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On Being a Doctor |

Our Family SecretsOur Family Secrets

Anonymous
Ann Intern Med. 2015;163(4):321. doi:10.7326/M14-2168
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Do any of you have someone to forgive from your clinical experiences? Did anything ever happen that you need to forgive or perhaps still can't forgive?

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Myths and Reality
Posted on August 20, 2015
Munita Singh
retired primary care doctor
Conflict of Interest: None Declared
After years of fulsome articles about medical sainthood that incited guilt in lesser beings, the Annals decides to horrify us with the antithesis of the myth of the 'noble profession'.
Why is it so shocking that doctors are just as prone to sociopathy and criminality as any other group in which vulnerable people are forced to place their trust? Perhaps the era of protecting the 'profession's reputation' is over. After all, doctors are now being rated alongside restaurant food on marketing apps, and self-promotion on social media will be compulsory for all corporate workers who are rated solely on the basis of the income they can generate. Narcissists and psychopaths are ideal for the technology platform model of business that will dominate the medical industry.
An Opportunity for Reflection
Posted on August 26, 2015
Gaetan Sgro, MD; Mark T. Gladwin, MD; Alexander Teng, MD; Akshata Moghe, MD, PhD; Shanta M. Zimmer, MD
VA Pittsburgh Healthcare System; Chair, Department of Medicine, University of Pittsburgh; PGY-1, UPMC Internal Medicine Residency Program; PGY-2, UPMC Internal Medicine Residency Program; Director, UP
Conflict of Interest: None Declared
Soon after “Our Family Secrets(1)” was published anonymously in Annals on August 18, our program director fired off an email to our entire residency. Would you please read this and tell me what you think? is how she put it, with an undertone of urgency, and a sense she wasn’t asking.

The article ricocheted along the corridors of our three teaching hospitals, off the white boards in our precepting rooms, and across the benches in our laboratories until it seemed no residents or faculty were left unscathed. Responses flooded her inbox, and our secrets started spilling.

There were accounts of physicians who needed forgiveness, and others who needed forgiving. Many expressed regrets for complicity in similar situations. “It left me numb and flushed and I couldn't write or speak for a minute… [There are things] I can't forgive myself for, simply because I was in that space when they happened.” Others recalled with embarrassment their own hesitant laughter, lamenting missed opportunities to confront impropriety.

The events portrayed by Anonymous were shocking and sobering indeed, but many recognized how little it takes to erode our empathy and to threaten our patients’ dignity. How we are all one off-color joke, one insensitive label, one unkind gesture away from inhumanity.

One response stood out for its positivity. An intern remarked that, “it reminds me of the importance of culture and culture leaders.” He recalled a particular intern on bariatric surgery, who was determined to focus not on his overweight patients’ shortcomings but on their inherent dignity and on the struggles they had faced. “He [demonstrated] that maintaining one’s integrity through words and actions not only protects against burnout, but could also make you a leader, even as an intern.”

And if a single, unifying theme has emerged from this week of reflection, it is that we should all demand such leadership, even as we search for that same inner strength. Rather than recoil from this portrayal of “medicine’s dark underbelly,(2)” we applaud the courage of the author and of the editors who understood the need for this dialogue. It is no longer a secret that we are all one family, and that we all have silences to break.

References:
1. Anonymous. Our family secrets. Ann Intern Med. 2015; 163:321.
2. Laine C, Taichman DB, LaCombe, MA. On Being a Doctor: Shining a Light on the Dark Side.
Ann Intern Med. 2015;163(4):320.

I was wrong, but somehow feel it was justified.
Posted on August 26, 2015
John Smith (obvious pseudonym)
.
Conflict of Interest: None Declared
I'm currently an ophthalmology resident in a south Asian country. We saw a six year old girl who had seriously injured her eye. As expected, the child was in pain, confused and terrified, and would let no member of the medical team examine her. The parents had initially taken for first-aid elsewhere and a large bandage had been taped to the injured eye and over the hair.
I do not particularly care for children. I dislike paediatrics. But as taught, I tried to speak to her soothingly and explain what we were trying to do. As she sat in her fathers lap I approached her with a spirit soaked swab to dissolve the adhesive tape and remove the bandage. Understandably, she was reluctant and needed some persuasion. As I was speaking to her, the Head of Ophthalmology appeared and told me to step aside. He tried to examine her but she resisted. He screamed at her and raised his hand to strike. The father and I intervened and stopped him. He responded by ripping of the bandage along with several strands of hair, then turned to me and remarked rather proudly how ripping it off in one go minimizes the pain.
I was appalled, and muttered about how horrific his actions were. The father overheard me, and later on in his written complaint cited this. I was called in and asked if I had said so. When I admitted that I had, he shook me forcefully by the shoulder while screaming that he had been in practice for longer than my lifespan.
He then refused to promote me to second year and tried to get me fired, but HR wouldn’t let it happen. I’m still here and have to work with him every day.
I do wish that maybe that I had chosen my words more carefully, but in an unguarded moment it was absolutely what I was thinking.
Cynical Humor in Medicine
Posted on August 26, 2015
Shafik Dharamsi
Professor & Associate Dean, University of the Incarnate Word School of Osteopathic Medicine
Conflict of Interest: None Declared
Not long ago my colleagues and I published a short article on the use of cynical humor in medical practice and the related implications for professionalism, empathy and the development of humanistic qualities in medicine.[1] We observed in our paper that health workers are almost always overworked, tired, and overwhelmed with the demands and stresses of their profession. Indeed, they are not immune from the numbing effect of the day-to-day clinical grind. Some turn to derogatory humor as a coping mechanism.

We acknowledged that laughter can be therapeutic, for patients and doctors alike. Yet, when used in ways that compromise human dignity, humor in the hands of those given the fiduciary duty to care for others becomes palpably dehumanizing, and little power to truly heal.

In the words of the late Ernest Boyer, the “crisis of our time relates not to technical competence, but to a loss of the social and historical perspective, to the disastrous divorce of competence from conscience.”[2] Preparing our future physicians to embrace humanistic values such as kindness, compassion, integrity, respect and humility is perhaps one of the greatest challenges of medical education in the 21st century. We need to develop pedagogical approaches that will not only prepare clinically competent physicians, but are equally as embracing of these values if they are to be transformative. Yes, humourless pedagogy is dull; nevertheless, the use of humor marks the distinction between learning and healing on the one hand, and distancing and destructiveness on the other. Medical educators and role models must enable our next generation of doctors to develop the capacity to reflect deeply and use carefully words that can bring hope in tragedy and compassionate laughter in the face of otherwise overwhelming exposure to the tragedy of others.

1. Dharamsi S, Whiteman M, Woollard R. The use of cynical humor by medical staff: implications for professionalism and the development of humanistic qualities in medicine. Educ Health (Abingdon). 2010 Nov;23(3):533.
2. Boyer E. Scholarship Reconsidered: Priorities of the Professo- riate. Princeton, NJ: Carnegie Foundation for the Advancement of Teaching 1990.
Speaking Up about Unprofessional Behavior
Posted on September 15, 2015
William Martinez, MD, MS; Eric J. Thomas, MD, MPH; Jason M. Etchegaray, PhD; Sigall K. Bell, MD
Department of Medicine, Vanderbilt University Medical Center; Memorial Hermann Center for Healthcare Quality and Safety, The University of Texas Medical School at Houston; THe RAND Corporation; Depart
Conflict of Interest: None Declared
We applaud the courage to publish “Our Family Secrets.”(1) As disturbing as the piece was, it takes speaking the unspeakable to foster change. Speaking up about unprofessional behavior is essential not only for maintaining the profession’s social contract, but also for patient safety, with unprofessional behavior among team members being associated with diminished diagnostic and procedural performance.(2)

Aviation research suggests that speaking up behavior is driven by implicit voice theories (i.e., individual beliefs about what, when, and to whom it is appropriate to speak up).(3) These beliefs are influenced by group norms and may be substantially different in different environments, particularly for learners, such as the student initiating the conversation in this piece.(3)

For learners low on the medical hierarchy, speaking up about unprofessional behavior may be particularly challenging. A strong desire to be accepted by other team members and fear of retaliation can undermine the moral courage necessary to speak up about unprofessional behavior.(4) While educators may encourage professionalism and speaking up in the formal curricula, the hidden curriculum may have a more powerful influence, suppressing speaking up, and shaping learners’ attitudes and behaviors.(4)

As clinicians and educators begin conversations sparked by publication of “Our Family Secrets”,(1) readers may be interested in two validated scales we recently published focusing on the extent to which speaking up is supported within the clinical learning environment; one for traditional patient safety threats and the other for unprofessional behavior.(5) These metrics can help assess organizational efforts to create a safe space to speak up, from the perspective of learners.

As part of our research, we collected data from 837 medical and surgical residents from six academic medical centers. We found that even at sites where traditional safety climate metrics were good, speaking up climates for patient safety, particularly for unprofessional behavior, were very poor. As our profession continues its ardent strides toward improving patient care, creating clinical environments that support speaking up may not only uphold commitments to professionalism, but also address ongoing safety gaps. We are grateful to the Annals for shining a light on this critical issue and are hopeful that it will be an important catalyst for change.

References:
1. Our Family Secrets. Ann Intern Med. 2015;163(4):321.
2. Riskin A, Erez A, Foulk TA, Kugelman A, Gover A, Shoris I, et al. The Impact of Rudeness on Medical Team Performance: A Randomized Trial. Pediatrics. 2015; Published online first [10 August 2015] doi:10.1542/peds.2015-1385d.
3. Bienefeld N, Grote G. Silence that may kill. Aviation Psychology and Applied Human Factors. 2012;2(1):1-10.
4. Martinez W, Lehmann LS. The “Hidden Curriculum” and Residents' Attitudes about Medical Error Disclosure: Comparison of Surgical and Nonsurgical Residents. Journal of the American College of Surgeons. 2013;217(6):1145-50.
5. Martinez W, Etchegaray JM, Thomas EJ, Hickson GB, Lehmann LS, Schleyer AM, et al. 'Speaking up' about patient safety concerns and unprofessional behaviour among residents: validation of two scales. BMJ Qual Saf. 2015; Published Online First: [21 July 2015] doi:10.1136/bmjqs-2015-004253.
The Bullying Subculture of Medicine
Posted on September 16, 2015
Jordan Cohen MD, Richard I. Levin MD
The Arnold P. Gold Foundation
Conflict of Interest: None Declared
Dear Dr. Laine,

We applaud the editors of the Annals for publishing the essay “Our Family Secrets,” and an accompanying editorial, in the August 18th edition. No one likes to expose the dark side of their field, but as professionals we have a solemn responsibility to acknowledge the darkness within medicine just as we celebrate its humanity.

Organized medicine has demonstrated a high tolerance for the kinds of appalling behavior that were the subject of the essay. Unfortunately these are not isolated incidents. Last month, when the Washington Post reported on the Annals essay [1], it hit a responsive chord. Over 290 comments were made on the story, many from doctors and nurses with their own horror stories of medical disrespect. Reading through those comments, we question the inference from the Annals’ editorial that these behaviors in medicine are uncommon.

We have allowed a code of silence to pervade the practice of medicine, which is especially inhibiting for students and residents. Our acquiescence has spawned one of the most insidious aspects of the “hidden curriculum.” According to Liao et al, writing in the BMJ [2], “a strong desire to ‘fit in with the team’ and fear of repercussions can trump the moral courage required to speak up about safety concerns and unprofessional behavior. While educators focus on formal resident patient safety curricula, the hidden curriculum may be a more powerful ‘teacher’, suppressing speaking up, and shaping residents’ attitudes and behaviors.”

Ilana Yurkiewicz, a third year medical student at Harvard, wrote a compelling essay last year on Aeon regarding what she termed the “culture of disrespect.”[3] She writes “many in medicine actively protect the culture of disrespect because they hold a fundamentally flawed idea: that harshness creates competence.”

Having worked in academic medicine all of our careers, we can state emphatically just the opposite: that mutual respect, empathy, and excellent communication among all members of the medical team are critical success factors. At the Arnold P. Gold Foundation, we have been working for almost three decades to re-center the practice of medicine around the patient and to advocate for more humanism in our increasingly fragmented healthcare system.

We hope the editors of the Annals will not hesitate the next time a clinician decides to “break the silence” and speaks out against the bullying subculture of medicine. That act alone will elevate the culture of relational medicine and humanistic practice.

Sincerely,

Jordan Cohen, MD
Chairman
The Arnold P. Gold Foundation

Richard I. Levin, MD
President
The Arnold P. Gold Foundation

1. Cha AE. In graphic detail, medical journal describes ‘heavy overtones’ of sexual assault in operating room. Washington Post. August 18, 2015.
2. Liao JM, Thomas EJ, Bell SK. Speaking up about the dangers of the hidden curriculum. Health Affairs.2014;33(1):168-171.
3. Yurkiewicz I. Medical disrespect. Aeon. January 29, 2014.
The Persisting Medical Mandate: Respect Patients’ Sexual Selves
Posted on September 18, 2015
James W. Walters, PhD
Loma Linda University
Conflict of Interest: None Declared
The publication of “Our Family Secrets,”(1) with an accompanying editorial(2) struck a raw nerve, with the Los Angeles Times soon thereafter reporting(3  on the Annals’ pieces and at least a half dozen websites running their own stories, with hundreds of comments.There is an underlying, substantive rationale behind the editors’ protestations of “disgusting,” “harrowing,” and “scandalous” behavior. These are appropriate and significant charges, and these terms deserve a thick reading.The concept of respect for all humans, especially human sexual sensibilities, possesses a longstanding and thick moral texture. And especially physicians, who are often welcomed by patients into their innermost lives, must never betray such confidence.As long ago as Hippocrates, physicians have sworn to refrain from acts of an amorous nature regardless of the patients’ rank or gender. Hippocrates was a spokesman for a Greek articulation of the importance of the individual person. Confucius, a parallel figure in the axial age of human evolution, a time of birth and rebirth of major world philosophies and religions, gave humanity what we call the Silver Rule: Do not do to others what you don’t want them to do to you. Jesus’ Golden Rule, a notion of basic human reciprocity found in all major world religions, came centuries later. 
Fast forward to the Enlightenment. Although the seeds of individualism’s centrality to contemporary culture were sown early, they didn’t fully bloom for two millennia. As Immanuel Kant classically stated: “Act so that you treat humanity, whether in your own person or in that of another, always as an end and never as a means only.”(4) With the proclamation of “unalienable rights” in the Declaration of Independence—“Life, Liberty, and the Pursuit of Happiness”—these seeds became firmly embedded in America’s political sacred texts.
Despite the demystification of human sexual intercourse and the popularity of hooking up among many, the mystique and intimacy of sexual relations persists—as witnessed in the growing feminist intolerance of all forms of rape(5). Of course, human sex is the means of pro-creation, but it is so much more. Modern societies have symbolically invested sex with significance that goes to the core of personal meaning. Novelist Milan Kundera’s prevalent use of sex, he says, is because sex is the most poignant of human behaviors in exploring the human soul. For millennia and still today sexual matters are as inseparable from whom we are as humans as are the prints of our fingers—and far more existentially consequential.

1.Anonymous . Our Family Secrets. Ann Intern Med. 2015; 163:321 doi: 10.7326/M14-2168
2.Laine C, Taichman DB, LaCombe MA. On Being a Doctor: Shining a Light on the Dark Side. Ann Intern Med. 2015; 163:320. Doi: 10.7326/M15-1144
3.Kaplan K. When ethics are breached in the operating room. Los Angeles Times 2015 Aug 23; Sect A:18,19(col 4).
4.Kant I. Foundations of the Metaphysics of Moral. Translated by Lewis White Beck. New York: Bobbs-Merrill Company; 1969; 54.
5.See the just-published book by Harding K.. Asking for It: The Alarming Rise of Rape Culture. Boston: Da Capo Lifelong Books; 2015.
Board of Medicine Members’ Perspective on Professionalism
Posted on September 21, 2015
Onelia G. Lage M.D., Cristina Fernandez BA, Bernardo Fernandez M.D.
Florida International University & Baptist Health Medical Group
Conflict of Interest: None Declared
Professionalism comes from the verb profess, which means to promise. What kinds of promises are we making to our patients when we behave in ways that make it difficult or impossible for others to forgive us? This was the case in Our Family Secrets. Some will be quick to condemn these actions, others to condone them and in the end, much like real families, we ask ourselves “who loses?” Is it the patient, the doctor, the student, the profession, or all?
For doctors who are called to serve on regulatory medical boards, these scenarios of breeches in professionalism continue to be disheartening, but unfortunately are not surprising. We have seen much worse. For the majority of physicians, we have been fortunate enough to work among competent and professional peers. Yet for those of us who have witnessed multiple medical board disciplinary hearings over several years, we have learned to see the situation with a wider-angle lens. In Florida for example, prior to 2009 we had been labeled the “pill mill capital” of the country when doctors were essentially “drug dealers” with a medical license. There was no regard for human life, for standard of care and for the social illness of addiction. Cases of Medicare fraud, unnecessary treatment, and sexual boundary violations were commonplace. We took action by developing policies and laws that protect our citizens and our profession from those who would do it harm.
Unlike some of these more egregious offenses, is it possible that stress and fatigue may have played a role in the reprehensible acts of unprofessional behavior in the above case? Much has been written about professionalism and depersonalization. In fact Google came up with nearly 45,000 references to the two words linked. Furthermore, we are familiar with the term “Compassion Fatigue”, often linked to chronic stress. As we wrestle with seemingly increasing demands on our time from both patients and regulations, it is important that we try to understand the drivers of such behavior. We need to encourage further study, discussion in our medical school curricula, and in postgraduate education, where professionalism is now part of the evaluation process. A Mayo Clinic study, by West et al published in JAMA, 2014 demonstrated that providing protected down time for physicians improved well-being, and reduced stress and depersonalization1.
Despite the pervasiveness of compassion fatigue in the medical field and its adverse impact on clinicians, this issue remains widely neglected. In an effort to evade feelings of hopelessness, anxiety, and emotional exhaustion, clinicians often distance themselves from those for whom they are caring. Unfortunately, this alone can lead us into a “downward-spiral and ultimately create a generation of desensitized physicians. In contrast to this lack of communication is open discussion among professional peers, where an environment of reflection and emotional expression is supported so that clinicians may learn to relieve, manage, and reframe stressful situations2.
Furthermore, in an attempt to neither accuse nor dismiss these behaviors, we can choose to refocus the camera lens to identify the root cause of the problem and find possible solutions. Early on in medical careers, it is our responsibility as educators to identify unethical behaviors and lack of professionalism, and uphold these values and principles so that our trainees learn through observation. Much like a family, we choose the kind of role model we want to be to our children. Papadakis et al reported a higher correlation between students who had professionalism issues in medical school with future disciplinary actions by a state medical board3. There is also a role for state medical board disciplinary hearings in teaching professionalism⁴. The American Board of Internal Medicine identifies elements of professionalism that include 1) altruism, the essence of professionalism, where the best interest of the patients, not self-interest, is the rule; 2) accountability to patients in honoring the patient/physician relationship; 3) to society by addressing the health needs of the public; 4) to the profession by adhering to medicine’s ethical precepts; 5) excellence and a commitment to service by enduring unavoidable risks in the care of patients and advocating best care regardless of ability to pay; 6) honor and integrity by consistent regard for the highest standards of behavior and the refusal to violate one’s personal or professional codes; and 7) respect for others including, patients, families, other physicians, and health care professionals5. In addition, the AAMC has implemented the entrustable professional activities (EPAs) that address many of these core values in students, which will allow them to be “entrustable” as they progress to residency training6.
When a profession does not regulate itself, outside forces need to intervene. The Florida Board of Medicine has instituted a task force comprised of the Board of Medicine members in an effort to outline what is considered physician disruptive behavior or “unprofessional” behavior and to further understand its causes. The purpose of this task force is to highlight the core principles of professionalism and ethical behavior with the goal of providing education and guidance to hospitals so that they may set their own professional standards. Moreover, the medical community needs to galvanize support and encourage reporting of these perceived unprofessional behaviors so that they can be addressed proactively.
It behooves us to tackle policies both in medical education and in the clinical setting that address physician/trainee burnout and compassion fatigue, by improving the practice of medicine through reflective exercises much like we do in classrooms in medical education today7. We need to find the courage to stand up and speak up for what is right in caring for our patients. In the end, we should expect to treat our patients as we would want other doctors to treat our loved ones. We must shift from a paradigm of risk and cronyism to one of resilience and humility, in other words, from a problem to a solution. The future character of our profession and the well-being of our patients depends on it.






References
1. West CP, Dyrbye LN, Rabatin JT, Call TG, Davidson JH, Multari A, Romanski SA, Hellyer JMH, Sloan JA, Shanafelt TF. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174:527–33
2. "RP401 - Session 3.1: Compassion Fatigue | Reflective Practice." Reflective Practice. Web. 18 Sept. 2015.

3. Maxine A. Papadakis, M.D., Arianne Teherani, Ph.D., Mary A. Banach, Ph.D., M.P.H., Timothy R. Knettler, M.B.A., Susan L. Rattner, M.D., David T. Stern, M.D., Ph.D., J. Jon Veloski, M.S., and Carol S. Hodgson, Ph.D. Disciplinary Action by Medical Boards and Prior Behavior in Medical School. N Engl J Med 2005; 353:2673-2682December 22, 2005DOI: 10.1056/NEJMsa052596

4. Lage O, Pomenti S, Hayes E, Barrie K, Baker N. State Medical Board Disciplinary Hearings as Tools for Teaching Professionalism in Medical Education. Journal of Medical Regulation. 2011; 97:8-12
5. American Board of Internal Medicine. Project professionalism. Philadelphia: American Board of Internal Medicine, 1998:5

6. “Core EPAs-Initiatives-AAMC.” Core EPAs-Initiatives-AAMC. Web. 18 Sept. 2015.
7. Malcolm Cox, M.D., and David M. Irby, Ph.D. A New Series on Medical Education. N Engl J Med 2006; 355:1375-1376September 28, 2006DOI: 10.1056/NEJMe068211
Editor's Response
Posted on September 30, 2015
Christine Laine, MD, MPH, Darren Taichman, MD,PhD, Michael LaCombe, MD
Amercian College of Physicians
Conflict of Interest: None Declared
We appreciate the attention that the On Being a Doctor essay, “Family Secrets,” has garnered. Whether readers appreciated or were appalled by our decision to publish it, the essay has clearly generated dialogue about an important issue. Prompting such discourse was exactly why we published the essay. Mr. Vargos thinks it was inappropriate for an internal medicine journal to publish an essay about an incident that occurred in an obstetrics and gynecology setting. We believe the issues raised in this essay transcend specialty divisions. Unfortunately, this sort of inappropriate behavior is not confined to a single specialty-- nor is it confined to male doctors and it is not solely directed only at female patients. We cannot say how common this type of behavior is, but that it happens at any frequency means it happens too often. Physicians should never act this way towards patients. Doing so in front of students and residents they are supposed to be teaching is especially abhorrent. Mr. Pegritz brings up the issue of humor being an acceptable way for highly stressed medical professionals to let off steam, particularly in the setting of actions that save a patient’s life. Yet, as Dr. Dharamsi suggests, while humor can be healing, the patient should never be the brunt of the joke. We seriously doubt that the patients in the essay would have chuckled at the sexually explicit “joke” or joined in a joyous chorus of La Cucaracha had they been awake during the procedures. When we become physicians, we take an oath and part of that oath is to treat patients with warmth, sympathy, and understanding. The ability to heal does not negate the importance of treating our patients with respect. We applaud Dr. Ray for never hesitating to speak up when she witnesses inappropriate behavior and emphasize that anonymous publication was a decision made by the editors. It was not intended to protect the physicians, but rather to avoid a patient who may have received care at an institution where the author worked to worry that she might have been the patient. Dr. Sgro and colleagues experience reflects our goal in publishing this disturbing essay—to prompt thoughtful discussion about professionalism among medical students, physician trainees, and their senior colleagues so that all are prepared to speak up should they find themselves in a situation such as those described in the essay.
Christine Laine
Darren Taichman
Michael LaCombe

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