Bad Surgeon: Barriers to Addressing Medical Misconduct

— Our culture rejects self-criticism, censors frank discussion, and too often hides misconduct

 A photo of Paolo Macchiarini
Lee is a psychiatry resident.

Welcome to "The Hypocritical Oath," my new ľֱ series where I explore ethical failures in medicine, from shortcomings in medical culture to abuses of power and patient harm. I try to give a voice to those that have been dismissed in an effort to inspire better doctors, committed to upholding our stated values.

Like the rest of the country, I followed the Paolo Macchiarini case with a fascination bordering on voyeuristic when Netflix's Bad Surgeon and Peacock's second season of Dr. Death aired. The was responsible for scientific misconduct related to airway surgery and research that led to the death of several patients, and romantically conned the NBC producer covering his work, Benita Alexander. Rather than on Alexander's judgment, I'm focused on the patients who suffered under Macchiarini's arrogance.

Whenever these cases hit national news, most people's , "Who let them become a doctor?!" It's a fair question that I'm trying to explore with this series.

The title of "physician" is universally revered, conferring a sense of gravitas and authority. As physicians, we are held to a high standard of expertise, personal conduct, and professional ethics. But doctors are as human as anyone else, and unethical behavior is not foreign to medicine.

Notorious medical predators -- Macchiarini, , , , and to name a few -- make the news precisely because their cases are so egregious. But doctors generally don't go from zero to sexually assaulting, maiming, or killing patients overnight. We often catch these cases too late, holding the perpetrators accountable only after they inflict significant and senseless harm, rather than while their behavior is visibly escalating.

Past behavior often predicts future behavior. Unethical behavior may start as early as medical school with smaller transgressions: cheating, falsifying clinical competencies, or impersonating doctors (not an exhaustive list). Fearing litigation or bad press, many institutions quietly ignore the problem, passing these students on to the next stage of training. But without accountability, ethically compromised medical students inevitably become ethically compromised physicians.

Unsettling patient deaths around now-convicted serial killer Michael Swango potentially as early as his medical school years. A classmate described him as "immoral to the point of being psychopathic." Concerns about Swango were never addressed or even mentioned in his medical school records and, despite poor clinical performance, he . He murdered as many as 60 people. Many were his patients.

Intolerance of Criticism

Former executive director of the Mississippi Board of Medical Licensure John Hall, MD, JD, MBA, once told me, "Doctors are, generally, terrible at self-assessment." As a new physician, I've indeed found some colleagues to be highly defensive about their fields, sometimes at the expense of rational discussion about improving the culture.

I recently on my first restraint order and the importance of maintaining empathy, even when restraining a patient is necessary. I also briefly reflected on the possible reasons behind patient hostility towards psychiatry. Although I stressed that staff and patient safety is my priority, I was censured by one colleague for "passing judgment on [my] chosen field," and advised by another to leave the field. My critics seemed more incensed that I seemingly disparaged psychiatry than they were concerned with empathizing with the patient.

In relaying this, I mean to say that doctors are not always good with self-critique and humility. Even perceived criticism may be met with disproportionate and irrational furor.

If we can't be remotely self-critical, we can't examine medical misconduct objectively.

Like Bruno and Fight Club: We Don't Talk About it

I worry that this preoccupation with optics over substance may be our downfall.

We apply the concept of defamation broadly to include not only speaking untruthfully about colleagues but also speaking badly about colleagues.

As an example, I initially pitched my first piece on sexual misconduct, discussing the Robert Hadden case and patient mistrust of male ob/gyns, not to ľֱ, but to a different medical publication. The piece was rejected: "We have a policy to try to refrain from publishing anything that speaks disparagingly of a specialty, credential, or other group of people." I was grateful that MedPage published it with few edits shortly thereafter.

Indeed, defamation and senseless vitriol targeting any group are unproductive. But some things deserve public sanctioning, including Hadden's decades of sexually abusing patients, and the callous lack of physician empathy towards patients who consequently distrust the system. Instead, we stymie discussion of misconduct, labeling it as "disparaging" or "defamation," and therefore unacceptable.

This censorship harms patients by forbidding physician and public education on medical misconduct.

If you have further questions about medicine's attitude towards those who report misconduct, look no further than the comment section of Mohini Dasari, MD's, her attending surgeon for misogynistic behavior, including dismissing concerns about patients that came from female staff. Dasari received support, but also encountered substantial anger and derision from many physicians for reporting a colleague, including an to "Calm down, or face the consequences."

Talking about any level of misconduct is often treated as a greater crime than the misconduct itself. In this context of troubling priorities, it becomes nearly impossible to report misconduct without fear of backlash.

Institutional Betrayal

In a particularly chilling scene from Dr. Death Season 2, medical staff hurriedly conceal Yesim Cetir, a patient maimed by Macchiarini, in an elevator, transferring her to a private wing of the hospital while she cries out: "They want to hide me!"

The literal act of concealing physical evidence of misconduct provides a horrifying allegory of institutional complicity that enables misconduct by ignoring or suppressing evidence over holding dangerous doctors accountable.

Concerns about Hadden's sexual abuse of patients extended over two decades. According to reporting by the New York Times, Columbia University hospital administrators on these complaints and interfered with the official investigation, failing to hand over evidence and declining to cooperate with prosecutors. Advocacy by , one of Hadden's more famous victims, and helped hold Hadden accountable.

It is unfortunate that Columbia did not use its extensive resources to demonstrate the same courage.

More concerningly, medical institutions may even target reporters of misconduct, who can find themselves under more scrutiny than perpetrators. The whistleblowers from the Karolinska Institute who reported Macchiarini, for instance, found themselves of research misconduct after reporting.

In 1997, Jennifer Freyd, PhD, identified the "DARVO" reaction -- deny, attack, reverse victim and offender -- among sexual offenders who face accountability. DARVO is additionally seen in , where institutions reactively harm people dependent on them.

This phenomenon exists in the world of medicine. A hypothetical example is a medical school dismissing a student victim of domestic violence by another member of the institution who reports the abuse as not credible, although the school has expressed concern about the perpetrator's behavior. Thus, the medical school protects the perpetrator.

"Until it comes out that there's a serial pattern, they assume they'll be okay," says Lana Lawrence, a sexual abuse survivor and friend of Freyd. "You'd think they'd want to be on the right side when it does."

Why I'm Writing This Series

If only Swango were not permitted to graduate, if only Baylor Plano had flagged Duntsch, and so many other "if only's." But a culture that rejects self-criticism, censors frank discussion, and conceals misconduct at an institutional level is a perfect breeding ground for predators.

Medical misconduct should not be penalized only when it has become egregious enough to turn into a true-crime drama. Failing to hold unethical behavior accountable in its early stages widens the reach of irreparable damage.

I'm taking a risk with this series. I just offered three structural and deeply-ingrained reasons why I shouldn't write it. But if it means mitigating the potential for harm, the risk is worthwhile.

is a resident physician in the Department of Psychiatry at the University of Rochester Medical Center in New York.