A Conversation With … Carl Elliott MD, PhD, on How the Unthinkable Becomes Normal in Real-world Medical and Surgical Practice

The best op-ed about medicine I’ve ever read [2] came out last spring. It made me feel more uncomfortable than I’ve ever felt while reading a newspaper. The essay, written by Carl Elliott MD, PhD, a physician turned philosophy professor, began like this: Fig. 1.Carl Elliott MD, PhD“Here is the way I remember it: The year is 1985, and a few medical students are gathered around an operating table where an anesthetized woman has been prepared for surgery. The attending physician, a gynecologist, asks the group: ‘Has everyone felt a cervix? Here’s your chance.’ One after another, we take turns inserting two gloved fingers into the unconscious woman’s vagina. “Had the woman consented to a pelvic exam? Did she understand that when the lights went dim she would be treated like a clinical practice dummy, her genitalia palpated by a succession of untrained hands? I don’t know. Like most medical students, I just did as I was told” [2]. Similar anecdotes also have been widely circulated for a long time now about similarly invasive, intimate, and inappropriate examinations that take place on patients who are men [6]. I don’t know whether these sorts of things still occur. In principle, they shouldn’t, since shortly before that op-ed [2] was published, the Centers for Medicare & Medicaid Services disseminated new guidelines [1] about sensitive examinations on anesthetized patients, which stiffened the requirements for explicit informed consent for breast, pelvic, prostate, and rectal examinations in this setting. But I’m guessing these things still do happen, for reasons this month’s guest has identified. That guest is Dr. Elliott, writer of the op-ed [2]. His recent work has helped me really understand that before one can have moral courage, one must first have moral perception. The problem in his story wasn’t that the students in his anecdote failed to speak up, it’s that they didn’t see that what they were doing was wrong. In his words, social institutions like the profession of medicine “create social worlds where unthinkable practices come to seem normal” [2]. What made me feel so uncomfortable reading his op-ed was that when I look back on similar experiences I recall from my time as a student and resident, I didn’t recognize my actions as wrong, either. It took reading his essay—so many years later—for any of this even to register. What a failing on my part. Obviously, I’m not writing this because you or I do many breast, pelvic, prostate, or rectal examinations. I’m writing it because many of those who read CORR® also teach orthopaedic surgery or learn it in academic settings, and because so many ethically awkward issues in surgical education persist. The most important ones pertain to the topic of consent; starting an operation in one room before another procedure is quite done in the next room over, or deciding when our residents are ready to point power tools in the general direction of named arteries (and what happens if things don’t go perfectly well when they do it). If we give too much responsibility to our residents, we may harm our patients; if we give them too little, they’ll harm theirs in a few years. There are related and rich tangents here, including when and how to confess errors in judgment or technique to patients (and how much to disclose), as well as what to do about the inherent power differentials between surgical teachers and their learners, or between surgeons and their patients. I gave a copy of Dr. Elliott’s New York Times op-ed [2] and one of my drafts of this essay to a trusted and thoughtful nonphysician confidante. Her initial reaction was to suggest that if something a physician is doing feels “off,” it’s probably wrong, and that physician should reconsider the action in question. She noted that it’s easy for professionals (more broadly, not just physicians) to become “nose blind” to ethical corners that are important not to cut. There is a lot of merit to her suggestions, though I’m not sure they’re easy to implement. I felt “off” the first time I was given supervised surgical autonomy as a resident, and the same was true as I scrubbed for my first case in practice. I remember distinctly feeling “off” for most of the year in gross anatomy in med school. In principle, none of those activities represented any sort of ethical lapse. But they called for some hardening of the soul, and medical education more generally is, at times, dehumanizing to the learner. Despite that, we’re expected to graduate and take care not to dehumanize the people we care for. This can be confusing. Some years ago, I wrote this in partnership with a close colleague and friend: “The dehumanizing of surgeons begins early. We enter medical school with a deep respect for surgery, but this may begin to change during anatomy training. We find ourselves in a room full of dead people with bags over their heads. Questions abound: Who is this person? Who loved him? What did he experience? What did he accomplish? Did he donate his body or was there no one to claim him when he died? But in that moment, these questions do not matter. We cut in, damaging the body. By the end, we have sawed and pulled and pushed and ripped and cut him in clumsy, untrained ways. We feel ashamed, as though we have violated him. Towards the end of the year, we remove the bag to dissect his face and head. Only then do we finally see, with no further possibility of denial, what we have done to another human being” [7]. Now after reading Dr. Elliott’s work, I see that, once again, I was wrong. The power of denial is a great deal stronger than I had acknowledged. I had been living in denial from the moment I participated in experiences like the one he described until the moment that I read his op-ed—two events separated in time by more than 30 years. We’re all responsible for coming up with better answers here: approaches to caring for patients that involve appropriate, honest disclosures of what is going to happen to their bodies and how, and approaches to educating surgical learners that aren’t quite so dehumanizing. For some good ideas about how to achieve these goals, please read the conversation with Carl Elliott MD, PhD, on about how we might avoid normalizing the unthinkable. Seth S. Leopold MD:Thanks, Dr. Elliott, for costing me a good night’s sleep (maybe more) when your New York Times op-ed came out [2]. But clearly, it was a good thing you did. Play armchair psychiatrist on me for a minute: I might’ve been 5 or so years behind you in med school. Why would the anecdote you shared be so emotionally disruptive to a medical reader so many years later, and what should we learn from that? Carl Elliott MD, PhD: Most of us—myself included—are pretty good at hiding our moral failures from ourselves. Some of us even manage to convince ourselves that our sins and shortcomings are an essential part of our jobs. In medical training, the conventional wisdom says that you need to develop some calluses in order to protect yourself psychologically—that too much empathy will eat you up from the inside. But the fact is, most of those calluses are already there. It’s shockingly easy to harden yourself to the humiliation and degradation of other people. It’s only when you happen to pass a mirror and catch an unflattering glimpse of yourself that you understand just what you’ve become. Dr. Leopold:The obvious balance here, as I alluded to, is that if we don’t give enough hands-on time to our surgical residents, they’ll graduate inadequately prepared and harm their patients. In this sense, one good surgical education experience during residency may prevent a great deal of harm later. But some may fear that if surgeons in teaching hospitals are overly candid with patients about how surgical education actually occurs, many will decline to receive their care in that setting or in that way. How should surgeons thread these needles? Dr. Elliott: Let me try to answer that in a roundabout way. For The Occasional Human Sacrifice [3], my book on medical whistleblowers, I spent some time with Mike Wilkins, the internist who exposed the barbaric abuse of mentally disabled children at the Willowbrook State School in 1972. The conditions at Willowbrook were horrifying: filthy, overcrowded facilities, little to no care, no attempt to educate the children… just a life of absolute deprivation. I wanted to know how Mike was able to see the abuses at Willowbrook that were so blindingly obvious to outsiders, but which were apparently invisible to all the other physicians who worked there. Mike told me that medical training indoctrinates you into a class system. Doctors are the aristocrats and patients are the peasants. By the time you finish your second year of residency, the indoctrination is complete. At that point it’s virtually impossible to see the world from the perspective of a patient anymore. Mike felt that the reason the physicians at Willowbrook were fine with the barbaric conditions there was that they were incapable of seeing those disabled children as human beings. Of course, all this changes when you become a patient yourself. That’s when you understand in a visceral way what it’s like to be powerless in the medical system. So, let me ask: If you were the patient here, rather than the surgeon—the peasant, rather than the aristocrat—what would you want to be told? I know how I would answer that question. Dr. Leopold:There may be many reasons why patients don’t ask their surgeons at teaching hospitals about the role of surgical learners: some may trust us, others may be afraid to offend us, and some may not even know to ask. A colleague who read a draft of my covering essay about your op-ed, above, took that a step further and wrote: “I find it offensive that the onus is put on me to ask the questions. Even more so, because I may not know what questions to ask or what is the most important question to ask. This is very convenient for the medical professional—‘You didn’t ask me that.’” On some level, the right thing must be “just inform each patient exactly how the teaching is going to happen during surgery.” But we can’t always easily explain or capture in an authentic consent process exactly what might happen in an operation, in which a skillful attending surgeon hands over key portions of a procedure to a well-prepared resident. There are just too many variables and what-ifs. What’s the “right” way to have that conversation with a patient in an emotionally authentic and ethically sound way that does not open up a 45-minute can of worms with every patient? Dr. Elliott: If you’re looking for advice on doctor-patient communications, you probably don’t want to ask a philosophy professor. I have zero claim to knowledge, competence, or expertise on this topic. All I can do is draw on my own experience as a patient (two Achilles tendon repairs) and, more to the point, that of my parents at the end of their lives. What I really wanted to know in every case was that I could trust the surgeons—not just their skills, but their judgment. It didn’t trouble me that residents would be involved in my surgery, or that of my parents, as long as the surgeons were honest about it, and I knew that the care would not be compromised. Dr. Leopold:A tangentially connected theme here pertains to how we let patients know that we erred, and what happens when we don’t let them know. Imagine that I’ve made a judgment call that turned out to be wrong, or a technical error; either way, let’s say I’ve harmed a patient. Many legal experts suggest I shouldn’t apologize, though this may be changing a bit in some places [5]. And even apologizing is a much narrower kind of communication than is disclosing error or failure, and all of this is very different from how people with integrity handle error and failure in almost every other kind of human interaction. How should surgeons do better given the pressures (medicolegal and otherwise) not to? Dr. Elliott: Of all the ways that a bureaucratic institution can choke the life out of you, I think that refusing to allow you to apologize for your mistakes has to be one of the worst. Not only is an apology a mark of decency and humanity, it also represents a deep moral need, at least for people with any sense of honor. Often it seems like the only way to relieve yourself of the shame and guilt you feel when you have made a mistake or done something you regret. That said, I’m not sure that this is the main issue. My father, who was a family physician in practice for 56 years, spent the last several years of his life as a patient. During that time, he was on the receiving end of some truly horrific medical care. These were not honest mistakes. They were the result of neglect, laziness, or indifference. One episode resulted in a life-threatening stay in an intensive care unit. No one ever apologized to him or gave him any indication that they felt any obligation to. In another episode, a surgeon simply lied to him, shamelessly and transparently. In yet another, the physician fired him as a patient. In a fourth episode—one where I spoke to the physician myself—the physician just laughed and ridiculed me for complaining. This was while my father was on a ventilator in septic shock. I had to fight the impulse to leap out of the chair and strangle him. All of these experiences were profoundly disappointing. My father loved being a doctor. He was good at his job, and he respected others who were good at theirs. When he needed medical care himself, he was deferential to the doctors taking care of him—far more than I would have been. He never complained about poor treatment, mainly because he thought complaints would just make things worse. Sometimes I thought that he actually felt ashamed of the doctors who gave him substandard care. It was as if they were letting down the profession. Dr. Leopold:On a slightly different note, there’s a serious power differential here between surgical and medical learners and those who teach them. One whom I spoke with in advance of this interview recalled vividly an experience like the one you described about a patient’s gynecological examination, and wrote me this: “I felt [the cervix]. And I felt that I wasn’t ‘supposed to feel it.’ It was the dehumanization part of the curriculum. The ‘hidden’ or ‘shadow’ curriculum…[but] I kept a ‘pilot light’ of humanity going. And then eventually, I allowed that to bloom more fully anew when I regained some independence as a senior and chief resident…” Because I don’t see the issues you write about changing overnight, can you offer some words of wisdom to surgical learners who want to “keep that pilot light of humanity” turned on? Dr. Elliott: With all due respect, I think that’s the wrong question. If you need to ask how to keep your pilot light going, you are overlooking the more important question, which is why the light keeps blowing out. You’ll never keep it going for very long unless you fix the underlying problem. And the problem here lies in the conditions of the job. In his book, The End of Burnout [4], Jonathan Malesic writes, “The person your job wants you to be is the person you tend to become.” To imagine that medicine doesn’t mold and shape you is delusional. The only issue is what kind of person it shapes you into. When I met Oscar Simonson, one of the cardiovascular surgeons who blew the whistle on Paolo Macchiarini’s lethal, fraudulent trachea implants in Sweden, he compared his medical training at the Karolinska Institute to joining a cult. That comparison might sound extreme, but you have to remember it comes from someone who was threatened and punished by his institution just for trying to prevent patients from being killed. Academic medicine is fiercely hierarchical and authoritarian. There is intense competition for funding, status, and power. Dissent is not encouraged. What is encouraged is social conformity, subservience, and toadying up to power. If you want to produce humane physicians, you have to change the culture of medical institutions.