How I tried to change medicine without an MD.

I was actually pre-med. I had a 4.0 science GPA and a high MCAT score. But I stopped wanting to be a doctor.

What I began to see, in my last years of college, was that most medical errors happen because of systemic problems. Even when the end-perpetrator is an individual, the solution is often systemic, as systems and processes can be designed to minimize the impact of human fallibility.

I imagined having a private practice, like my dad’s, treating one patient at a time. This wasn’t what I wanted. I asked my dad who really controls the standard of care. I asked him who dictates training standards, treatment guidelines, privileging. He didn’t think becoming a doctor would be an avenue. Maybe he was wrong. Maybe I should have gone to medical school after all.

But I didn’t.

I got it into my head that I could change training, treatment guidelines, and privileging in OB/GYN. Back then, I thought I could do anything I set my mind to. My arrogance probably set me up for failure.

I tried bringing gaps in training and education, and negligent privileging to medical leadership back in 2010 and 2011. But I got discouraged too easily. I got emotional because this was all related to a trauma — the innervation of my clitoris had been cut during a labiaplasty.

I was so afraid of people telling me there isn’t a need for training standards, for better privileging, or even for the inclusion of clitoral neurovascular anatomy in textbooks. I barely contacted anyone.

What I did was write a paper I’ll probably never publish — a paper I’ve been afraid to share because, frankly, it isn’t any good. It’s ~200 pages long and split up into multiple documents. I have about 10 different versions of each chapter, and I still need to edit out the expletives. I thought if I could write the perfect paper with enough evidence to support each argument regarding a need for change, no one could tell me “no.” But that’s not how people work.

I finally started meeting with people this year. I finally started emailing professional societies, medical boards, textbook authors, and residency program directors. I tried crashing the ACOG convention to find people who would want to help get clitoral neurovascular anatomy added to textbooks and curriculums. I wanted to find OB/GYNs who agree there should be training standards for labiaplasties as long as ACOG is approving them.

But what I really want to happen is to change how these systems work. Entities responsible for the standard of care and actually capable of changing it are not liable. They are not really incentivized to actually ensure a high quality of care.

Why does ABOG refuse to add clitoral neurovascular anatomy to board exams?

Why won’t ACGME dictate that it gets taught it residency?

Why won’t ACOG offer continuing medical education for surgeries they approve, which OB/GYNs are not trained to do in residency?

What impact does it have on systemic negligence when an individual surgeon gets sued?

When there is systemic negligence in medicine, as is the case when doctors are board certified to do surgeries they are not trained to do on anatomy they do not know, what mechanism is there to correct this? The medical liability system? In a working system, a problem like this should self-correct. Instead, it has not changed in decades.

What does suing an individual doctor really do? There is little correlation between actual negligence and a patient winning a lawsuit. And if the negligence is systemic, that makes the case very difficult to win, as generally establishing negligence requires proving the standard of care was not followed. What if the standard of care is negligent? How much learning actually takes place when 60% of doctors who lose lawsuits believe they followed the standard of care and did nothing wrong?

The current medical liability system is an inadequate feedback mechanism.

Getting clitoral neural anatomy included in OB/GYN textbooks. It was finally added for the first time in July 2019. BME/EE @WUSTL

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