Monday, April 21, 2008

Disturbing Behavior

photo still from Grey's Anatomy

Having been figuratively removed from the world for the past few days, I almost completely missed the explosion of the Vicente Sotto Medical Memorial Center Video Scandal into the Philippine media firmament. Now, because of some unthinking, insensitive, and generally stupid health care workers' behavior, the medical profession is once more being given the spotlight - and not in a good way.

My resident batchmates and I discussed this issue over dinner last Saturday. Having been trained in charity teaching hospitals, we are not unfamiliar with being surrounded with so many young student spectators, whether nurses or medical students, while in the heat of an urgent medical procedure - like an urgent intubation or even an on-going resuscitation.

Despite this understanding and experience, my batchmates and I were all hard put to justify the behavior of the nurses and doctors who are involved in the above case. While at the time, I had not yet seen the video, the mere narrative of what had transpired disturbed me. More so after I had.

As a medical resident, I have often taught my medical clerks and interns bedside with the patients themselves. Patients with textbook clinical findings are asked if it is okay for them to be made clinical learning material for medical students during consultant rounds. While their personal information is never divulged, some of these patients' clinical history and course are discussed lengthiliy over medical conferences in order for medical trainees to gain insight on managing similar cases in the future.

The nature of medical education hinges on the principle "see one, do one, and teach one." Unfortunately, there is much we cannot learn by mere lectures and working with dummies - and even more that we must learn with practice. When patients have themselves admitted in a charity hospital, they tacitly agree to becoming "learning material" for medical students and nurses in exchange for not paying fees charged by private hospitals which they cannot afford. If circumstances were different, I am sure the patients would never have chosen to be admitted to a charity institution in the first place, but circumstances simply force them to take the lesser evil of being taken cared of by medical trainees like myself than not being treated at all.

To be fair, I did not see anything technically wrong with the way the procedure was done. I have read blog reactions to this video, and some have commented about the way someone was shouting instructions while the patient was being operated on. This is standard practice in surgery, where the primary surgeon tells his first and second assists to maneuver instruments in such a way that he can perform the procedure with optimal light and exposure. He also needs to do this to inform the scrub nurse which instruments he will need next. In every operation, there is also a "circulating nurse," who does not "scrub in" so that he can retrieve things that are needed outside the operating field so that the team that is already "sterile" remains so.

Also, it is not uncommon for interesting surgical cases to be documented by video or still photos for future teaching purposes, although a patient's consent is always secured before this is done. It is also not uncommon for such cases to be observed by young trainees. Those of you who watch Grey's Anatomy are familiar with the viewing deck for the interns that overlooks the operating theatre where surgeries take place. Unfortunately, in the Philippines, we do not have the luxury of a similar viewing deck. So while the number of people in the OR is often regulated, students are allowed to observe some surgeries at ground level.

The above could explain why there were so many people in the OR that day and why perhaps an "official" video was being made. However, this does not justify the way that even the student observers were taking out their phone cameras and taking pictures of the patient, who was in no state to prevent them from doing so. That a copy of such a video was uploaded on a public server and could be accessed by anyone from anywhere in the world smacks of insensitivity and disrepect beyond the bounds of professional ethics. It completely disrespects the social mores by which we live.

The primary surgeon also shares some fault here, because as "captain of the ship" it was within his power to control the number of people in the OR that day. Instead, for whatever reason, he allowed it to be a spectacle for whoever "usiosero" wanted to come in and watch and tape. The mood of anticipation and underlying amusement was palpable and translated through the camera quite clearly.

The video is no longer on YouTube, but the damage has been done and is not easily repaired.

Again to be fair, laughter is - fortunately or unfortunately, depending on one's perspective - a common form of stress release for those of us in the medical profession. Humor is one valve which we must use from time to time to cope with the enormity of the responsibility we carry from day to day. The "baby out!" expression and the cheering could have been an expression of relief that the operation - by no means as simple or as easy as it looks - was a success, without any untoward events. But these expressions take on a new and less innocent meaning when one of the medical personel takes the canister, faces it to one of the cameras, and sprays it for no good reason. To me, it crosses the line between benign amusement into mockery.

This patient, regardless of the absurdity of his dilemma, certainly deserves much better than he was dealt. He may have been divested of his medical ailment, but the mockery and the humiliation that this incident has caused him has magnified his suffering several times over.

I am a doctor, and I am ashamed.

The public is, understandably, enraged that something like this can happen. Aside from feeling sorry for the violated patient (the fact that the video does not show his face at any point notwithstanding), it triggers that visceral fear in every mind with regards to becoming patients and the power doctors have over them. "What if I go into surgery and this happens to me? What if I get sick, and I have to expose myself - will they be laughing at me, too? Are they making me into a guinea pig?"

This incident has eroded into the already-precarious relationship between the doctor and the patient. Even if in their minds people do know that they cannot make a sweeping generalization that all nurses and doctors are like the ones who were seen in this clip, the gut fear will always be there now that there is solid proof that something like this could happen. It has tarnished once more the image of doctors in the country, at a time when we are being demonized as it is.

I just hope that the public will keep in mind that this incident is an exception rather than the rule. The good majority of medical professionals do not take their oath as lightly and continue to practice medicine to the best of their abilities to ensure their patients' well-being.


Blog Challenge Award said...

I love the way you write your thoughts. Why not try joining the Blog Awards Challenge - a literary competition?

See you.

dr_clairebear said...

will check that out! :)

Manggy said...

Great post, Dr. Claire. Some (many?) people really can't help but be usi. It's what makes the traffic jams bigger at accident sites. I hate it. I like to keep out of things that aren't my business; I hate the burden of having to know or see things I shouldn't. I would also hate for strangers to take a keen interest in my personal life and my humiliation. I hate hearing stories that obviously should have been kept secret.

Those people are gross. I do agree, though, that it's the exception. I wish more people would apply the golden rule.

Joey said...

Dr Clairebear, you have put my thoughts on the matter into concrete words! This incident smacks of insensitivity and complete disregard of the patient's privacy and right to confidentiality!

dr tes said...

in fairness to the people involved in this fiasco, i know all of them and they are not the devils being portrayed in some posts. they are all good surgeons and the staff nurses are the best in terms of experience. i dont condone their actions but i think they were just carried away by the bizarre and a little bit naughty case they were handling. they are suffering enough now of their own public humiliation.

dr_clairebear said...

@manggy: i think it's the bane of humanity to be curious. remember the 1989 coup (whoops... you might be too young! *lol*). so many people were injured and killed because they didn't do the sensible thing and run away from the "gulo" because they wanted to make "usi." hay!

@joey: nakakahiya siya on many levels. i'm not going to be a poncio pilato and deny that there have been patients we've been amused by for many reasons, but i think that this was taking it too far.

@doc tes: i really don't question the skill of the people involved - that was never the issue. but it's pretty obvious that everyone was carried away. i guess everyone's amusement fed on the others' - one reason why they shouldn't have allowed too many people there.

to be fair, i would like to believe it wasn't any of the operating team who uploaded the video - and to me, i still feel that it should be that person who should feel the brunt of this whole mess. however, they also did not really do anything to prevent the fiasco from happening, and that's where their fault lies.

it's sad that something like this stands to break the career several years in the making. on the other hand, the repercussions of what was allowed to happen cannot be very well ignored. mali din naman kasi talaga.

the public cannot help being outraged by what they had seen. i mean, if doctors who know what's going on are appalled by the scene, what more pa people not in the medical profession who don't understand the usual practice inside the OR. the crashing of public opinions towards doctors are bound to crash. and there will definitely be a renewal of the push for passing the medical malpractice bill.

dr_clairebear said...

hahaha... sorry, may poor grammar ako at the last paragraph. what i meant to say was, "the crashing of public opinions towards doctors is inevitable." :P sorry again!!!

MegaMom said...

I'm glad you picked this up. Was avoiding it like Class IV TB. Had to do a lot of fending off at the office! The company lost a lot of productivity because of this fiasco!
This is the big diff in practicing in the Philippines vs the US. Filipinos are just too uzi, and unfortunately, they don't know when to stop.
These doctors are humiliated?!??!?! What about the patient? Golly, I'd be crazy to have surgery at that hospital for fear of being video'd without my consent!
Patient consent is such a foreign concept here. I was so used to it when I was still practicing in the US. I had to secure written consent for each and every vaccination I conferred, and I gave lots and lots!
Here no one even bothers to explain to you that you'll get fever from this shot and you can take some paracetamol. Or that there is a 1:10,000 risk of developing Guillain Barre. Aargh! So frustrating. Should've just blogged about this myself kaso, I spent so much time already snitching on office staff regarding inappropriate use of the company network.

dr_clairebear said...

does anyone know how i can edit my comment short of deleting it? kung ano-ano pinagsasabi ko dun! (it's too long to rewrite! hehehe...)

@megamom: guilty! guilty! while PGH training does emphasize the importance of patient education and explaining procedures and getting consent, i admit there are times i tend to hurry it along for the sake of efficiency. :P hay. sorry po!

it's really got people worked up, and with good reason. *lol* lost prductivity ba? i can't imagine something like this happening elsewhere, which is in itself a commentary on being Pinoy, I think.

GraceMags said...

I was absolutely floored by this scandal. grabe talaga. now i have second thoughts about some doctors.

although i never experienced being videotaped i did experience being laughed at by an internal medicine doctor when he told me that i needed to have my intestines looked at. grabe talaga. i felt bad about that

gervacio said...

After reading this, I am enlightened. The more I get acquainted with the nature of medical profession. I come to understand why there are "observers". Like you, I feel ashamed and desperately saddened with the incident in VSMMC.

Yes, What happened to VSMMC is an isolated case. It doesn't hapen all the time. In fairness to the medical professionals in VSMMC, I would say that their expertise and professionalism cannot be questioned.

After VSMMC released its fact finding report, followed by the report of DOH-7, many are dismayed because both reports failed to mention the name of the doctors. While I insist that appropriate actions must be done but I stand that it will also not fair to mention the names of the surgical team, not this time, not until there is a FINAL report.

Doc, if you don't mind, the hospital is officially called: Vicente Sotto Memorial Medical Center (VSMMC).

dr_clairebear said...

@gracemag: thanks for dropping by! it's really sad how this incident will now put the patient-doctor relationship in jeopardy because of building mistrust between them.

@gervacio: i'm glad i cleared things up a bit for you, and i'll edip my post to correct the name.

i am all for serious penalties, but i'm not sure about the stripping them of their license part, if the doctors and the surgical team themselves weren't the ones who uploaded the video. but their mistake was in being permissive enough to let the filming happen - which they also have to answer for.

pinaywife said...

thanks for posting about this.. ive been wanting to post something about this but keep stopping myself coz I feel so strongly emotional about those insensitive and annoying uzi med staff..

i just wished they'd act professionally and treated their patient with utmost respect.

great post, keep it coming!

dr tes said...

yes, dr. clairebear, it was not an MD who posted it nor the medical interns, it was an overeager nursing student from a local university.although various video versions were recorded from the nurse trainees (there was 20 of them at that time, 2 or 3 were assigned to the Emergency OR), only one surgical intern was present(who scrubbed). it was uploaded 2x already pero parang na-konsensya ata yung dalawa, dini-lete. the 3rd post was pick up by ABSCBN, the king of sensationalism.

btw, it was a double set up, with expectations for explore lap ( with additional 1 scrub, 1 circu, 1 CI, 2 nursing students aside from the "manual removal team" of the same set up). so, marami talagang tao sa loob. i find it disturbing that some media outlets doesn't know the difference between medical interns, nurse trainee and nursing students. As one local newspaper editorial said today (SuperBalita), the one who breach the confidentiality of the case was the one who uploaded the video, not the surgeons. But yes, there was an official video footage, the patient signed the consent, the surgeons asked his permission because they were going to present it during the interhospital conference. VSMMC is a training hospital and lots (and I mean LOTS) of nursing schools are affiliated with it para maka-kuha ng cases for PRC/graduation. Surgeons are often complaining of their numbers in the OR but we cannot do anything, they already sponsored/pledge projects to the hospital amounting to millions, so, the hospital cannot refuse their presence. Let's be honest, the surprise factor for us MD's are much less, we have seen many bizaree cases during our clerkship, internship and residency, as they say medyo astig kana but some of these students are only rotating for 2 months in the OR. it's always a good conversation piece that you have assisted such and such bizarre cases, and see in real life the unique cases. i'm not blaming them for this, this is just the human way.
The surgeons are my friends and they are suffering now for their actions. The nurses are suffering too for their failure to control the OR.

Im sorry if im so passionate with this because the people involve are known to me. di kaya ng konsensya ko na talikuran sila, this is the time that they needed friends. I have already expressed my feelings of disgust to them about their actions and believe you me, they were remorseful and just wished that it didn't happened but unfortunately its real. and the patient right now are changing and adding details to his original story. it's really difficult when you have a lot of advisers with all different motives. i pity the patient kay parang nalilito na siya. daming bumubulong.

pasensya na po, dr clairebear kung parang post ko na itong komentong to. isip ko na tuloy na magandang topic ito ah para sa TBR, Foreign Bodies where it should not belong, hehehe!

have a happy day!

dr_clairebear said...

hi, doc tes! siyempre okay lang yung comment mo kahit mahaba. :) maybe you should blog about this nga.

i can understand how frustrating it must be for you kasi you know some of the people involved. ako naman, i really think the person who should get the worst of it is the person who uploaded the video, e.

i'm glad to hear nga na it wasn't the doctors and consent was secured. one other person accountable here is the nurse instructor with the students that day na dapat pinagbawal ang pagkuha in the first place.

mahirap talaga din maintindihan ng mga tao kung pano pwedeng magkaroon ng super daming tao sa OR, and i guess this has gone beyond the point where any rational investigation of the matter by media is possible. unfortunately, a lack of action by the PMA or PRC or DOH at this point will be played up by the media and sobrang maeemphasize how doctors can get away with anything in this country.

it's a lose-lose situation, no matter how you look at it talaga.

dr tes said...

true! pagka-lose-lose talaga!
( there's a naughty version to this, you might want ask a bisdak to say this)
whatever you say, be it wrong, right, or pam-bola lang, it will still be wrong to others who has an opinion already of the mess. there will be no right for them as long as it's not their version of the events. the instigator is a from the media and whatever findings of the DOH and VSMMC it will not be enough for him.

i just felt that somehow someone should take the other side. thank you, dr clairebear, for the space!

J.A. said...

Just this morning, we fell into a discussion about this with the radiologic technologist at our department. I think one of the actions clearly unnecessary was making the entire thing look like a joke. The staff was right with one thing, it would redound to the simple folk generalizing and thinking: Could the same thing happen to me? Unfortunately, having had previously assisted operations, I can say really say that yes, it can happen to you, since some surgeons, nurses and staff can really make crude comments in the operating room. Hopefully, you won't get filmed. As a doctor, I'm ashamed of the whole incident, but usually, when the discussion comes up, I'm the only one who would ask "Has he filed physical injury charges towards the person who did this to him? How come we don't know who he is when we already know the hospital staff who were not conducting themselves properly in the operation? I mean, he started the whole thing in the first place..." Just a thought...