Why is medicine so slow to change?

Last weekend, I crashed the ACOG convention in Austin, armed with flyers about the need for better vulvar anatomy and training standards for vulvar surgeries. As anticipated, I encountered some resistance, largely due to the fact that doctors don’t really like getting accosted by a layperson with flyers. But surprisingly, I encountered a lot of support and agreement as well.

I used to read the content of OB/GYN textbooks and journal articles and conclude that the world must be against me. I could maybe see how older, male-dominated OB/GYN leadership could perpetuate systemic negligence concerning vulvar anatomy and female sexual function, but I couldn’t understand why young OB/GYNs weren’t speaking up when most of them were female. Back in 2012, a physician ex of mine called me to let me know the OB/GYN residents he talked to about this problem agreed with me — they too were mad when he pointed out that the nerves of the clitoris were omitted from their textbooks. Instead of feeling encouraged, I got upset. Why weren’t they fighting to change it?

I think the answer is that most doctors, especially younger doctors, don’t feel like they have the power or seniority to change much. Shouldn’t their professional societies enable more influence from all their members rather than only those in leadership positions, far along in their practice? Insofar as culture dictates medical literatature content, the effect of elderly medical leadership is that medicine is not caught up with mainstream culture. While the public recognizes women as equal, female orgasms as important to overall health, the clitoris as essential to those orgasms, etc., this is simply not reflected in OB/GYN literature, where major textbooks continue to devote more space to male sexual response than female (ultimate craziness) and say things like “sexual function seems satisfactory” after cutting the nerve supply to the clitoral glans.

Another problem is doctors tend to trust that the state of the art is adequate. They aren’t looking for problems, errors, omissions. One textbook author told me his omission of the neurovasculature of the clitoris had not been intentional. He explained that he mainly just copies what is included in previous editions and did not notice a deficit until I pointed it out. Somehow people just don’t notice what is missing.

Finally, there is inadequate error feedback. It is difficult to convince professional societies to issue a statement that says doctors should not be doing a given surgery without training when there is no data on impact. Not only is there no data on how many patients are harmed, there is no data on the numbers of these procedures. If anyone is reading this and knows how to get these numbers, please post in the comments and/or contact me on Facebook.

Ideally, medical systems should be capable of learning from mistakes. Every adverse event should trigger an evaluation of what went wrong and why. Often it may be difficult to determine if there was a problem with the quality of care, but patterns in outcome data should be analyzed to identify where there are problems. Sure, people do quality research that looks at how many patients die within 30 days and some other metrics, which frankly, aren’t that useful. But rarely do people evaluate when there are gaps in training and privileging that cause this. Inadequate privileging policies are a huge culprit, as allowing doctors to do surgeries they are not trained to do obviously puts patients at greater risk, but at least last I checked, this was rarely identified as a point of error in root cause analysis of adverse events.

Maybe I’m wrong and this is beginning to change. All I know is I’ve asked USPI, which owns and operates nearly 300 surgery centers, to update privilege cards so that doctors need to demonstrate training to do certain surgeries, and they told me it doesn’t make sense for them to make the effort when there aren’t enough of them being done. But I called around to a few different centers, and they are at least getting done a few times per year at each. Doesn’t it add up? Patients have been harmed at their surgery centers due to inadequate privileging requirements. Don’t those patients matter?

Textbook authors tell me they don’t think they have space to include the neurovascular anatomy of the clitoris (in the clitoris and not just leading up to it). I wish I’d had a mic on me last weekend when an older, male OB/GYN explained to me why this anatomy is not relevant to procedures they do (untrue). Also, insofar as orgasm is important to female health, and insofar as a knowledge of anatomy is integral to an understanding of health and pathology, is not this anatomy important? 19th century GYNs certainly thought so until it was ultimately established that female orgasm played no role in conception.

Another OB/GYN told me she does teach this anatomy to her residents, and she agrees it is important, but she said she doesn’t have the seniority to change ABOG exams, CREOG exams, ACGME guidelines, and textbooks. How can I get voices like hers to matter?

Another OB/GYN explained that there are many who would agree and support better coverage of vulvar anatomy, but they already are so busy with other problems. She told me every tiny problem takes a tremendous amount of effort to change due to bureaucratic inertia.

Another OB/GYN told me ABOG and ACOG are bureaucracies, impossible to reason with, and simply will not change until they get sued or called out in the national media. But there is no legal precedent for suing professional societies or specialty boards for malpractice. Is not a system that requires such extreme intervention fundamentally broken?

Why is medicine so slow to change? I’m not sure if I’ve answered this.

What can be done to fix it?

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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