"I bet she's enjoying this," one doctor reportedly said while prepping a woman for a vaginal hysterectomy. In another case, an obstetrician performed an obscene dance after saving the life of a woman who was bleeding out after having a baby.
The article is an unusual one for the the journal, which was established in 1927 by the American College of Physicians and typically publishes technical articles about disease management and medical research.
In a letter accompanying the essay, the editorial team agonized over whether to publish the piece. They said everyone agreed that the piece was "disgusting and scandalous" and could damage the profession's reputation. But some argued that this was why they shouldn't publish it while others felt that was why they should publish it.
"The discussion was so impassioned and opinions so disparate that we needed a 'time-out,' " editor-in-chief Christine Laine and her deputies wrote in a letter accompanying the essay.
In the end they said they decided to do so in order to "expose medicine's dark underbelly." They said the first incident "reeked of misogyny and disrespect — the second reeked of all that plus heavy overtones of sexual assault and racism."
"It is our hope that the essay will gnaw on the consciences of readers who may recall any instance of their own repugnant behavior. The story is an opportunity to see what this behavior looks like to others and starkly shows that it is anything but funny," they wrote.
The editors said the author — identified as a practicing physician who is affiliated with a medical school — originally submitted the narrative essay with his name but the journal decided to publish it anonymously in order to protect any people who might be identified, most importantly the patients. Annals of Internal Medicine said the piece was peer-reviewed before publication.
The author said he learned of the first incident when teaching a medical humanities course and asking, "Do any of you have someone to forgive from your clinical experiences?" "Did anything ever happen that you need to forgive or perhaps still can't forgive?"
A student he called David said he was observing the surgery when an attending physician made the lewd comments while cleansing and scrubbing the patient. David commented, "Man, I was just standing there trying to learn. The guy was a dirtball. It still pisses me off."
The author says the student turned the discussion around by asking him the same question. He said he "felt my face flush" and before he knew it, he told the class about the second incident, which occurred in his third year of medical school while he was on an OB/GYN rotation. He said that he ended up laughing and joining in on the doctor's disrespectful dance until the anesthesiologist in the room yelled "Knock it off" and swore at them.
In the one-page narrative essay, the author doesn't offer any judgement or opinion about the incidents but says that the discussion in the class made him realize "this is my silence to break."
The journal's editors said that they hope that medical educators and others will use the essay as a "jumping-off point for discussions that explore the reasons why physicians sometimes behave badly."
"If the essay squelches such behavior even once, then it was well worth publishing," they wrote.
Deborah Hall, president of the American Medical Student Association, told U.S. News and World Report that medical students might be reluctant to express their objection even though they know they should because they are at the bottom of the pecking order in an operating theater filled with doctors, nurses and technicians.
"Students feel incredibly vulnerable," Hall told the publication. "It's incredibly difficult to speak up."
Harlan M. Krumholz, a cardiology and social and policy professor at Yale, told MedPage Today that "there needs to be a mechanism where such behavior can be reported — and then the issue needs to be investigated by an ombudsperson and handled appropriately.
"We want to avoid false accusations or misunderstandings — but also, some of these actions are downright criminal — and so need to be addressed immediately," Krumholz said.