Heart Failure - Miscarriage of Justice

by Michael Greger, MD and United Progressive Alumni

[ Medical School Resources | Appendices | Discussion ]


Miscarriage of Justice

Back in the hole. First day and furious at the garbage they're teaching. "All postmenopausal women must be on hormone replacement. It's imperative. They're crazy if they're not." What a coincidence, lunch brought to us by Premarin*. Grand rounds or infomercial?

* Premarin is a brand name of "hormone replacement therapy." It is now one of the most commonly prescribed drugs in the U.S. Premarin is inhumanely derived from the urine of confined and catheterized pregnant mares.

Appendix 48 documents some of the industry's hormone marketing tactics.

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"Anesthetized women look so vulnerable."[119]

I am all gloved up, fifth in line. At Tufts, medical students - particularly male students - practice pelvic exams on anesthetized women without their consent and without their knowledge. Women come in for surgery and, once they're asleep, we all gather around; line forms to the left.

In the medical ethics literature this practice has been called, "an outrageous assault upon the dignity and autonomy of the patient...."[120] "The practice shows a lack of respect for these patients as persons, revealing a moral insensitivity and a misuse of power."[121] "It is just another example of the way in which physicians abuse their power and have shown themselves unwilling to police themselves in matters of ethics, especially with regard to female patients."[122]

We learn more than examination skills. Taking advantage of the woman's vulnerability - as she lay naked on a table unconscious - we learn that patients are tools to exploit for our education.

It all started on the first day when the clerkship director described that we were to gain valuable experience doing pelvic exams on women in the operating room. I asked him if the women knew what we were doing. Are the women asked permission? "No," he said. And not only no, he described that he was, "ethically comfortable with that." I did some reading.

Massachusetts state law reads: "Every patient... has the right... to refuse to be examined... by students... and to refuse any care or examination when the primary purpose is educational or informational rather than therapeutic."[123] Yes, the right to refuse, but what if the patient doesn't even know? Was the director's attitude what-she-doesn't-know-can't-hurt-her? The confrontation continued.

He countered, "These women sign off that right to refuse on their surgical consent form." Having long learned a healthy skepticism about the pronouncements of authority, I got a copy of the form. The only mention of students reads as follows: "I am aware that occasionally there may be visiting surgeons/ healthcare professionals/ students observing techniques." Observing? We were going to be doing a lot more than observing. I went back to talk to him.

"Women are smart," he told me. "They know that when it says a student observes, that the student will be participating in the procedures." My eyes widened. And anyway, I was told, "Most women wouldn't mind." My jaw dropped. And, "Why are you so sensitive?"

I was just stunned, a stranger in a strange land. I was reminded of the summer I spent in Louisiana, where I had a debate with an orthopedic surgeon over whether or not the abolishment of slavery was really a good thing. "Now just think about it," I was admonished. What do you even say? How do you even respond?

So if the patients already secretly know and wouldn't mind regardless, then surely the course director wouldn't mind me wasting my breath to ask the women permission. (For that matter, he shouldn't mind a quick letter to the Boston Globe either.) No, I was told initially, I am not to ask women permission to use them - their bodies - for our education. I shouldn't let them know. Why? "We would just confuse the patients," he said. "You don't ask permission for male genital exams, do you?" I was asked. "We don't get them to sign permission for every little detail?"

John M. Smith, in Women and Doctors writes, "Many doctors regularly abuse women as a result of underlying prejudice and self-deception."[124] The whole situation reminds me of a famous James Thurber cartoon. A male doctor is leering over the headboard of a hospital bed at a female patient. Caption: "You're not my patient, you're my meat."[125]

"It is grossly unjust to exploit the vulnerable."[126]

Maybe the women wouldn't mind not being asked. After all, he is a doctor. I went back to the library. Sixty-nine women were asked in a British survey whether they thought permission should be specifically sought for students doing pelvic exams in the operating room. One hundred percent said yes; they all thought that specific permission should be sought.[127] A Swedish study found that 90% of gynecologic patients "would feel aggrieved if they discovered that they had participated in [any kind of] clinical training without first having been informed or given the opportunity of declining."[128] And of course, "Express consent does not mean a signature on a piece of paper... [it means] the patient must understand the general nature of the procedure - that is, that she is being used for teaching."[129]

I brought this to the director's attention. I gave him a copy of the British study. He dismissed it; how could I possibly extrapolate data from a British low income clinic to our population? Again, speechless. Even if the data were two orders of magnitude off and only one out of a hundred would mind not being asked, shouldn't that be enough?

The practice may even put the school and hospital in legal jeopardy - battery, professional misconduct, perhaps even aggravated sexual assault. Maybe I should just walk out of the OR and call the police. As written in a British Sunday Times article, "There is nothing to stop a woman bringing a legal action of assault. The only reason no one has done it is because they don't know what's going on."[130] The attending assured me they had thought of that too. "It's been past the risk analysis committee," he told me as he patted my shoulder, "there's nothing to worry about." At that point I gave up.

Appendix 49 offers some perspective on this outrageous practice.

It is often easier to fight for principles than to live up to them.
- Adlai Stevenson

The patient is a Cantonese speaking woman. No English and no interpreter. In the OR an epidural catheter is placed in her back with a big needle. They bark orders at her, but she doesn't understand. When she's under I am all gloved up, fifth in line, with another medstudent behind me.

Medical students and unethical conduct - Appendix 50.

From the book Humanization and Dehumanization of Health Care:

The literature stresses structural rather than psychological causes of helplessness in depersonalizing institutions. People appear to be crushed by hierarchies of power, often arbitrary in application, and rendered impotent by bureaucratic inertia that frustrates attempts to change 'evil' norms, behaviors and values.[131]

From another commentary:

Students often react with a policy of silence when they observe or take part in ethically suspect actions. This is not surprising given the pressures to conform, the fear of punishment or prejudice, the complex nature of moral judgments and the power imbalance between student and teacher.... Placing students in morally untenable situations or failing to support their concerns that they voice represents a failure [of the medical education system]....

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It will be weeks before I regain consciousness from the sleep deprivation. How much longer to regain conscience-ness? Instead of a suspension of disbelief, third year is a suspension of belief - in one's ethics, one's integrity, in one's sense of self. "How unhappy is he who cannot forgive himself" - Publilius Syrus.

Medical school is particularly difficult on activists. See Appendix 51a.

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Morning lecture. We are told of the guild system that medicine education used to be, where apprentices were evidently sold to masters. And so if it feels like slavery....

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The dean gives us a booklet she wrote on getting into residency. In the interview, she advises, "Questions regarding days off... are 'no-no's.'" Of course they are.

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Friday afternoon lecture. "Ultrasound works best through water." Accompanying slide? Bikini Clad Woman. Of course. From the "Passing Through Third Year" guide: "On Ob/Gyn, you can carry anything you want, but avoid being seen carrying Ms. Magazine."[132] The slide show ends with the perfunctory naked woman painting. The afternoon taught me more than I expected. Mark Twain: "I have never let my schooling interfere with my education."

One needs look no further than Ob/Gyn textbooks for the specialty's views on women. Appendix 52a.

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Having to plan a fourth year schedule forces me to see a picture larger than tomorrow, overwhelming through the denial. On the outside I walk slower than I used to, days in a daze.

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Back to the squeaky smell of the OR floor wax. With 14 hour days you can't have an existence outside the hospital. I live days within myself.

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Writing a letter, I start using medical short hand. "c" for with. I'm just on a different circuit.

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A male gynecologist is like an auto mechanic who has never owned a car.
- Carrie Snow

A week on outpatient. I look at the list of appointments - 3:00, 3:10, 3:20 - ten minutes each. Robotic. Write, write, write - patient tells doctor newborn infant has inoperable brain tumor; doctor looks up, "That must be difficult," - write, write - "when was your last menstrual period?" It's an assembly line. Insert breast self exam schpiel here. "Not diagnosing breast cancer is the number one cause of malpractice," she tells me. "So that's why you should tell them, and document it in the chart. But don't ever run behind."

Florence Haseltine, co-author of Woman Doctor and a doctor herself:

Many patients are angry that we're not better than men. We're callous. We hurt them when we examine them. A lot of people have been very disappointed. I don't know what they expected of women doctors. If they expect us to say, 'Yes, you've been horribly treated, and the males did everything wrong, and now women are going to do everything right,' they're not going to get that, because we're trained the same way.[133]

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"Give her... [this drug] to cover," shouts the doctor. But I realized it's not to cover the patient, it's to cover himself, from liability.

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The chief resident is a zombie from sleep deprivation. He tells me he can't think; he can't remember phone numbers. And he did seven hours of surgery that day. He walks around hugging himself.

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"My empathy went asleep," I heard the Ob/Gyn Fellow say when confronted over an ethical impropriety. "If it was before midnight I would of felt bad."

More on the loss of empathy in Appendix 53a.

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My intern on being an intern: "You're deprived of being good to yourself."

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Are we going to become them? I ask a peer. He jokes that after medical school we'll all need to see an exorcist. "Resilience," he says, "may not be enough."

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A lecture from the oldest faculty member in the department. He sees my Ad Hoc Committee button, "Patients Not Profits." "I like your altruism," he said, "but you're going to lose it. Doctors need incentives."

A nurse reads the button and comments, "Oh, he's a radical." Only in America.

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My text has a section called Financial Aspects of Practice:

If you allow the patient to leave without paying, then the first and second billing notices that are sent to the patient for payment will increase your overhead expenses. You should educate the patient as to how these charges are arrived at, so that she will in turn recognize that when she fails to keep her appointment without notifying you, she eliminates a block of time in which you could have received income by seeing another patient.[134],[135]

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I am asked by someone with a clipboard why the hell the patient was just under observation. "She should be admitted," she said, "it's $1500 versus $600."

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One of the residents tells me she wants to practice in the South. "Doctors get more respect." I wonder what she means. Another wants New York City. "They make money. And they don't pretend," she tells me. "They want to make money."

Conservatism in medicine, Appendix 54.

I believe the power to make money is a gift from God - John D. Rockefeller

Plummet, fell and shrank. "Between 1993 and 1995 radiologists watched their inflation-adjusted pay plummet... to $244,400. Anesthesiologists' salaries fell... to $215,000; and general surgeons' shrank... to $269,400."

I hear a doctor complain about the regional physician glut. "In Boston you can't really make more than 135." Echoes from the literature: "I totally agree that most physicians are paid much less than they are worth," one physician writes to Pharos. "Society seems to choke when hearing that the 'average' physician earns over $100,000 per year...."[136] From a letter published in the New England Journal: "It is ethical to be paid reasonably, and in a manner that is commensurate with the value of the product. Last time I looked, a patient's life was deemed precious."[137]

Doctors and money, Appendix 55.

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The chief resident asks if I want to draw blood. If it looks like an easy stick, yes. "Well we don't want it to look like we're practicing on her," he replies.

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Pelvic exenteration, where they basically take out the whole pelvis. "This is going to be exciting," the resident says, eyes wide.

"I want to keep her in here [on the service] so we can learn off her," she says.

Patients as teaching material, Appendix 56.

"Are we going to mismanage her?" The intern asks. "Maybe; I'm not confident."

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I daydream of soaking beans to make hommus with dill from the garden, dipping carrots - unscraped - and whole wheat pita toast. Bare feet in warm grass, cool earth. Reading, in the shade, shooing cats. Susan my pillow. I wake to bloody scissors, standing my seventh hour retracting organs. And still years to go.

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They laughed at a patient today for not knowing the difference between endometrium and endometriosis. While we're at it, let's make fun of the older woman's vaginal prolapse! From Women and Doctors: "It is common and acceptable among practicing gynecologists to speak about their patients and their patients' bodies, sexual behavior, or medical problems indiscriminately, in terms that are demeaning and reflect a lack of simple kindness and respect."[138]

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From my Ob/Gyn text: Girls with "confusing" family dynamics, "may fall in with a disenchanted crowd of teenagers...." Further, "these girls do not compete well."[139]

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Anorexia nervosa is defined in part as 15% below expected body weight. Where do "ideal" weights come from? The text I'm using hints at the irony:

The ideal weight for an average 5 ft 4 in woman in 1943 was approximately 130 lb.; in 1980 charts, it was under 120 lb.... These revisions have not been based on morbidity or mortality statistics, but on measurements of the heights and weights of 25-year-old graduate students... [reflecting] the upper-class emphasis on fashion model thinness as a standard of beauty.[140]

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It's still so difficult to stand residents without semblances of basic decency. No hello, good morning, thank you, please. Is eye contact too much to ask?

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We are taught how to present infants at rounds. "Baby boy Smith is a 2000 gram product of a 40 week gestation." The mother is cut out too.

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One commentator writes, "A friend of mine who was in the final, yowling, human-cannon-ball/get-the-net stages of labor at 11:45 p.m. was quietly reminded by her obstetrician that if she could just hold off until midnight she'd get another day in the hospital."[141]

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Sitting at the nurse's station I see a pricing guide on the wall. I look down the Patient Price column. Vaginal Delivery, $1211. Epidural [thrown in for another] $303.

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A patient wants a tubal ligation with her C-section, but she has no insurance. I ask the doctors why they just don't do it anyway. They look at me like I'm from another planet. "If we do it we won't get paid."

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According to a recent story in Kenya's largest newspaper The Nation, a Nairobi physician who had just removed a bean from a young girl's ear, "jammed it back in when her parents came up short on cash for the $6 procedure."[142]


Dad sent me a clipping from the LA Times describing a similar practice in California. Evidently, a Ms. Chavez - deep in the throes of labor - told her doctor to begin the epidural for the pain. The nurse came in and said, "That will be $400," to which the patient said, "Sure, no problem." "No, you don't understand," the nurse replied, "I need $400 now."

"Her asthma kicking in," the article reports, "hardly able to breathe, Chavez asked her husband to write a check." But the anesthesiologist refused to accept it. The anesthesiologist also refused her credit cards. So Chavez had her mother wire cash in from England, but the anesthesiologist wouldn't accept the confirmation number from Western Union as proof that the money was on the way. The nurse noted in the chart, "Pt. unable to pay cash."

Chavez had Medi-Cal, California's version of Medicaid, which reimburses doctors $57 for the initial insertion of the epidural, and about a dollar a minute after that. The anesthesiologist's attorney described this amount as, "so nominal it's nothing." Not to let suffering get in the way of making more money, "some doctors suggested that anesthesiologists should refuse to accept Medi-Cal recipients as patients - even if it means leaving them in pain on the delivery table."[143] Which is exactly what happened.

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It took me a minute to realize that when the anesthesiologist was describing how risky certain procedures were on pregnant women, he meant for him, in terms of malpractice, not her. As reported in a recent book Enemies of Patients, "A few years ago newspapers reported that all obstetricians in a large region of Georgia came to an agreement that they would no longer provide obstetrical services to women who were lawyers, married to lawyers, or worked in any capacity in a law firm." The author describes this as evidence of a desire to put one's self-interest above the interests of patients.[144]

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Today I left and walked in the sun. (Home to get my forgotten beeper.) The birds sang.

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Third Year is about dis-integration.

Third Year is about frat-house mentality hazing rites of passage.

Third Year is about teaching by humiliation; teacher as enemy.

Third Year is about always feeling one needs an alibi - "But he said I could go get lunch."

Third Year is about hurry up and wait

Third Year is about habituating to fear.

Third Year is about having sufficiently low expectations for life.

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The gynecology-oncology attending stops outside the patient's room to tell the residents, "Let's make this quick." She tells the woman inside that she has a particularly bad form of invasive cancer and will need radical surgery and maybe chemo and radiation. The doctor continues to speak right through her sobs, talking about nodes and spinals. And then leaves while the patient is still crying. The secretary gives her some handouts on the way out.

This type of treatment is all too common - Appendix 57.

Sometimes the patient's aren't told at all. One cancer patient's account:

Being fed 'tailored' truth and outright lies was psychological torment - I felt continually humiliated, manipulated, out of control.... Smiles deceived, reassurances deluded, suspicions were not shared. But misplaced kindness became brutality as the bad news broke. And the deceit hurt.[145]

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With his crown and raised scepter, this morning's Dogbert exclaimed "I need a job where my immense ego seems normal." Next frame: "I've decided to be a doctor. I will determine who lives and who dies." Then, patient on table clutching stomach, "What? I can't die from an ulcer!" And Dogbert, "Maybe not, but I enjoy the challenge."

"The doctor says there is no hope, and since he does the killing he ought to know" - Gaspar Zavala y Zamora.

Doc as God - Appendix 58.

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I pick up the Herald.

A doctor and Boston University medical professor, who was the subject of 13 stinging complaints [including sexual assaults over a period of 18 years] but never disciplined by the state's medical board, has been indicted for raping one patient and molesting three others.... [The doctor] touched their breasts or made them remove their underwear even though he was examining them for simple hand or knee injuries. 'Shocked, I immediately began to cry,' one distraught woman wrote the Board in 1997. 'Dr. Ramos continued to touch my breasts as I cried uncontrollably.'[146]

This example is far from isolated. See Appendix 59a.

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From pleading with time to slow to wishing years gone.

The breeze at dawn has secrets to tell you.
Don't go back to sleep.
You must ask for what
you really want.
Don't go back to sleep.
People are going back
and forth across the doorsill
where the worlds touch.
The door is round and open
Don't go back to sleep.
- Rumi

"What is the use of such terrible diligence as many tire themselves out with, if they always postpone their exchange of smiles with Beauty and Joy to cling to irksome duties and relations?" - Helen Keller.

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Medicine needs more music.

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I compliment an intern on her bedside manner. She tells me how one can use relations with patients to deal with the brutality of internship.

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I got my surgery grades back today. I just pass. I flip to the comments and am incredulous at the irony. "Social skills were described as awkward." I, "sometimes displayed a lack of empathy." And from surgeons! "Reviewers commented that he had questionable professional conduct and he seemed to exhibit a 'political agenda'"

"If a man really knew himself he would utterly despise the ignorant notions others might form on a subject in which he had such matchless opportunities for observation" - George Santayana. Or as the button Holly gave me yesterday says, "Gandhi Would Have Smacked You in the Head."

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Lightening rounds through the ICU. A patient waves to me with her foot. I go to her. "I'm being held prisoner," she says in desperation. All I feel I can do is apologize - for everyone else, but especially for me. I leave her to catch up with rest of the team.

From a doctor's personal account published in the Western Journal of Medicine:

I read Dalton Trumbo's 1939 antiwar novel, Johnny Got His Gun, as a teenager: The plot remained buried in my memory until I started working with comatose, nonresponsive, postoperative or intensive care unit (ICU) patients as a medical student and later as a resident. After one particularly difficult case, the memory of 'Johnny' - blind, deaf, dumb, a multiple amputee, sustained in a hospital bed, struggling to communicate with the outside world - began returning to me. The parallels with ICU patients - intubated, lined (with central line, oxygen, feeding tubes), paralyzed - became apparent to me.[147]

No man who is in a hurry is quite civilized - Will Durant

From an article in JAMA:

Although most patients may perceive a 2-minute encounter with a physician seated at the bedside as more reassuring then a 2-minute chat with him standing at the doorjamb, 2 minutes is still only 2 minutes; patients placated enough to comply (or not complain), still may not feel connected to their physicians in any meaningful sense.... The healing touch in major medical centers rarely lingers. Patients suffer - and so too do those who desire to be healers....

A student or house officer may wonder, 'would it be right for me, a temporary stranger, who just wandered into these patient's lives, to engage them on an intimate level when I only spend 8 hours on call with them? Wouldn't that be the emotional or therapeutic equivalent of a one-night stand?' We believe that too many students and residents incur long-term personal damage by engaging in transient relationships with strangers.[148]

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A patient swears her three year old gave her the black eye. The head of the department tells the resident just to document it. "As long as it's in the chart we're safe."

Medicine's treatment of domestic violence has been less than ideal. See Appendix 60.

One study found that 37% of obstetric patients - across class, race, and educational lines - were physically abused during pregnancy. One enlightened obstetrician reminds me how rampant domestic violence is in this patient population. I ask him if he asks patients about it, screens for it. He laughs. "With the way we see patients?" Eighteen patients in three hours.

So why don't doctors just see fewer patients? Because they'd make less money. As Dr. Zarren - one of the few docs I've ever met deserving of the title "doctor" - told me, "If you're willing to make a low enough salary, you can do anything you want in medicine."

According to an article in Medical Economics, family practitioners who make more than $250,000 a year do so because they see an average of 164 patients a week.[149] If you see 150 patients per weeks, you average $178,000 a year. And if you see 50 a week, you net only $146,000.[150]

I explained to a surgeon that at Gesundheit*, initial interviews will go on for hours. "You are a lousy doctor if you spend three hours with a patient," he replied. "You should only need 5 minutes."

* The Gesundheit Institute is Patch Adams' dream of a hospital utopia designed to spark the conscience and imagination of the world.

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Four a.m. breakfasts at the hospital. I sit by the window and watch people. I hope to never take outside for granted again.

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The bitter stale taste of ghosts of coffees past. "The damp of the night drives deeper into my soul" - Walt Whitman.

Dizzy-sick tired, I suck on ice to stay awake, humming, "Show me the way to go home (bum, bum, bum) I'm tired and I want to go to bed."

Coming home I trip on steps, my body screaming for sleep. I cringe like a vampire from the morning sun.

"It is rather incredible that things as important as human lives are being taken care of by people who are dead tired" [151] See Appendix 61.

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Thoreau: "We must learn to reawaken and keep ourselves awake, not by mechanical aids, but by an infinite expectation of the dawn.... To be awake is to be alive." Shut up Henry.

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I tighten the hood over my face in the cold rain. I can only see a circle around my feet. Though I cannot see ahead, I just keep walking.

I was much further out than you thought
And not waving but drowning
- Stevie Smith

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I continue to get stares as the only one washing my hands.

One of the many ways doctors kill patients, Appendix 62a.

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Two residents have red surgical clogs. They run around like smurfs in their bright blue scrubs.

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I find myself harder. Notices of meetings, lectures, protests go straight into the recycling. I can't even stand to read them. Throwing my life away. One hesitates to become unidimensional in fear of becoming undimensional. I'm embarrassed to walk by the Food Not Bombs table. Just another shirt and tie. Susan sums third year up in a word, disconnection.


Ram Dass: "At one point I asked him how I could become enlightened. Maharaji said, 'Serve everyone'.... At the next opportunity I tried a different tack and asked him how I could know God. He replied, 'Feed everyone.'"

An article about Tufts called "Medicine as a Vehicle for Social Change"? Yes, a 1967 rural Mississippi health center where prescriptions were written for food.[152] There is nothing like the face of a mother to whose child you just gave a cup of hot soup.

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The hospital just issued little ink stamps to all the residents to clarify their illegible signatures. Results from a 1997 study of doctor's handwriting: Twenty out of 176 of the medication orders and 78% of the signatures of 36 different physicians were totally illegible or legible only after consultation with one or more nurses or use of references.

Medical students may actually, "gain advantage from illegibility," one doctor notes. "A school report once read: 'Alas, the dawn of legibility in his handwriting only reveals his utter inability to spell.'"[153]

Illegible handwriting may also, however, be used as an unconscious symbol of superiority: "My time is more valuable than yours," it says. "You can take the time to decipher what I write."[154]

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Preparing to put in epidurals, doctors ferry the husbands out of the room for the same reason they do the moms on pediatrics for spinal taps - it's just too obvious that patients are unwillingly practiced upon.

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An intern tells us of her medschool experience in New York City. "Indigent medicine is wild medicine. You learn a ton."

Doctor Sims, the father of American gynecology, learned a ton that way too. See Appendix 63.

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On postpartum days we are equivocably told to do breast exams. Shouldn't we ask permission? "No, that's weird," proclaimed my intern. Of course, student exams are only for the uninsured. The paying patients aren't woken up, questioned or fondled by the students. The medical students see the "service patients."

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Studying for the exam at the end, there is too much to learn - risking spontaneous rupture of my-brains.

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"We're going to 'section her," I hear a doctor say.

"Of all the 36 countries I have visited to observe maternity facilities," writes Doris Haire, past president of the International Childbirth Education Association. "I am absolutely convinced that the United States has to be the most bizarre on earth in its management of obstetrics."

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A woman describes her midwifery experience:

When I attended home births I carried no pain medications; I told the women they would have to go to the hospital if they needed such.... An angry obstetrician confronted me once at a meeting in New Jersey, where, shouting across a table which separated us, he asked, 'But... what do you do when a woman is in pain?' He was shaking his fist, accusing me of cruelty and inhumanity. 'When a woman is in pain, I put my arms around her and I hold her,' I said.[155]

Midwives have been viciously persecuted through the centuries - Appendix 64.

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Many find it troubling that Ob/Gyns, whose training is primarily surgical, are entrusted with so much of women's healthcare[156]. One commentator asks, "Why are surgeons prescribing birth control pills?"[157]


Examples of the surgical frame of mind:

Nobel Laureate and former medical school dean Frederick Robbins:

The dangers of overpopulation are so great that we may have to use certain techniques of conception control that may entail considerable risk to the individual woman.

From the Textbook of Contraceptive Practice:

Contraception is not merely a medical procedure; it is also a social convenience, and if a technique carried a mortality several hundred times greater than that now believed to be associated with the Pill, its use might still be justified on social if not medical grounds.[158]

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I am twenty-five years old. Wow. Emerson: "The days come and go like muffled and veiled figures sent from a distant friendly party, but they say nothing, and if we do not use the gifts they bring, they carry them silently away."

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A doctor from Texas spoke of tubal ligations being done, not for the benefit of the patient but for the doctors in training. He said, "Sure, they push them all the time here, from third year medical students to residents. If an intern got them to sign he'd get to do it, so they'll do anything even beg them... for the practice. Yes, they would ask them during labor."[159]

Doctors sterilized people for other reasons too. See Appendix 65a.

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Outside, I can see Spring present as open car windows and in the morning, the Doc Bronner's is clear instead of white.

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I sent an Email out to everyone in my class in preparing a talk for the class of 2000 on how to survive third year. I see my classmates are in pain too. One woman reminds me to tell next year's class, "They [the doctors] always have more power. [Tell the students] don't let your independence get in the way. Yes it's ridiculous, but you got to bow and scrape like a servant.... Suck it up." Inspiration from another classmate, "[Tell them] the year ends; Time marches on."

Days later, on the panel with other classmates, I mostly just sit and shake my head. I see them changing. Amidst the have-fun's and be-enthusiastic's, one pediatrics bound panelist complains about mothers who don't want medical students involved in their child's care. Her advice to the audience is, "Just tell the mom that the resident is busy." Another fourth year advises lying to the doctors too. "Whatever rotation you're in, tell the doctors that's what you want your specialty to be."

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Last day. Out of the dark and into the light. Na na. Nana na na. Hey hey hey. Good-bye.

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I look back at the month's entries. Where's the miracle of life? The precious moments/baby holding/hand holding? The joy, celebration, congratulation? Good question.

Four-pointed star

The day of the test I unearth my clashiest violet pants, neon shirt and sherbet yellow tie-die. I'm colorful because I'm happy; I'm happy because I'm free. "I am here to live out loud" - Emile Zola.

I want a button with the three words a dear friend ended an Email with: "Defiantly Still Smiling."



[119] Harrison, M. A Woman in Residence New York: Random House, 1982:234.

[120] Tishelman, R. Letter. Hastings Center Report 1994(July-August):45.

[121] Dwyer, J. Letter. Hastings Center Report 1994(July-August):45.

[122] Tishelman, R. Letter. Hastings Center Report 1994(July-August):45.

[123] Chapter 111, Section 70E.

[124] Smith, JM. Women and Doctors New York: Atlantic Monthly Press, 1992.

[125] Shem, S. Mount Misery New York : Ivy Books, Jan. 1998:486.

[126] Sukol, RB. "Teaching Ethical Thinking and Behavior to Medical Students." Journal of the American Medical Association 273(1995):1388-1389.

[127] Lawton, FG and DM Luesley. "Patient Consent for Gynaecological Examination." British Journal of Hospital Medicine 44(1991):326.

[128] Lynoe, N, et al. "Informed Consent in Clinical Training - Patient Experiences and Motives for Participating." Medical Education 32(1998):465-471.

[129] Bewley, S. "The Law, Medical Students and Assault." British Medical Journal 304(1992):1551.

[130] Rogers, L. "Anaesthetised Women Suffer Unauthorized Medical Probes." Sunday Times 21 May 1995.

[131] Humanization and Dehumanization of Health Care:57.

[132] Ricks, AE. "Passing Through Third Year." New Physician 31(1982):16-19.

[133] Osborne, D. "My Wife, the Doctor." Mother Jones 1983(January):21-25, 42-44.

[134] Fundamentals of Gynecology & Obstetrics Philadelphia: Lippincott-Raven, 1992:346.

[135] I do not endorse any of the textbooks I used - they just happened to be what the library had to lend.

[136] Lanard, MS. Letter. The Pharos 1997(Winter):39.

[137] Zwelling-Aamot, ML. Letter. New England Journal of Medicine 339(1998):1326.

[138] Smith, JM. Women and Doctors New York: Atlantic Monthly Press, 1992.

[139] Fundamentals of Gynecology & Obstetrics Philadelphia: Lippincott-Raven, 1992:346.

[140] Goldman, HH. Review of General Psychiatry Stamford: Appleton & Lange, 1991.

[141] Dusen, LV. "This Business Called Medicine." Canadian Medical Association Journal 157(1997):1724.

[142] News of the Weird (1998).

[143] Bernstein, S. "Childbirth Anesthesia Refusals Spur Probe."LA Times 14 June 1998:A26.

[144] Macklin, R. Enemies of Patients New York: Oxford University Press, 1993.

[145] Tattersall, M and P Ellis. "Communication is a Vital Part of Care." British Medical Journal 316(1998):1891.

[146] Estes, A. "BU Doc Indicted of Rape, Molesting of Patients." Boston Herald 19 Feb. 1999:1,26.

[147] Dyer, KA. "A Cry From Within." Western Journal of Medicine 169(1998):251.

[148] Christakis, DA and C Feudtner. "Temporary Matters." Journal of the American Medical Association 278(1997):739-743.

[149] Guglielmo, WJ. Medical Economics 23 November 1998:146-155.

[150] "Income Rises in Busier Practices and With Time Invested" Medical Economics 9/7/98:181.

[151] Harvard researcher Lucian Leape in Duncan, DE. Residents: The Perils and Promise of Educating Young Doctors. New York, NY: Scribner, 1996:107.

[152] Rogers, DA. "Medicine as Vehicle for Social Change." New Physician 1970(Nov.):917-918.

[153] Kandela, P. "Doctor's Handwriting." The Lancet 353(1999):1109.

[154] Winslow, EH, et al. "Legibility and Completeness of Physicians' Handwritten Medication Orders." Heart and Lung 26(1997):158-163.

[155] Harrison, M. A Woman in Residence New York: Random House, 1982:76.

[156] Fugh-Berman, A. "Training Doctors to Care for Women." Technology Review 97(1994):34.

[157] Ibid.

[158] Robbins, J. Reclaiming Our Health Tiburon, CA: HJ Kramer, 1996.

[159] Stevens, W. "Doctors Should Have Their Tongues Tied." Off Our Backs 7(1977):24.



Reader's Comments

At the age of 41 I had a hysterectomy. In the two and a half years since, I have lost all faith in the medical community. My body has been turned inside out and my once vital self has become a person who is looking at having to work only part time because I have no energy any more. And I have seen more than ten doctors in the meantime; every one of them until the last two has insisted that all of my symptoms have nothing to do with the hysterectomy. Why do doctors believe that ripping out one complete endocrine system will have no impact on a woman's body and general health? My gynecologist assured me that I'd be better than new; instead I aged thirty years overnight. He never even said the word "hormones" to me before the surgery; now my quest for the right balance of hormones rules my life. This is America in the new millenium?

-- Polly Elledge, April 23, 2000
Thanks to Dr. Greger for these candid insights.

I want to express to any and all med school students, that hysterectomy, is most often NOT a surgery or procedure that a woman feels *great* afterwards, life is better than ever, sex is better than ever, etc., despite what you will hear. Yes, you will hear it, and for a select number of women, this seems to be true.

For many other women, this is very far from the case.

I know, I hear from them everyday, and have been hearing from them for the last four years. I am also one of them.

I had all my female organs removed 4 years ago, at the age of 36, due to endometriosis, painful adhesions, recurrent painful ovarian cysts, and chronic pelvic pain.

I was at peace with the decision of tah/bso, all other treatments to eradicate pain and slow the disease had failed, my quality of life was seriously suffering.

I was not prepared for the multitude of complex endocrine related changes that would take place within my body, and the endocrine related health problems that would follow. The aftermath of ovarian removal has been as devastating to my health as the endometriosis was. I would not have changed my decision to have a tah/bso, even if I had known of the possible consequences of ovarian removal, but it sure would have been nice to know! No one even hinted at what would follow.

Organ removal (ovaries) is serious and permanent. Once the ovaries are removed and your body no longer can produce it's own natural hormones, there can be serious consequences to health and finding effective, low side effect hormone replacement can be extremely challenging, at best. even though I am free of the endo pain,I have ended up with health problems and challenges that have been equally as difficult and painful as the endo was (severe hormone loss when the ovaries are removed at a younger age, fibromyalgia, weight gain, low sex drive, severe fatigue, joint pain,etc.)

Women suffer in many ways after removal of their female organs, some do fine, some develop many problems it is not in their head, it is a true physiological response to hormone loss and sometimes even hormone disruptions, hormones produced in the body of both women and men affect every cell in the body. Women go back to doctors after hysterectomy with and without removal of the ovaries presenting with clear hormone loss/disruption symptoms and health problems, only to often be told it is in their head, or given anti depressants, or the ever popular synthetic hormones which are often not effective and come along with many negative side effects of their own, it is truly a disgrace in this age of medical advancement. That is the reason I have spent every single day of the last four years answering emails and working to raise awareness, perhaps when men speak up and out about the negative effects that this often life changing surgery has had on their partners and family, perhaps then those in a position to effect change will listen.

Respectfully, Jeannah McElroy Hysterectomy Awareness http://www.hysterectomyawareness.com

-- Jeannah McElroy, August 21, 2001

I turned my back on the World of Medicine twelve years ago and have been running fast on the road less traveled. My message to those who have read this book, and are looking for answers is that YOU don't have to be a victim, you don't have to live the life the corporate powers that be dictate. I pulled out despite the odds that were against me, and you can too. After being tortured by the psyche profession, told not to have anymore children and left for dead by the side of the medical professions road, I picked myself up, dusted myself off and ran like crazy the opposite direction. Having added four beautiful children to our family, the last two born at home after doing my own prenatal care, and helping my husband through difficult and distressing physical and emotional illnesses using nutritional therapies and alternative healing - I feel passionate about parents gaining the skills and knowledge that will enable them to heal and wean from the medical profession. I wrote some books detailing our experiences and organized A conference for couples to teach the princinples of husband and wife taking personal responsibility for the health of their family, especially birth. These materials are available from my web site www.naturalfamilyco.com

Thanks Michael, for sharing your story. I pray that you can stay true to your heart. For some of us, life outside of medicine is really nice. Come take a look! Jenny Hatch
Image: Benjamin - One Week Old.jpg

-- Jenny Hatch, January 1, 2004

I found this article to be informative and very disturbing. It just confims again the "inhumanity" of most doctors, especially Ob/gyn's. As a doula I see how women are often treated by drs using scare tactics to get the woman to have interventions. They are very often only told half-truths of all the interventions, epidural risks, c-section risks. Women should and must make informed decision to their care, don't hand your body over to a doctor! It's your birth, your baby! Again the medical profession, the abortion business, formula companies, its not them caring about mothers and babies its all about MONEY!! They should ask whether they would like their wife, sister,mother to be treated as they treat patients. I also was fondled by doctor and with the nurse in the room. I was young and scared and in I think a state of shock! This same doctor followed me into the hallway when I left his office cursing me and telling me I was a "damn" fool for wanting unmedicated childbirth and be able to nurse my baby right after birth. I always wished I'd reported him, but would it have done any good?? I also wonder how many other women were humilitated by him. Dr Robert Mendelson wrote Mal(e) Practice it is very informative also.

-- Bobbie Avery, January 23, 2004
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