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What really goes on in an operating room?

This week, the Annals of Internal Medicine published an anonymous essay recounting two appalling incidents that took place while gynecological patients were unconscious. The medical journal challenged doctors to call out colleagues who behave inappropriately, but so far the response has been polarizing. While some physicians and consumer advocates applauded the journal for shining a light on abhorrent behaviors, some doctors, mostly obstetrician-gynecologists who felt singled out by the essay, have criticized its publication, calling it inflammatory, unsubstantiated and sensationalistic.

The incidents described in the essay are troubling, and some of the details are too graphic to repeat. In one case, a male doctor made a sexual comment while prepping an anesthetized woman for vaginal surgery. In the other, a doctor had just performed a lifesaving procedure on a Hispanic patient who began bleeding after giving birth. While the sedated patient was still in a compromised position, the doctor began dancing and singing a popular Mexican folk song.

In both cases, medical students who observed the behavior were deeply disturbed, but feigned amusement and played along, reluctant to confront a supervisor.

The editors of Annals of Internal Medicine decided to publish the piece as an anonymous essay even though the author originally submitted it to the journal under his real name. As a result of the anonymity, the incidents could not be verified. The journal declined a request for an interview with the author. In an accompanying editorial, the journal editors said they published the essay to encourage physicians to call out colleagues who behaved inappropriately, and that they hoped it would “make readers’ stomachs churn,” and “gnaw” at their consciences. They opted for anonymity to protect the identities of the patients involved.

“These are extreme examples, but there is no reason to believe these weren’t true events,” said Dr. Christine Laine, the journal’s editor in chief. “When I said to our 15-plus editorial team to ‘raise your hand if you think this stuff never happens,’ nobody raised their hand.”

She said the decision to publish was not easy, but that the editors felt refraining from publishing would, in a sense, make them complicit in the behavior as well.

While it has long been known that doctors sometimes adopt gallows humor to defuse tension or make provocative comments when they think patients aren’t listening, it is unusual for a medical journal to highlight such behaviors. Earlier this summer a Virginia man won $500,000 in damages after the doctor was recorded making disparaging remarks during a colonoscopy.

But does publicizing the bad behavior help patients? Not everybody thinks so.

Dr. Mark S. DeFrancesco, president of the American College of Obstetricians and Gynecologists, said in a statement that in his 31 years of practice, he had “certainly never witnessed activity like this.”

Dr. Sigal Klipstein, chair of the college’s committee on ethics, said in a telephone interview that she was concerned the piece would deter women from seeking medical care.

“What was the point of publishing this article?” she asked, adding that since both of the patients received sound medical care and were not physically injured, “No harm was done.”

Nancy Berlinger, a scholar at The Hastings Center who writes about ethical challenges in health care as well as issues of power between junior and senior clinicians, disagrees. “Doctors must be respectful even if a patient is sedated,” she said. And in these cases, she said, the supervising physicians also did harm to the medical students they were responsible for training and mentoring.

“This is the worst thing a role model can do: to suggest that wrong behavior is acceptable, to nudge junior people to be callous and to misuse power,” Dr. Berlinger said. In both cases, the senior doctors made a trainee student complicit in their abuse and “made them feel dirty at an early stage of their careers.”

The anonymous essay prompted one physician blogger to recall her own experience as a medical student who was uncomfortable with the way a physician conducted a pelvic exam on a young girl. The experience, she wrote, still haunts her today.

“Now as a mature women I would handle it differently,” said Dr. Valerie Jones, a physical medicine and rehabilitation physician.

In his essay, the anonymous author explained that he was prompted to write it after a discussion in a medical ethics class. He asked the students if anything had happened in their clinical experience that they needed to forgive or could not forgive. The ensuing conversation revealed that both student and teacher were haunted by the uncomfortable experiences described in the essay. The teacher noted that he had felt cowed into laughing along with the singing doctor, and it was only when the anesthesiologist in the room yelled at them that it stopped.

“We all need the strength to act like the anesthesiologist in this story,” the editors of the journal wrote, noting that doctors should call out colleagues for inappropriate behavior. They concluded, “We owe it to ourselves, to our profession and especially to our patients.”

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