just after this time that

1:05:33

we learned that what we thought about the peritoneum

1:05:36

and needing to close it simply wasn't

1:05:38

true , and so the benefit of incorporating the

1:05:40

round ligaments into that closure as well is something

1:05:42

that wasn't true . So all these steps

1:05:44

are omitted in the technique

1:05:47

that I teach and write about , but obviously

1:05:49

they can persist for a variety of reasons and

1:05:51

the way we teach surgery .

1:05:52

All right . Well , hopefully that helps our friend

1:05:54

eliminate an unnecessary step they

1:05:56

were taught . Well , I think we need to wrap

1:05:58

up for today , but good

1:06:01

luck to all the interns getting started

1:06:03

and send us your

1:06:06

stories about how things are at your

1:06:08

training programs . We're interested

1:06:10

to hear it . We will post links to

1:06:13

the studies and also that website

1:06:15

we talked about on the Thinking About

1:06:17

OBGYN website . So check that out

1:06:19

. Check out our Instagram and we'll be back

1:06:21

with the next season very soon .

1:06:27

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1:06:29

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1:06:32

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1:06:34

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