Episode 7.13 Uterine inversion, Trainee Harassment and Mistreatment, and Suicide
In this episode, we discuss four tips for uterine inversion. Then, we discuss mistreatment and abuse of trainees in OB/GYN plus physician suicide. Finally, we answer a question about closure of peritoneum.
00:00:02 Managing Uterine Inversion in Obstetrics
00:13:39 Combatting Harassment in Medical Training
00:25:41 Addressing Mistreatment in Medical Training
00:31:13 Workplace Mobbing and Bystander Dynamics
00:37:29 Identifying and Addressing Workplace Abuse
00:59:30 Listener Question
Links Discussed
Sexual Harassment, Abuse, and Discrimination in Obstetrics and Gynecology
Consequences and potential problems of operating room outbursts and temper tantrums by surgeons
Suicide among doctors: A narrative review
A study of non-closure of the peritoneum at vaginal hysterectomy
Transcript
Announcer: 0:02
This is Thinking About OB-GYN with your hosts Antonia Roberts and Howard Herrell.
Howard: 0:17
Antonia.
Antonia: 0:18
Howard.
Howard: 0:19
What are we thinking about on today’s episode?
Antonia: 0:21
Well, we’re going to talk about mistreatment of residents and medical students and about its consequences, and we’ll also try to answer a listener question that we didn’t get to in the last episode. But first we’ve got four tips for the management of uterine inversion. So this is a very rare but scary obstetric emergency where the fundus of the uterus inverts inside out, often during attempts to deliver the placenta, or perhaps right after the placenta delivers, and it just it’s exactly how it sounds it inverts into the cavity of the uterus and maybe all the way out through the cervix and even past the introitus, completely inside out. This can happen outside of that immediate placental delivery setting, it can happen later, but most of the time, if it’s going to happen, it happens right then and there, during the third stage of labor, and the incidence is about one in every 3,500 births.
Howard: 1:20
Yes, it can be very scary because significant postpartum hemorrhage can occur, as the uterus may not be able to contract down correctly when it’s turned inside out. So there’s a fairly high rate of blood transfusion and shock and emergency surgery even associated when a uterine inversion occurs, and then, of course, a significantly higher risk of maternal death that goes along with all those things.
Antonia: 1:41
Okay, so we have four tips for management of acute uterine inversion and, like in a lot of other four tips and emergencies that we’ve discussed before, the first tip is prevention.
Howard: 1:53
Yeah, it’s always easier to not have an emergency than to deal with an emergency. So, understanding what we can do to prevent uterine inversion, or what we might do that causes it, and avoid those things, well, that’s difficult because it’s still a relatively rare condition. So it’s hard to study this and hard to control for many confounding factors. One obvious risk factor, and maybe the greatest risk factor that we know of, is abnormal placentation, and there’s nothing we can specifically do about that, except perhaps have an awareness that if the third stage of labor is prolonged, then you should consider that the placenta might be inappropriately attached, and I’m fond of having an ultrasound at the bedside whenever I have a prolonged third stage of labor so that I can see what I’m doing and just understand where the placenta is located. But risk factors that we have the most control over include how we manage the third stage of labor. One management decision that’s often criticized is umbilical cord traction in terms of are we pulling it out and causing the inversion? But newer studies really don’t show that this is associated with an increased risk of uterine inversion. The cord may break if you have excessive traction, but you’re not likely to increase the risk of uterine inversion.
Howard: 3:03
So a couple of things that still remain as risk factors that we might be able to control is manual extraction of the placenta. If this is done, perhaps it indicates that there is some abnormal placentation and therefore the risk was increased anyway, but it also just might be born out of impatience. So don’t do manual extraction unless you really need to, and then be prepared for uterine inversion as a possible consequence. But the one technique we can probably do without is putting a hand on top of the uterus and massaging the uterus before the placenta is delivered, or even really just having the mother bear down with delivery of the placenta. We don’t need to increase the pressure on the top of the fundus, either with our hand or with that maternal Valsalva effort, while we’re at the same time pulling down on the placenta. So that’s the one thing that probably really shouldn’t occur in modern obstetrics.
Antonia: 3:52
Yeah, I’ve been in a lot of deliveries where somebody whether it’s a nurse or my senior colleague or junior colleague asks the mother to push while we’re waiting on the placenta, and sometimes the patients themselves will either just start pushing or they’ll ask like, are you ready for me to push for this part yet? But the maternal Valsalva efforts are not contributing to the placenta separating from the uterus, and neither is the cord traction, by the way, and the maternal Valsalva really isn’t doing much after the placenta is separated to expel the placenta out through the vagina. That’s the part that the cord traction works on, just so it’s not sitting there in the birth canal. What’s getting the placenta to separate is the uterus contracting and the placenta not being morbidly adherent. So it is at least theoretically possible, if you think about the physics of it, that if the mother is pushing really hard, her intra-abdominal pressure could push down on that big floppy part of the fundus inwards into the cavity and invert it. And you can also do that unwittingly yourself if your hand is up at the fundus and you’re pushing, pushing downwards as the placenta is coming out.
Antonia: 5:10
I’ve visually seen this once during a cesarean, but at least at that time we were able to see it and immediately flip it back. But it was pretty clear how, before the placenta comes out, sometimes that uterus is floppy and it can easily turn inside out like a little sock. So don’t get tricked into doing that, because you might really regret it. So, okay, we’re going to summarize the additional tips for actually managing it. But obviously the first step is prevent it by not doing things that will cause the uterus to flip inside out. But let’s say that it has anyway. Maybe the mom pushed even when you didn’t ask her to, or maybe you know, maybe the placenta is stuck and now it’s inside out. So the next tip is you have this inverted uterus, the placenta is stuck. Do not try to remove the placenta.
Howard: 6:00
Right, at least not immediately. So your best opportunity to restore the fundus and revert the uterus is as soon as you see that this is happening and if you remove the placenta that’s still attached. But also, during this time, prepare for the emergency. So start a second IV, request a type and cross or even unmatched blood if that’s what you need. Get fluid boluses started, call for help, get an OR team, call for an anesthesiologist while you’re attempting to replace the fundus. Now it may be that you can’t replace it because of the size of the placenta and that’s why it’s tempting to people to take it off. And if you’re going to try to take it off and replace the fundus after you’ve removed it, that’s fine. But take advantage of the time that the placenta is still attached to prepare for this impending emergency if you don’t get it back in.
Antonia: 6:57
Right, you can wait to remove the placenta. Remember that there’s some cases, there’s some case theories where with placenta accreta, they actually successfully just never remove it. They just leave it there and of course there’s morbidities and stuff with that. But it’s not an emergency to leave the placenta on if it’s not coming off. So, either way, the first thing you’re trying to do is replace the uterus, re, flip it back back to right side out, and while you’re doing this, you’re getting a second IV and everything available you need. So the third tip is, while you’re doing this, you are probably going to need to use a uterine relaxant.
Howard: 7:38
Right, you don’t have to do this with your first attempt and obviously you can ask for this while you’re attempting. But you can give the patient 100 micrograms of nitroglycerin to relax the muscle of the uterus and this may significantly help your efforts. Remember that also for Zavanellis. We talked about that before in our emergencies episodes.
Howard: 7:56
But be prepared for the fact that now the uterus is going to be relaxed when you get it replaced and you may have subsequent hemorrhage. So using something like a Bakri balloon afterwards or our acne protocols may become very necessary. So you want those things ready too.
Antonia: 8:10
Yeah, so essentially you’re going to hold the inverted fundus in your hand and you can use your fingers to try to dilate the cervix and the lower uterine segment in order to accommodate the fundus, push it back with as much of your hand as you can and hold it back up in the pelvis and if you can successfully un-invert it or revert it, then you probably want to keep your hand in there for at least a few minutes, firstly to help squeeze the uterus with a bimanual while the other uterotonics are working, and also just in case you need a Bacri. You have your hand already there and you can start feeding it in a Bacri or I don’t know if places are. Some places are already using Jada’s now, but you know some kind of device and doubtful that the uterus would re-invert, but if your hand’s there, then you can. You know you can catch it.
Howard: 9:03
It might if you take your fist off and immediately start doing fundal massage to try to yeah, yeah exactly.
Antonia: 9:08
Yeah, OK. The fourth tip is prepare for operative interventions.
Howard: 9:14
Right. So if you’ve done all those things and you still don’t have it corrected, then you may need to do surgery, and we don’t have to describe all those techniques right now. But I think the important part is that early on you’re preparing for that. So you have to call up front for an operating room to be made available, call for anesthesia to come to the bedside you may need them with your hemorrhage efforts anyway and now if you’ve not been able to get it at the bedside, you’re going to need to go to the operating room and prepare for surgical intervention.
Howard: 9:43
So usually if you’re not able to restore the uterus, it’s because of a contraction of the cervical-uterine junction In an unstable bleeding patient. In this situation you want to make an abdominal incision, like you would for a cesarean, and grab the fundus with a pair of Alice clamps, pull the fundus back up through this inverted tunnel. That’s what’s called a Huntington procedure. And if the cervical vaginal junction is too constricted to allow you to do that, then you can do a Haultan procedure, where you cut the constriction band with a vertical incision, usually on the posterior side, to avoid the bladder, and then pull it up through.
Antonia: 10:18
Like all emergencies, early recognition and a team approach is going to be key. So if you have an acute uterine inversion, do not feel bad for calling for all these things that you anticipate you could need in the worst case scenario. Even if then, 20 seconds later, you reverted it and everything is fine and you can call them all off, that is a good outcome. No one should be upset with you for making that call only to have them turn back around and walk away. That is so much better than the opposite, where you’re afraid to call. You actually need them. The mom’s about to go into shock and you still haven’t even called.
Howard: 10:53
Yeah, absolutely.
Antonia: 10:54
Yeah, better to call up front and remember, if she’s like really pouring out blood, someone can hold pressure against the aorta. You can actually push back through just the abdominal wall and if a patient’s open then you can even call in a surgeon to cross clamp it if you’re in that bad of a spot.
Howard: 11:15
Yeah, better to be prepared and not need things than the opposite, for sure. So well, folks should definitely read about these surgical procedures and look at pictures and understand how to do them before they might ever need to in real life. This is another type of emergency where simulation can be very beneficial. It doesn’t mean that you have to simulate the actual procedures and need some fancy mannequins or anything, but simulating the readiness and preparedness of your team is useful. Preparedness of your team is useful. For example, you might find that if you do an in situ simulation, that no one knows where the nitroglycerin is or where the dose is, or how it’s administered or just things like that. So in situ simulation can help prepare for some of these rare emergencies.
Antonia: 11:56
Yeah, I’ve found it’s always nice to have a run through of how long does it take someone to get to the blood bank and back, for the emergency release is usually that needs a little polishing. Anyway, let’s move on to our topic.
Howard: 12:09
Well, this is the last episode of this season and our, I think, 91st episode overall.
Antonia: 12:15
And we’re going right into another season, just in case anyone’s worried. But that’s pretty exciting. So at this point it would take someone about four days of like straight listening to the podcast and nothing else to get through all our episodes.
Howard: 12:29
Well, this episode comes out on Wednesday June 26. So if there are any new interns out there who start residency on Monday July 1st, well, you have exactly four days in between to listen to every episode and be ready for work bright and early Monday morning.
Antonia: 12:44
four days in between to listen to every episode and be ready for work bright and early Monday morning Perfect timing. I think that would also prepare them for sleep deprivation, because that would be four days with no sleep and then going straight into work on Monday morning, first day on the new job.
Howard: 12:56
Okay, so maybe they don’t have time to listen to every episode with the new work hour restrictions and all, but they could still get through two thirds of them, or they could listen to them at 150% speed and have time for sleep, and then, if they have any leftover, they can get to those in the evenings after their work is caught up.
Antonia: 13:13
Well, I think probably a less fanatical idea or less crazy idea would be to spend the next four days in their happy place, get lots of sunshine and fresh air. Definitely be aware of our podcast. Maybe over the next four years you’ll have gotten through all our episodes. That would be fine and you’ll probably want to like stand in front of the mirror and practice your power poses and just really psych yourself up. I know we’re about to go into a discussion about this, so at a minimum, there’s going to be a lot of humbling experiences, but even the first day intern is going to be a hugely important role. It’s easy to joke that you think that you’re nothing and you’re just a baby intern, but they’re all already really depending on you to carry the team and any little bit of enthusiasm, curiosity and zeal you can bring is going to lift the whole team up and it’s going to be very defining. So really get excited, go into it positively.
Howard: 14:11
And everybody makes jokes about July 1st being the worst day to be in the hospital, but actually it’s one of the safest all year.
Antonia: 14:18
Yeah.
Howard: 14:19
The. There’s a lot of attention, a lot of people on their toes, a lot of people looking, a lot of double checking, and so I would have no problem being taken care of by an intern on.
Howard: 14:29
July 1st in a hospital in the United States. Well, speaking of new residents starting on July 1st, there is a study that was published in May in JAMA Network Open Access that made a few waves At least. This was called sexual harassment, abuse and discrimination in obstetrics and gynecology a systematic review. So this was a review of studies that had already been performed and published, which included data from nearly 9,000 participants students, residents and also attendings and fellows. They have data from both trainees and, as I said, those already out in practice. Some of the studies were done with gynecologic oncologists, but a lot of it was from trainees. So some of the highlights about 70% of OB-GYN trainees reported some harassment, which included gender harassment, unwanted sexual attention and sexual coercion. A quarter of students on OB-GYN rotations reported some mistreatment during their rotation and about 30% of that came from physicians, while smaller amounts came from other trainees or operating room staff or things like that.
Antonia: 15:35
Well, that’s pretty terrible and disgusting because of course, this lifestyle, especially this training, is already hard enough. Lifestyle, especially this training, is already hard enough, even when everyone around is behaving in the most appropriate collegial way possible. So obviously those numbers should they should be zero. This shouldn’t be happening at all and it’s indefensible. So I guess the only good thing I can personally say is that I had no idea it was this prevalent, because I really hadn’t encountered this myself in my career, so maybe I’ve been blind to it being so common. But yeah, in this review, among the trainee responses, only about a third reported their harassment. But of those, almost three quarters of those that did report it reported it to another trainee. So that essentially means the vast majority of harassment is going unreported to anyone that would have the authority to do anything about it. And 40% of the trainees in these studies said they didn’t report because they feared retaliation.
Howard: 16:39
Well, when I read this article, one of the things that I thought about at this time of year, as new interns and residents and students are starting their rotations, wasn’t so much the overt sexual harassment or things like that, but some of the microaggressions and bullying that accompanies new students and new residents in particular. There’s this culture of hazing and bullying that often accompanies new trainees, and some of it’s from other residents or senior residents, some of it’s from attendings, some of it’s from nursing staff and operating room staff who are just establishing their primacy over the new trainees. But they do this through abuse and things that don’t quite rise to the level, maybe, of reporting, and these sorts of things have often been called microaggressions, and they do also include some data about that in the study as well.
Antonia: 17:28
Yeah, I think it’s really informative. Like it’s good that they captured that as well, because often it can be the small things that add up day to day and month to month that can just crush someone’s morale, and it can be sometimes so small that maybe the target even doubts themselves about it. Like, did that nurse really mean to upset me and make me embarrassed, or am I just being overly sensitive? But usually if you’re asking yourself that me embarrassed or am I just being overly sensitive? But usually if you’re asking yourself that there usually was some kind of malice underlying or at least some insensitivity. So some of the microaggressions they listed here are more explicitly in terms of bias, usually gender bias, and that could include female physicians being referred to as a nurse by include female physicians being referred to as a nurse by well, whether it’s patients or other medical professionals or that.
Antonia: 18:22
This kind of stereotypical being told to smile more, being told to dress prettier, being told to act more feminine, maybe being criticized, either overtly or covertly, about decisions with family planning, taking off too much time for maternity or child care or just breastfeeding pumping. In one study of 18 OBGYN trainees, 17 of them said they had been mistaken for a non-position, and 16 of them said that they routinely apologized in advance when asking for something from either a surgical technician or a nurse. 15 of them said they routinely had to make requests multiple times because they would never be addressed or acknowledged the first time they asked for something, and most of the offenders here were in the OR setting surgical technicians or circulating nurses. They also cited a study where nearly half of OBGYN clinicians reported burnout directly related to these sorts of microaggressions.
Howard: 19:25
Yeah, it has to be frustrating to feel not respected or not listened to in your role on a daily basis and have to deal with that, and it’s also important to note that these sort of gendered microaggressions although not all of those are specifically gendered, but most of the studies have been on that Well they’re not limited, at least in our specialty, to males mistreating females, and that certainly was likely the case many decades ago, but most of these scrub techs and circulating nurses referred to in these newer studies were themselves female, treating female trainees in a different way than they might treat male trainees, and among male trainees, though, they reported less workplace discrimination than women did still nearly 40% reported discrimination, and most of this was gender discrimination, which is a paradox of OBGYN that doesn’t really probably exist in other specialties, perhaps because male trainees and male physicians have now become the minority in a field that’s increasingly dominated by females, but also obviously because the patients are female, and we’ve talked about gender bias before on another episode and some data about that, but just as a personal commentary, I see many females treat other women far worse than I sometimes see males treat women.
Howard: 20:39
That could be a bias, but it seems true.
Antonia: 20:41
It seems like the overall tolerance of discrimination and possibly the flavor of it. Who does it target the most or what direction it flows in. It’ll vary widely by program and I think it’ll vary widely by the senior leadership, and I think we all know it can go in so many different ways and the power differential really is the key factor there.
Howard: 21:03
Right. A lot of these studies focus on abuse that’s clearly delineated along gender or race or sexual orientation lines something like that, which generally are all supposed to have legal protections at this point against such discrimination or mistreatment. But the same power differentials that would allow these protections to be violated can also create just malignant and toxic environments where mistreatment and harassment runs in the form of hazing and verbal abuse and petty jokes and mobbing of junior trainees or students. They did cite literature about medical student mistreatment and a quarter of medical students reported occasional or frequent mistreatment, including verbal abuse and coercion, mostly coming from resident physicians. In another study, three quarters of medical students reported belittlement and a quarter reported frank harassment by OB-GYN residents, and compared to other clinical core rotations, including general surgery, which we might think of as a very intense and potentially merciless environment, it was actually OB-GYN that had the lowest professionalism scores. In one older study, four out of 16 medical students actually reported physical abuse while on their OB-GYN clerkship.
Antonia: 22:12
I just don’t know what to say about that. I keep being surprised and shocked, I guess, by this whole conversation so far. Who, what kind of a preceptor is delivering a baby and then turning around and hitting their students like that’s?
Howard: 22:28
And we don’t know yeah, and we don’t know the nature of the physical.
Antonia: 22:31
Yeah, but yeah.
Howard: 22:32
But I can imagine some things.
Antonia: 22:34
Yeah, that’s just like child abuse. Honestly, that’s really cruel. But I could imagine if that is happening and then there’s a student that has nerves of steel enough to still want to go into OBGYN despite being treated that badly, they’re going to become a resident who maybe they still get belittled and harassed and bullied by their seniors for years and years until eventually they’re in the position of power and they end up doing the same thing to their students because that’s all they know. It’s not even conscious anymore, and so this whole thing creates a vicious cycle that’s negative for education and for patient care and a huge detractor from someone good, someone that we want being interested in pursuing a career in OBGYN, when that’s the experience they see on their core rotations.
Howard: 23:24
They do also review literature about potential interventions for these types of behaviors and note from other non-OBGYN literature that the rates of harassment, in particular of surgical trainees of any sort, are very high. In fact, so-called academic bullying was reported by 32% of general surgery trainees, 25% of OBGYN trainees and a little less in other specialties. And then about a quarter of OBGYN trainees also reported sexual harassment and this was still second to general surgery, which had the highest rate of sexual harassment reporting. They also found a high tolerance of things like tantrums and swearing and humiliation and just a cultural acceptance of undermining trainees as some sort of rite of passage.
Antonia: 24:06
Yeah, I’m pretty thankful that I really don’t relate to this at all. I suppose I’ve seen and experienced my fair share of being nervous presenting something at Morning Report. That’s probably the extent of I don’t know if I’d even call that academic bullying. But I think we we learn enough from taking care of patients as a team and then reading about or witnessing or talking about the complications that we want to make sure we minimize and that’s it.
Antonia: 24:34
And I think the lessons I’ve learned most strongly have all been in settings where you know, maybe that maybe there was a complication, whether it was in my hands or my colleagues hands, but there was never any finger pointing. There was just a really productive analysis and discussion and a kind of a commitment to do better and not any kind of name calling or this was all your fault kind of thing. But I wonder if that does happen to someone in their training. Maybe those doctors who have been academically abused think that it made them stronger because they survived it. Maybe they think that it made them learn certain principles well because they did learn it, even though it was maybe even despite being yelled at as they were learning that stuff, and maybe they are comparing it to this idea of military boot camp or SEAL training or something where the candidates are intentionally and strategically torn down so they can be built back up. But if that’s the case, I don’t know that I’m really seeing the whole intense building back up piece in all of these studies.
Howard: 25:41
Yeah, certainly among general surgery programs. A lot of the large academic general surgery programs around the country were really developed with Korean War trauma surgeons as their initial surgeons and chairs in this modern age of intensive care and surgery, and so a lot of the surgery attendings came from that. So that’s what surgeons talk about. Is this legacy of a militaristic kind of thing? But that’s not the world we live in anymore.
Antonia: 26:05
Yeah, yeah, specialties that have high pressure environments, like OBGYN general surgery and many, probably many other surgical or intensive care type environments, will have their moments where even the well-meaning and otherwise very gentle and calm people they can get tense and snap if there’s a life or death situation and there’s kind of chaos in the room. So that can happen much more so, obviously, with someone that already has baseline anger management issues. More so, obviously, with someone that already has baseline anger management issues.
Howard: 26:49
The high stakes environment probably does contribute in some way to this kind of mistreatment that we’re talking about, than it is to address these other things that create a toxic environment, like bullying and hazing and undermining and demeaning language or temper tantrums or verbal abuse by physicians, particularly attending physicians, who are probably in a stressful situation when it occurs, but it’s just ignored and I think that’s more likely to be ignored than, frankly, outright violations of policy. That would include sexual harassment or using a racial slur or something like that. Hazing and abuse is what new med students and new residents are getting ready to potentially experience next week in large numbers in OB-GYN and other specialties, according to this new data.
Antonia: 27:32
Yeah, I know that probably now doesn’t feel like such a great pep talk anymore, but hopefully we’re going to help with awareness and help turn this around a little bit. Keeps happening down generations because it’s the children who were abused that often grow up to parent their own children in a more abusive way because they don’t know what’s not normal about it. They think it’s normal and expected and it’s just difficult to break that cycle. And that certainly does exist in surgery and OBGYN residencies and probably many other type of residencies as well. And you might even hear people say things like when I was an intern, we had to do blah, blah, blah any kind of unpleasant thing you can just insert there.
Antonia: 28:28
And interns these days they’re soft or no work ethic whatever because they’re not being subject to whatever unpleasantries that older person was subject to.
Antonia: 28:39
But somehow there is a disconnect there that they were being mistreated and maybe they shouldn’t have had to do that unpleasant thing that now they’re basically bragging about.
Antonia: 28:50
And just because they were mistreated, it doesn’t mean that they need to pass that mistreatment on to others or hold it against others that they need to pass that mistreatment onto others or hold it against others that now things are slightly better. The only thing I can relate to here now that I think about it is when a lot of my attendings would talk about their work hours that they used to have before the ACGME restrictions came into place. They were in place when I was training. Maybe that qualifies as maybe a systemic kind of mistreatment in a way, but I remember they seemed to have very little sympathy for any of us being tired after our 80 hour work weeks and maybe even if we went a little over that on one week and having average five to six hours of sleep a night when they would always want to bring up. I used to work 120 hours each week and I would just fall asleep on my drive home.
Howard: 29:41
Yeah, it’s like bragging about driving drunk or something. Right, and it’s a microaggression to make you feel bad about being alive in this era where we are concerned about safety.
Antonia: 29:52
Yeah, yeah, but I’d say, other than that there’s occasional someone being a little bit snippy or rude here and there, but overall I think I had a lot of really good role models that I still try to emulate that were actually very understanding and patient and professional. Yeah, so it is possible, it already is happening. That is not that. That’s not 100% what people are going to go into if they’re already starting to get scared about us talking.
Howard: 30:20
It sounds like a lot of other programs should be taking notes from your program and we’d love to hear listeners’ perspectives and experiences on this good or bad, or ideas about how to make it better or examples or things like that and certainly this data doesn’t represent the majority of programs or the majority of academic teachers of OBGYN, and so those good experiences need to be highlighted. I also think this paper got a lot of flack because a lot of people were in shock about this is not really going on, and sometimes that’s because it’s not at their program and sometimes it’s because they just have an unawareness of some of the things that are happening and don’t even view them as bad because they don’t have the perspective of the student or the trainee. But we’ve talked before about how male medical students on OBGYN rotations will often feel excluded and denied certain educational opportunities because of their gender, and the residents who are listening to all of our episodes in the next four days will run across that one at some point. I’m sure we also all have examples of mistreatment from our own training and we probably have all seen examples of where perpetrators of that mistreatment went unpunished or, if there were reports made, the person who was victimized ends up being victimized again because of the power differential that exists. So my turn for a story.
Howard: 31:32
When I was an OB-GYN clerk which was not at my medical school, by the way On the first or second week of my eight-week rotation, I was verbally abused and threatened by a second-year male OB-GYN resident who I just met minutes before at 6 am, and this happened in front of a chief resident and three other residents during a period where we were running through the list of patients. Now, a lot of people who know me personally have heard this story and I won’t share all the details here. But basically the cause of the mistreatment was because I had made a comment that not all genital herpes is caused by HSV-2, and sometimes and actually today now more often than not is caused by HSV-1. But this particular resident believed that all cases of genital herpes are indeed caused by HSV-2. And then he proceeded to reenact a scene from the first 15 minutes of Full Metal Jacket. If you’ve not seen it, watch it.
Howard: 32:27
And none of the other people in the room said anything during this sort of two-minute tirade threatening and really just horrible. And none of them corrected him or stopped him in any way and his abuse and harassment continued. And it actually continued for years after the rotation. I heard stories. Apparently he thought it was funny to treat medical students in that way and he would tell jokes about how he got the better of me, I guess, and he never suffered a real consequence for it. So he was probably emboldened by the lack of a consequence and continued, maybe to mistreat other students as well.
Antonia: 33:04
Well, that’s just really appalling. It sounds like he was embarrassing himself the whole time and no one really wanted to point it out. Maybe they didn’t like him, but did you report him or how did you handle that?
Howard: 33:16
Well, of course I’m worried at that point about my evaluations, as any student is, I suppose, and my grade, and as someone who was there, interested in OB-GYN and honestly interested in a potential residency at that program, one of the reasons why I did the rotation there and again, this wasn’t my home medical school. Well, I wasn’t sure how to handle it and I had never seen anyone have success in handling things like this either. I did a few things, I talked to people in the room and they were reassuring and made excuses for him. I had lunch with the chairman one day, who I think is I still do think is a wonderful doctor and a fine person, and I felt comfortable in telling him that this had happened. And I did that primarily to protect myself because I wasn’t sure where this was going to go or what the resident would do.
Howard: 34:06
And there were other episodes of abuse beyond that initial day, a couple of more episodes and some more overt threatening, and I don’t know for sure. But I do think the chairman said something to him because eventually he just steered clear of me or was nicer in the last month or so, not conciliatory but steer clear. But by the end of the rotation he produced a scathing evaluation full of just overt lies that was immediately discredited and unbelievable, honestly, by the clerkship director because it was so inconsistent with other evaluations and just also had verifiable fallacies in it. But the bad talking continued for a couple of years, as I said after that, and I knew that excluded me from consideration in that program, even just for the sake of having to work with him as my chief resident for a year. By the time I would be there just seemed impossible. So that’s when I first learned about workplace mobbing, and unfortunately it wasn’t the only time in my career where I experienced workplace mobbing, which is really a subset of workplace violence.
Antonia: 35:07
Why don’t you go into that idea a little more? The workplace mobbing?
Howard: 35:11
Well, the condition in my situation there, and for all medical students and many other trainees, is that we’re there on a rotation for a very short time. You may only work with a group of people for a few days or a week, and even your whole rotation may never be longer than a month or two. But the longer term faculty and residents and nurses and all those other folks they have to work together with people for years, including such an offensive person. And so this offender, who may be harassing a student or a trainee and around other people, well, they’re forced to make an uncomfortable choice, and so, in my case, the chief resident, who was sitting there when it happened, and three other witnesses to this behavior. They all made a choice to do nothing because they would have to continue working with him for another two and a half years or whatever, but I would be gone in a few weeks and they only would interact with me for a few days in their entire life, but would have to be around him for who knows how long.
Antonia: 36:07
Kind of reminds me of that TV show called what would you do. It’s hosted by John. It’s like a reality show where people are put in different situations on hidden camera and and the vast majority refuse to do anything when they personally witness someone verbally or physically being violent or mistreating another person.
Howard: 36:31
Yeah, and I guess that’s human nature. But even in that example that you mentioned, well, that depicts people who don’t really have any skin in the game. They’re just bystanders. They don’t know the abuser, they don’t know the abuser, they don’t know the abused. So I think it’s even worse in workplaces, where they may not like this abusive person and they don’t like his behavior, but they stand by and do nothing because they have to make a choice about how much of this treatment they want to suffer themselves or what the repercussions may be for dealing with this.
Antonia: 37:01
So they unfortunately tend to naturally align themselves with the abuser and then a whole group does that and it has this sort of inertia about it and that’s called mobbing. So maybe they think they’re just not getting involved or keeping the peace, but really they and really it’s supporting the abuse, and they might even go as far as supporting the abuser in overt ways as well.
Howard: 37:26
Yeah, that’s right. Silence is support here. The evaluation that was made that was negative, that I found out about at the end of the rotation. It actually wasn’t written by the abusive person, it was written by an intern and a second year resident and the second year resident I had never even met. But he dictated this evaluation to them, didn’t put his own name on it because he knew that it would be flagged as biased or discredited if he did it, but he dictated it to them and they turned it in.
Antonia: 37:54
Well, that’s just so spineless and unnecessary and I don’t know. There must be some kind of pathology with that person just psychiatrically, because that’s a whole lot of effort and thought spent by someone who probably had very little free time, probably was sleep deprived, and could have used that time well to better educate themselves on HSV-1 and HSV-2, or maybe take a nap or get some anger management counseling like something productive, anything but what they were doing. But yeah, from those other residents’ perspectives, that second year and that intern that even participated in this it was maybe it was easier to take his word for it if they were never there, but they probably knew he was embellishing things. They were probably in survival mode too. They probably were worried about coming under the fire of this monster. You know they still had years and years ahead of them.
Howard: 38:51
Yeah, and he was going through some things and I’m not going to talk about any of that here.
Howard: 38:55
But you’re right, we all have personal stress and things that happen to us, or accumulation of things, and then we act perhaps differently than we normally would.
Howard: 39:05
But that doesn’t mean it’s allowable. We don’t make excuses for bad behavior just because of personal stress. We intervene and we help the person and help the situation and we don’t allow vulnerable people to be abused just because someone else is having a bad run of luck. But, interestingly, one of the two residents that I mentioned that wrote the evaluation on his behalf later, many years later, apologized to me for her part in the whole thing. We were having a couple of beers at a meeting and she admitted that he had dictated the evaluation to her and that she knew the things in it were made up, and she apologized for going along with that and for not reporting him or putting her name to this and not helping me. And that’s exactly what she said that he was a bully to all of them and so it was just easier to dump on me. I would be gone and probably didn’t need to be a resident there anyway with him in that picture, and it was just easier to do that than to suffer further abuse.
Antonia: 40:02
So she actually felt guilty about it.
Howard: 40:04
Well, of course she did. She’s not a bad person at all. She’s a good person and good people go along sometimes with this type of overt abuse and just bide their time and let it pass and don’t want to be disruptive and don’t want to deal with things and everybody’s busy and have complicated lives and it takes a lot of courage to stand up to someone viewed as powerful in these situations. So they may be desperately beat down themselves and in survival mode and maybe have clouded judgment in the moment and regret it later, even if overall it doesn’t align with their own personal ethics and principles to support such abuse.
Antonia: 40:41
It seems like a lot of this stuff, as you said, can start with smaller events, like the microaggressions, and then build up like how?
Antonia: 40:49
Now? I’ve never done this, but I’ve heard that if you put a cold blooded reptile like a frog into a pot of water at room temperature and slowly crank the heat up, they won’t be aware that they’re about to boil. So it’s a slower buildup and the abusive person just gets emboldened after getting away with the smaller aggressions and they become larger and larger over time and then they just keep getting away with them year in OBGYN. They may not have ever had to practice dealing with such immature people that are both in a high stakes environment and have significant authority over them, but it does seem like the solution here actually is to at least mentally practice this and prepare this, prepare yourselves for this somehow, and get comfortable with calling out microaggressions early on, nipping it in the bud before it gets out of control. So how would you do that and do you think? Do you ever think about something you would have said if you could go back in time?
Howard: 41:55
Well, it’s all hard. I do think that getting comfortable with calling things out is an important step and there’s some behavior that all of us would respond to and maybe just think of it as we need to turn our threshold down for response and I’ve tried to do this. I’m not perfect by any means, but I have learned something from this lesson and I’ve tried to do these things. I joke around as much as anybody, but there’s just unacceptable things to do. But it’s hard, especially when it comes from someone you work with all the time and how you deal with that. And maybe you do it privately the first time, although that’s not very supportive of the person being victimized. So it is difficult.
Howard: 42:30
But obviously someone who’s a bit of a bully and is using this sort of language or being abusive to learners doesn’t believe that they are being abusive and they’ll probably respond negatively to having someone call out their microaggressions to them, which can make this even more intimidating to the victims. But in response to an outright insult or threat, I’d start with something like I’m not sure I understood that. Could you please say that part again, maybe follow up with did you mean for that to be hurtful, just to make him hear himself and say it again, and those are effective strategies that you read a lot in literature about responding to these, and they’re similar tips to what a guy named Jefferson Fisher recommends. He’s a lawyer in Texas who does personal injury cases not Med Mal, but nothing really specific about us, so we can like him, but he makes little videos on you know, on TikTok and stuff about how to deal with difficult people in the workplace that have suggestions like that.
Howard: 43:25
But these are things that you can learn and practice and implement. In my case, obviously, we didn’t have smartphones at the time, but I wish I had said something like okay, maybe you’re right, let’s just go look it up and come back to this later. Although I wasn’t really given that opportunity, I did look it up. I was at the library that night and carried around the papers in my white coat for the next two weeks about incidents of HSV and genital cultures, but that wasn’t helpful either.
Howard: 43:50
This wasn’t about the facts, right?
Antonia: 43:52
Right right.
Howard: 43:53
I think each institution and department should have examples of behaviors that would include both overt abuse and these microaggressions, and a described policy that these behaviors are not tolerated, with defined consequences, and then, of course, a system of reporting and enforcement of that. So that seems to me the easy thing to do, and to have required harassment, training for students and residents and attendings with these examples. But then when the most important maternal fetal medicine doctor, or the chairman of the department, or the well-respected but temperamental ganank or whoever that’s seemingly really important, exhibits this behavior to a learner, the question is then actually is it going to be enforced or the consequence is going to be enforced? Is it going to be dealt with seriously? Because the moment that it’s not enforced and people are given some special treatment because of their seeming importance to the program, well, they’re emboldened and it goes on and I think that’s what promotes the cycle of abuse.
Antonia: 44:49
Yeah, we really should consider and have this perspective of how miserable someone must be to be treating someone else that abusively, and that might not help the victim, especially in the moment when they’re basically being flogged. But you can probably guarantee that the abuser has some combination of either self-hate or unhealthy relationships or maybe a traumatic upbringing. That could include their professional upbringing, as we’ve been talking about, and their behavior is still completely unacceptable regardless of any of that context. But maybe it could also be a trigger for someone to check in on them and say, hey, are you okay? Or maybe even to offer or mandate like I think you need help. You’re really being aggressive here. That’s a bad sign.
Howard: 45:36
And they could even be narcissistic sociopaths. The incidence of mental health problems and personality disorders is not different among physicians than it is the general public, so those people are out there.
Antonia: 45:46
Yeah, and you can’t. Yeah, I guess you can’t really remedy certain things, but you know, maybe, yeah, maybe our new interns also need to think about what are the traits of sociopathic narcissists, so that I can just avoid them.
Howard: 46:01
You just smile and nod and avoid it as much as you can and just know that’s that person’s pathology and yeah, and if the system, if the system works as it’s supposed to, those folks won’t be teaching trainees, they’ll be right, right, exactly A hundred percent, yeah.
Antonia: 46:16
They have no, no place teaching. So anyway, I think you you mentioned briefly, you experienced this in kind of a bigger way. Was there anything else that you wanted to say about that here?
Howard: 46:27
Well, I don’t want to talk about those things on here, I think, but I think it’s the same consequence, where things should be nipped in the bud early, so to speak, to prevent bad habits and complex and perverse power dynamics from setting in that lead to larger systematic abuse.
Antonia: 46:44
Yeah, like there needs to be institutional protection from the highest level, but even like, even if there isn’t even one person recognizing it and actually standing up, it makes a huge difference. So it needs to be all of the above, I agree. So a lot of when hazing is prevalent. It generally occurs right at the beginning of a rotation, before people really get to know each other, and it could include maybe some belittling comments or sarcasm and just making the new learners feel and look stupid in front of others, including nursing staff or medical students, and really when people do this, it’s to try to make themselves feel more important and powerful by making others look smaller.
Antonia: 47:26
Obviously there’s an inferiority complex there and like they’re trying to put the new intern in their place, so to speak, and obviously that’s very shameful and inappropriate and just bad, and it takes as much energy, or probably less energy to do the opposite and instead create a welcoming, warm environment for new learners.
Antonia: 47:46
We want an environment that’s supportive of asking even obvious questions and understanding that new interns are going to need to learn a lot of rather basic stuff, and in fact, you want your interns and residents to feel comfortable asking you even dumb questions and not feeling like they’re going to be shamed or humiliated for asking them. If a bully thinks something is obvious, they might just roll their eyes and be like how do you not know this? Maybe the learner did read the material like they were supposed to and they’ve gone ahead and they just couldn’t quite grasp it the way it was written and they’re trying to clarify. Or okay, maybe they didn’t read it, they were supposed to and now they probably feel dumb that they didn’t read it, so you don’t have to rub it in their face.
Howard: 48:30
Yeah, and shaming is not a great motivator.
Antonia: 48:33
Right, okay. Well, on this subject, I’ll confess a little bit that when I’ve been in didactic settings, silently, I could get that this was a pet peeve of mine, that if we were assigned reading I would read it. Sometimes I would have a fellow colleague that didn’t read it and then they would ask a question that was very clearly answered in the reading and I would feel like we have just an hour on this and you’re wasting our time. I wanted to get to some further questions here, and I would sometimes be seething, but yeah, is that why they made you the academic chief?
Antonia: 49:06
I guess maybe it wasn’t that subtle but probably I tried not to be a meanie ever I don’t think I was. But yeah, probably the attendings recognized they needed to keep me busy so I’d stop glaring at people who didn’t study like I did whenever they asked the question. But I really made it, made a point of never insulting anyone, just maybe kind of silent judgments.
Howard: 49:27
Well, people need to do their jobs and need to read what they’re told to read, and they need to show up on time and all that. And there’s ways of dealing with people who aren’t doing those things in a constructive and edifying way. And so if your only trick as a teacher is to humiliate or belittle someone or shame them, then you’re in the wrong job. But I’m glad you at least have eased up a little since then.
Antonia: 49:50
I think we were all everyone won, because then I got to teach and shape things a little bit and then the people that didn’t read, just they would just listen to me. So we were all, everyone won. We all came out knowing what we needed to know and we’re all happy. So I do remember what it was like being an intern, going to those initial events even before intern year really started and me and my whole class were the outsiders coming in. Everyone else had been working together for years. They had all their inside jokes and they’re not. I knew they were not necessarily excited about having to baby us and hold our hands and it was like us against the world a little bit.
Antonia: 50:31
And hopefully everyone that’s going into an intern class will get very close with their classmates because you know that will really help carry you through.
Antonia: 50:38
So just support each other as much as you can. But you go into it having to keep up with the seniors and hoping that if we can’t impress them, at least hopefully we’re not annoying them too badly, because any mistakes or misunderstandings or growing pains that the learner has can either be remedied discreetly with understanding or they can be treated as an opportunity for a quick laugh in front of everyone at the learner’s expense and maybe even that might be intended and just good fun. We’re just friendly teasing. But if it’s taken the wrong way by a super nervous brand new learner, they may feel humiliated and just start learning to fake it till they make it. Stop asking questions that could be vital and essential questions to ask. So for all of you rising interns, of course, learn to laugh at yourself, but still do keep asking questions, because if you don’t worry about looking smart now, just do your best. Don’t worry about how it looks. Then you will actually help yourself and your whole group be more smart by the end of this process than if you hold back.
Howard: 51:43
More smart. Oh, am I being belittling? There’s an example, right, don’t do that.
Antonia: 51:51
Yeah, there you go, fine, smarter you happy.
Howard: 51:55
Yeah.
Antonia: 51:55
Okay, well so, and to anyone else who’s past intern year, if you’re someone that’s in charge of teaching interns, just try not to shoot them down. It really doesn’t matter what you think about them, but they are looking up to you and they need your guidance. So give them something that’ll inspire them to do a great job, and then they’re actually going to be really helpful to you and not an annoyance.
Howard: 52:20
And we all need different things and we learn in different paces and in different ways and sometimes we get it immediately and sometimes we need iteration and so respect, that’s just the nature of learning and I think all that’s a great example of how we can affect the learning culture for better or for worse. In other critical circumstances those things should be debriefed afterwards in a supportive and educational way and it should be well understood that there’s no role and no tolerance for temper tantrums and shaming and blaming and when those sorts of operating room or other stressful environments. Well, we’ll put some links to some literature about this, but did you ever watch R the show from the beginning?
Antonia: 53:07
No, I did watch some of them with great interest when I was much younger, but I probably need to rewatch them. Those are the ones with George Clooney right.
Howard: 53:14
Wow, women always go to George Clooney. Yes, well, I’ll refresh you. So, in, one of the main themes in the second season of ER was the mistreatment of a surgery intern named Dr Gant, who was played by Omar Epps.
Antonia: 53:29
You mean Omar Epps from House MD.
Howard: 53:31
That’s Omar Epps. Yeah, before House he was on ER, but yeah, well, he suffered all the sorts of things that we’re talking about in that second season, except maybe sexual harassment I don’t think he suffered that, but he had some degree of racial discrimination because his character is black. But more than that, he suffered abuse from his supervising resident, dr Benton, played by Eric LaSalle. And then he finally stands up for himself and reports the abuse to the chief of staff, who was another temperamental surgeon who was abusive in his own ways.
Howard: 54:02
And unfortunately the report was not believed, mainly because Dr Carter, who had witnessed the abuse, but he didn’t back him up because he was worried about his own problems that were going on and the potential ramifications for his own career. So shortly after all that plays out, that day, dr Gant apparently kills himself by throwing himself in front of a train, and I’ll put a link to a YouTube video of that pivotal scene where all that happens.
Antonia: 54:28
Unfortunately, that really does sound too close to reality. We know that physician suicide is very real and prevalent problem and it’s always painful to hear those stories and usually involves some kind of struggle. Everyone’s different, but maybe there’s a professional struggle. I know this does happen a lot too with malpractice cases or medical board complaints academic, personal, financial struggles, or maybe a combination of those and then some kind of either a real or a perceived lack of support and then their struggles just become unbearable to them.
Howard: 55:03
Yeah, I’ll put a link to a study from a few years ago that looked at the causes of death of residents in US residency programs over a 14-year time period. Residents do have a lower risk of death overall compared to other folks in their age group, which we would expect, because they typically have more resources, better social determinants of health, more general health knowledge than the general population might. But still in that 14 year time period there were 66 residents who died by suicide and another 33 who died by an accidental poisoning, and many of those, of course, those are their overdoses and they may be suicides or they may be accidents. But why were they using drugs? It’s still the same issue, but the intent’s unknown. And they actually listed 28 who died by some mechanism where the intent was unknown. So that would be Dr Gant’s case, because we don’t know if he slipped or jumped.
Antonia: 55:52
So the real number of deaths by suicide might be twice as high as the 66 that was officially reported, because we don’t. The other ones are questionable as to whether they were intentional overdoses or slips or whatever the other mechanisms were, or were they accidents?
Howard: 56:09
Yeah, and again, that episode of ER where Dr Gant dies really does lean into that idea, because again he’s killed by a train. So did he slip or did he fall? Was it intentional or not?
Antonia: 56:20
That was a cliffhanger, but of course, if you’re watching the show and have seen what’s happened all season, we know that he killed himself, but it makes his family and everyone else feel better to think that he died by accident and it makes the people who didn’t support him feel they tried to make it look like an accident so that their family would get the benefit that would not have been paid out for suicide or even just so it’s easier for the family to not feel bad or guilty about not doing enough.
Antonia: 56:56
Exactly which? That still doesn’t make things any better, but, as I just brought up, this phenomenon continues beyond residency. As I just brought up, this phenomenon continues beyond residency. About 400 physicians die each year by suicide, and a 2020 report found that the rates of suicidal ideation were as high as one in every four physicians, and the vast majority were reluctant to seek help for that, even though theoretically, they have more access than anyone else, but they’re reluctant because of what it could mean for their career. So, in fact, physicians have among the highest rates of suicide of any occupational group, at least in the US.
Howard: 57:34
Yeah Well, I think the solution to all these sorts of issues must start with creating a better work environment and ending these cycles of mistreatment and abuse that exist in medicine. It’s enough that the job is stressful and high risk, but it’s too much when our own colleagues or the staff that we work with make our lives difficult with harassment or belittlement or workplace violence or even subtle microaggressions, and we have to develop a zero tolerance for these behaviors in ourselves and in others. So this coming Monday, when new interns or new medical students start, there’s no need to jokingly call them all fresh meat or make any jokes at the expense of something you know that they do not know, and there’s no excuse to do anything but be supportive and encouraging. Hierarchy in training programs is essential and important, but that’s different than creating a perverse power dynamic. People often aren’t punished because they’re viewed as powerful, but they aren’t inherently powerful. They’re empowered by systems that fail the victims ultimately.
Antonia: 58:35
So basically treat people the way you want to be treated. I think that’s what you’re trying to say.
Howard: 58:39
Yeah, exactly.
Antonia: 58:41
We will link to a website called physiciansupportline.com and their phone number as well, which is 888-409-0141. They’re available for US physicians and medical students free, confidentially, with no appointments necessary, and if you just check the website out, it’s pretty good. They’ve got some nice little resources on there, nice little links to look at. But, yeah, if you’re in crisis, it’s a really easy, discreet thing to look at and at least get started with some kind of help, and there are many other resources that are available to people who are struggling.
Howard: 59:20
And most hospital systems or employers have these resources available too, for free.
Antonia: 59:24
Yeah, yeah, all right, do we have time for a listener question?
Howard: 59:27
We skipped it last time. We’ve got to pack it in.
Antonia: 59:29
Okay, let’s pack it in. Okay, I’m going to read it out then Quote I have appreciated your book on vaginal hysterectomy and your podcast. I have a question that was not addressed in the book when closing the vaginal cuff, is it beneficial to close the anterior peritoneum? I was taught to do so, but I have found a small study indicating it’s not necessary and maybe better not to close it with the vaginal cuff. What are your thoughts? Thanks, signed. Piercing Peritoneum in Peoria.
Howard: 59:58
Nice consonants Wow.
Antonia: 1:00:00
Yeah.
Howard: 1:00:01
Well, there are a surprising number of techniques employed in all surgeries, including vaginal hysterectomy, obviously that date back decades 100 years or more in some cases that are continually taught as important based upon principles that we no longer believe, and they’re done without empiric evidence from controlled trials with their benefit. There’s a lot of history and just we did a thing and it worked, and so we kept doing it, but we didn’t know if that was the reason why we had good outcomes or not, and that’s part of the culture of surgery, I think. So we see this a lot, for example, in the technique of cesarean delivery, where things like the creation of a bladder flap or the closure of parietal and or visceral peritoneum are still very commonplace, despite those practices not really having any scientific evidence that they’re beneficial and some scientific evidence that they’re in fact harmful. So this is the case as well for closure of the peritoneum at the time of vaginal hysterectomy, and I use that comparison because the origin of peritoneal closure for both procedures really has a common surgical traditional source.
Antonia: 1:01:03
It’s difficult sometimes to separate out what we do because it’s traditional, versus what is evidence-based, and this is more difficult when there just aren’t studies for like a specific technique that we do.
Howard: 1:01:17
Yeah, A lot of stuff hasn’t been studied, at least in isolation. It may be studied in combination with other bundles of techniques. So it is difficult. But in this case there is a study which is, I’m assuming, the one that piercing peritoneum and Peoria actually already found and this was a case control study back in 2003, and I’ll put a link to that and they concluded that there was no difference in the group who had peritoneal closure compared to the group who didn’t, particularly in things like infection or bleeding or subsequent problems with the vaginal cuff, and the group that had peritoneal closure actually had a higher rate of bowel dysfunction, meaning return to bowel function, Although I don’t know how clinically significant that finding was or if it’s even related. That might just be a false positive finding. In any event, they didn’t find any benefit from closing the peritoneum for these patients.
Antonia: 1:02:01
So why is it even done in the first place?
Howard: 1:02:09
Well, in the early days of surgical technique, after, say, the 1880s, when most of the modern tools of surgery came about, when this modern era began, there was a big focus on viewing surgery as applied anatomy. So first you went to the cadaver lab and you did the surgery there, with a careful dissection of every anatomic layer, and you identified them and you treated them very tenderly and, just as importantly, you closed every anatomic layer as you finished your surgical procedure. And this is the cornerstone of what a lot of people call the Halsteadian technique, named after William Halstead, the influential surgeon at Johns Hopkins at the turn of the century.
Antonia: 1:02:38
Wasn’t he the doctor who was addicted to cocaine and also gave his sister a blood transfusion when she almost died after delivery?
Howard: 1:02:46
Those things aren’t related, but they are both true, yes, so anyway, I don’t think they’re related, but he did emphasize very careful dissection of every layer and closure of every layer. And people believe that this was necessary for good wound healing. So this is one of the reasons why this technique pervaded early cesarean and hysterectomy techniques just all surgeries really. But over time, each of these individual procedures gained their own justification for peritoneal closure, and that made sure that we kept doing this for decades.
Antonia: 1:03:14
So this fake justification that’s like that’s called a narrative fallacy.
Howard: 1:03:18
Exactly, and there’s a lot of them out there. So for vaginal hysterectomy, it was felt that closing the peritoneum would help isolate infection from the vagina that would go up into the peritoneal cavity. And in fact for a long time many surgeons weren’t even closing the vaginal epithelium, they were just closing the peritoneal edges together and tying the ligaments together and allowing the vagina to heal by secondary intention. And this was a popular thing to do in the decades before we had prophylactic antibiotics, so before the mid prophylactic antibiotics, so before the mid-1950s.
Antonia: 1:03:46
Obviously, that led to more dehiscence and evisceration.
Howard: 1:03:50
Right, yeah, but then in the late 90s we learned that the peritoneum actually heals on its own very quickly and putting suture material in it, if anything, delayed the healing due to the inflammatory response. So in the late 90s and then early 2000s, where this new study comes from, you start to see a lot of data questioning the benefit of peritoneal closure in a lot of surgeries and for the most part we haven’t closed the peritoneum, at least with any good scientific backing at the time of vaginal hysterectomy or cesarean delivery since about 2004 or so.
Antonia: 1:04:22
Yeah, there’s a lot of things that don’t work like we think they do, and just another reminder yet again that we shouldn’t do things without clinical evidence of benefit.
Howard: 1:04:31
Well, a lot of these old techniques still hang around. There’s also just the issue that a lot of older and influential textbooks contain many of these steps as if they were dogma, and of course we all read them and it takes a long time to get that stuff changed. I recently spoke about vaginal hysterectomy at a conference in Mexico and one of the attendees afterwards asked me about incorporating the round ligaments into the peritoneal closure. So she was still doing that routinely at the time of her vaginal hysterectomies and at first this was done because people thought that the round ligaments would help to support the vaginal cuff and so they were including them into the peritoneal closure. And then we learned that the round ligaments don’t really offer any support.
Howard: 1:05:08
But the habit continued, and by the time that Dave Nichols and Clyde Randall wrote about their book about vaginal surgery at least in the fourth edition that I have in 1996, they were still recommending incorporation of the round ligaments into the purse string to help better peritonealize the pelvis. Now Nichols also had a habit of trimming the anterior peritoneum and that technique became quite popular as well for a while. But it was just after this time that we learned that what we thought about the peritoneum and needing to close it simply wasn’t true, and so the benefit of incorporating the round ligaments into that closure as well is something that wasn’t true. So all these steps are omitted in the technique that I teach and write about, but obviously they can persist for a variety of reasons and the way we teach surgery.
Antonia: 1:05:52
All right. Well, hopefully that helps our friend eliminate an unnecessary step they were taught. Well, I think we need to wrap up for today, but good luck to all the interns getting started and send us your stories about how things are at your training programs. We’re interested to hear it. We will post links to the studies and also that website we talked about on the Thinking About OBGYN website. So check that out. Check out our Instagram and we’ll be back with the next season very soon.
Announcer: 1:06:27
Thanks for listening. Find us online at thinkingaboutobgyn.com. Be sure to subscribe. Look for new episodes every two weeks.
