Bad Surgeons and Good Faith

This is a bit of a strange post, not least because it involves citing sources – a blog post, and a whole blog -that have since been taken down from the net, for reasons that will become clear.  It’s also going to involve a pair of fairly hefty quotations, largely because it’s the absence of a source that motivates this post – which means I can’t simply tell you to follow the links.  It has to do with an apparent case of a surgeon deliberately causing a serious injury to a patient in the name of teaching, and with deceptions, and with apologies for those deceptions.

It’s also a very long post, even by my prolix standards.

OK: so, as quoted by Orac on his Respectful Insolence blog, here’s the case that gets the story going.  It was originally recounted by someone calling themselves “Hope Amantine”, and was cross-posted atKevinMD.com, which bills itself as “social media’s leading physician voice”, is written by someone called Kevin Pho, and is a part a site called MedPage Today.  This means that Orac’s version is at least third-hand; but I can’t do better than that, for reasons that will become clear.  That’s a pain, but I’m going to have to take things on good faith – which, given what comes later, is perhaps asking for trouble.  Either way, here’s the story:

So here I was, handling the plane (the layer, or space) around the IVC [inferior vena cava] with care to avoid ripping it. It seemed like the intelligent thing to do. My attending asked, “Why are you being so dainty with your dissection there?” I answered that I wanted to avoid ripping the cava because they’re so much harder to fix.

Big mistake.

I take it he interpreted my comment as fear, and decided upon a teaching moment. He took his scissors and incredibly, before my eyes, and with no warning or preparation of any kind, cut a one-inch hole in the cava.

I was stunned. As I tried to process what I just saw, incredulous that he would actually intentionally make a hole in the cava, and as dark blood poured out of the hole, the tide rising steadily in the abdomen, he remarked, “Well, are you just going to stand there or are you going to fix that?”

And so I did. Whatever thoughts I might have had about his behavior, his judgment, and his sanity (and believe you me, there were many), I put my fingers on the hole to stop the flow.  I suctioned out the blood that had already escaped, and irrigated the field, the Amazing One-Handed Surgeon did nothing to help me.  This exercise was clearly a test. I got two sponge sticks to occlude flow above and below the hole which I instructed him to hold in position (which he dutifully did), and then I got my suture and I fixed the hole.  No problem.

All he said was, “Good job.” And we proceeded to complete the case uneventfully.

[…]

Though I may not have agreed with his actions on that day, I do understand them. How do you teach someone to take charge when there is a crisis? I am certain that if I was put on the spot and shriveled and sniveled, and couldn’t control the bleeding, he would have taken over. And I would have failed.

[…]

So on that day, when the vascular attending cut that hole in the cava, he was preparing me, both for the oral exam, and for life as a surgeon. He wanted to see if I could handle it.

I guess I made the cut.

The excisions are mine – they’re where Orac makes a comment.  However, there’s one more part that’s important – and this is now in Orac’s voice:

The reaction to Dr. Amantine’s post was furious and uniformly negative, both in the comments and in the Twittersphere, and yesterday there was an addendum:

Author’s note 7/8/2015: This is a fictional article. No one was harmed, then or ever, in my care or in my presence. I apologize for any remark that may have been misconstrued.

Orac calls BS on this, and I’m tempted to do likewise; but I’ll put that to one side for now.  I’ll also note that I can’t check the flow of the original post, because it no longer exists.  Indeed, Hope Amantine’s whole blog would seem to have been taken down.  In the meantime, other blogs and pages also picked up the story from KevinMD: PZ Myers noted it on Pharyngula, Janet Stemwedel commented in a piece on Forbes‘ site, and I’m sure there were more.  This is noteworthy, because, as I said, the OP has now gone.  If you want to read it, you’ll have to go to where it was cross-posted or quoted (which makes this whole thing rather like a game of Chinese Whispers).

Indeed, not only has the OP gone: the KevinMD post has also gone.  Where it was, there’s this message:

On July 7th, 2015, I cross-posted an article from “Hope Amantine,” a pseudoanonymous surgeon who previously blogged at Simple Country Surgeon: “A lesson in the OR that prepared this doctor to be a surgeon.”

On July 8th, 2015, 11 a.m. Eastern, I was notified by an editor at MedPage Today about the controversy questioning the truthfulness of the story.

I then reached out to “Hope,” asking whether her story was fictional or not. I received her reply at 12:38 p.m. Eastern, and added her addendum to the story.

The story was initially presented as non-fiction, then amended to fiction after criticism.   I don’t have any further explanation for the change, other than the author’s addendum, nor do I know whether the story is really true or not.

Of note, “Hope” has since deleted her blog and Twitter account.

OK.  With me so far?  Here’s a simplified account that tries to be as charitable as possible to everyone.  Hope Amantine published a blog post telling a story about what appeared to be a serious physical assault on a patient carried out in the name of teaching.  This story may or may not have been true.  Either way, it was subsequently deleted, but not before it had been picked up by at least one medical blog – in this case, run by Kevin Pho.  Pho’s post was also deleted when Pho realised that the OP was unreliable, but not before it had attracted the attention of a number of high-profile bloggers.

Right.  I think we’re about half-way through now.  Time for another quotation, this time from Ivan Oransky on the MedPage Today site.

On January 8, 1988, in an episode that captured widespread media attention, and even launched a lawsuit, JAMA published a first-person column called “It’s Over, Debbie,” allegedly describing how an obstetrics-gynecology resident performed euthanasia on a woman dying painfully of ovarian cancer.

I write “allegedly” because there came to be serious doubts about whether the incident actually took place. As then-JAMA editor in chief George Lundberg, MD, wrote at the time, “As we do with authors of all articles and essays we receive, we trusted the author of ‘It’s Over, Debbie’ to be telling the truth, and we made no independent investigation of the facts.”

What made determining the truthfulness of the account even more difficult than usual for readers, however, was the fact that the author of “It’s Over, Debbie” had insisted on anonymity, a request JAMA honored even following a lawsuit. Honoring a reasonable request for confidentiality is a standard practice at news organizations, and elsewhere I’ve noted why anonymity is necessary for vulnerable informants such as whistleblowers. But it can complicate matters.

[…]

One lesson from [the Amatine] story – and I have some expertise in scientific retractions, which are somewhat different beasts – is that trust is a very tricky subject. Whenever I use an anonymous source, whether in a story in a guest post, I make sure to verify that person’s identity first. That doesn’t prevent someone from lying to me about something else, but it means some level of accountability, at least to me. And if I’ve earned my readers’ trust, that accountability passes through, hopefully.

I’m reminded again, as I write this, of Lundberg’s comment about “It’s Over, Debbie:” “As we do with authors of all articles and essays we receive, we trusted the author of ‘It’s Over, Debbie’ to be telling the truth, and we made no independent investigation of the facts.”

I think Lundberg’s attitude is the right one here.  It seems to me to be a tenet of minimal decency that, if someone says something, the starting assumption should be that it’s honest.  It might still be wrong, of course, but a presumption of honesty seems to be a prerequisite of getting anything much done.  (Thinking about it, I wonder if that might be an element of the difference between a journal like the JAMA and those “journals” who keep sending me spam emails: it’s obvious the latter are shysters, and one therefore has that much less of a reason to take anything in them seriously.)  There’s a moral peril here, of course, but so it goes.  Get duped too many times, and readers’ trust will take a hit; but that doesn’t really alter the desirability of the basic position.

All of which brings me back to Kevin Pho, and one of the things he says in the message that replaced his post about Amantine:

I apologize for publishing the story, and will obviously learn from this experience.

For what is the apology offered?  For misleading or deceiving his readers?  That can’t be it, because there’s all kinds of ways in which a person might innocently deceive or be deceived.  There’s no obvious reason to think that he wasn’t acting in good faith when he made his post; if anyone was deceived as a result, it’s not clear that Pho is at fault.  It’s possible, I suppose, that bloggers have a duty to verify stories on which they comment – but that doesn’t seem all that persuasive, because bloggers are generally just that: bloggers, and not investigative journalists.  Besides: even allowing that being taken in by a story warrants an apology, to whom should it be addressed?  “I am sorry for believing something that may not have been the case” is a strange thing to require an apology to third parties.

Further, even if an apology were warranted for passing on a story without taking pains to verify it, doesn’t that come with a bit of a discount, on the basis that if we can’t take everything we see on the internet at face value, then Pho has companions in guilt in his own readers?

But, really, it seems to me to come down in the end to a question of trust.  The JAMA took a story about euthanasia on trust; Pho took a story about serious malpractice on trust.  Maybe they could have dug more, because these were both extraordinary stories, and extraordinary stories probably require extraordinary evidence.  But, still, we ought to be wary of making trust the vice here.  It isn’t.

(Maybe this is one of those occasions in which “I regret that this happened” would be better than “I am sorry/ I apologise that this happened”.  It’s more neutral.  Often, that’s a slimy move to pull.  In this case, and cases like it, maybe not.)

Without the assumption that those with whom we’re interacting may be fallible but are nevertheless basically trustworthy, a lot of that interaction becomes impossible; and even if its possible, a world that is not built upon trust is a vile world, and life lived in it is much less worth living.

That does leave us vulnerable to the unscrupulous, to be sure.  That is a risk.  But it’s similar to a risk that is built into open societies generally – that they are, to the extent that they’re open, vulnerable to their enemies.  That is not a reason to favour closed societies.

Neither is it clear what Pho should be learning.  (I’ll add, too, that to treat every screw-up as a “learning opportunity” is horrible.  If you did screw up, isn’t it implicit in admitting it that you’re going to try to avoid that same pitfall in future?)

Pho probably should have edited his post to make it clear that Amantine may be unreliable; but why he should apologise, and what he should learn, is much less clear to me.

  • You can find the old post using the waybackmachine. It will pull up the old post and you can see the history of how the post changed over time. I once saw this with an EHR vendor which fabricated a blog post to try and cover their backside. The internet captures everything and stores the history, so you can find any website/blog post and how it’s changed over time.

    Personally as a blogger, if I happened upon a story like this, I’d have put the disclaimer that I didn’t know of its accuracy or not, but that I thought it drove a good discussion. That way we have the discussion which is interesting without accusing or condemning the people in the story. We’ll let the legal and medical system hand down judgement. As a blogger, I just want to continue the conversation so others can avoid pitfalls I find interesting.

  • Dak

    The original post from Hope if anyone is interested,

    https://archive.is/y6kOH#selection-741.34-745.45