Call to Stakeholders to Speak Out Against Medical Assault

(Originally published on Facebook, July 23, 2018)

Women who are diagnosed with breast cancer, especially in the later stages, are asked to submit ourselves willingly to poisoning (chemo), burning (radiation), and amputation (breast surgery). It’s a sudden and difficult transition from seeing yourself as a healthy individual, to accept that you have a ticking bomb inside your body and that you might die of this disease even if you undergo all available treatments.

The one aspect of the treatment plan that the patient does have some measure of control over, is the reconstruction decision. Having your breasts amputated is no small thing. But there *is* no reconstruction option that can offer you new breasts. Reconstructed breast mounds, whether implant or autologous, are typically numb and non-functional. And they require multiple surgeries to install.

For some women, reconstruction feels right, and helps them heal psychologically from the devastation of breast cancer. For other women, the prospect of having numb, non-functional material on their chest is far from desirable, and healing from the devastation of breast cancer means getting back to their normal life as soon as possible. Both perspectives are valid. Both choices deserve to be respected.

This choice belongs to the individual woman – she knows her body, her mind, her heart, and her circumstances better than anyone else.

To have this choice stolen from you, is nothing short of devastating. I felt physically ill when I looked under my bandages after waking up from surgery. I knew instantly that the surgeon had left pockets for implants against my consent. My carefully considered choice to be one and done, was thrown away like trash on the side of the road.

To intentionally inflict this additional suffering (and additional surgeries) on a patient who has just been through breast cancer treatment – five and a half months of poisoning to the point of becoming bedridden for weeks on end, losing all of your hair, being unable to taste or properly digest your food, then having your breasts amputated, knowing that you will soon face six weeks of radiation while you heal from chemo and surgery – is unconscionable.

The difference between torture and lifesaving cancer treatment, is consent. We cannot allow this gross violation of woman’s bodily autonomy to continue unacknowledged and unchecked.

I call on Cleveland Clinic ( Cleveland Clinic Avon Hospital, Cleveland Clinic Union Hospital, Cleveland Clinic – Brunswick Family Health Center) to take a stand against this injustice. I call on the Clinic’s executive administration, headed by CEO Tomislav Mihaljevic, to protect their patients now, as they failed to protect me.

I call on surgeons and hospitals across the nation and beyond, to lay down your pride and pretenses and acknowledge this problem. And take the necessary steps to protect your patients as your Hippocratic oath demands. History will hold you to account.

I call on national stakeholder organizations to address this problem as well. Its easy to ignore patients. Not so easy to ignore large, powerful stakeholders.

American Cancer Society
American Society of Plastic Surgeons (ASPS)
National Organization for Women (NOW)
Young Survival Coalition (YSC)
Susan G. Komen
Gloria Allred
ACLU

Informed Consent: The Difference Between Medical Care, and Battery

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Legally and ethically, surgeons must obtain informed consent from their patients before they operate. The AMA code of medical ethics is crystal clear:

“… informed consent occurs when communication between a patient and physician results in the patient’s authorization or agreement to undergo a specific medical intervention.” (1)

A surgical patient’s consent is specific to a defined intervention, and is not of a blanket nature wherein the surgeon is authorized to take liberties unilaterally while the patient is unconscious. A skin sparing mastectomy and a mastectomy with complete removal/flat closure, are two different procedures. If a patient consents to one procedure, and then while they are unconscious the surgeon decides to perform a different procedure, that action is unethical and a violation of the patient’s consent. It is also illegal, and constitutes battery:

“As a pure legal issue, forcing treatment on an unwilling person is no different from attacking that person with a knife. The legal term for a harmful or offensive touching without permission is battery. Battery is a criminal offense, and it can also be the basis of a civil lawsuit. The key element of battery is that the touching be unauthorized, not that it be intended to harm the person. Thus forcing beneficial care on an unwilling patient would be battery… If the patient has been lied to about the treatment or there is other fraud in the informed consent, then the entire consent is invalid.” (2)

The legal definition of battery does not require that the surgeon intend to harm the patient, only that the surgery was unauthorized – the fact that the patient did not consent to the procedure, alone is enough. In many cases of mastectomy patients wishing to go flat, the surgeons do act fraudulently in obtaining informed consent. My own surgeon literally told me, “I’ll make you flat,” after extensive discussion about the specifics and risks/benefits of the procedure.

In my specific case, in addition to battery, I was also subjected to assault, which is the threat of battery. When my plastic surgeon said, as I was lying on the operating table, “I’ll just leave a little extra in case you change your mind,” that was a threat of assault. A threat to violate my consent. And he knew that I was unable to defend myself because I was about to be anesthetized. Unconscionable.

Most women who have been subjected to this type of battery, were not assaulted in advance, but rather told afterwards that their battery was in their best interest. “I left you a little extra in case you change your mind,” “I left you some cleavage.” The surgeons routinely admit to battery, but they don’t call it that, of course. They frame their decision to batter the patient in paternalistic, confusing terms. This is a psychological manipulation technique known as gaslighting (not currently defined in US law).

“Gaslighting refers to a form of intimidation or psychological abuse where false information is presented to the victim. The purpose of such act is to make them doubt their own memory and perception. This term is also known as ambient abuse.” (3)

Patients hear their surgeon, to whom they entrusted their bodily integrity and their literal life, telling them something that is factually untrue, to their face, while they are in an extremely vulnerable state post-op and dependent on the offender for their surgical aftercare. In my case, because my surgeon had assaulted me as I was lying on the OR table, his gaslighting afterwards was along the lines of flatly denying the physical evidence on my chest, rather than re-casting it as a positive (the usual strategy). My surgeon told me that he had not left extra skin, and that it would “tighten up.” He lied.

Let me be perfectly clear. As a patient who was battered, my intention is not to sue the hospital and receive compensation personally. My intention is to bring this unethical, illegal practice to the public light, and put a stop to it for good. And I will do whatever it takes to make that happen.

Kim Bowles

Not Putting on a Shirt

(1) https://www.ama-assn.org/delivering-care/informed-consent

(2) https://biotech.law.lsu.edu/map/BatteryNoConsent.html

(3) https://definitions.uslegal.com/g/gaslighting/

$$$ Conflict of Interest for Flat Closure $$$

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When a patient facing mastectomy brings on a plastic surgeon solely to perform a flat closure after their SO (surgical oncologist) performs the mastectomy, this is called “co-surgery,” and reimbursement by insurance can be complicated. Often, it results in both surgeons receiving less than full payment for the procedure. Medicare, for example, splits 125% of the single procedure fee between the two co-surgeons, so each gets paid 65% of what they would have if they’d done the entire procedure themselves. Other insurance will pay 100% to the first surgeon performing the “primary procedure” (onc) and only 50% for the “secondary procedure” (plastics).

Since the plastic surgeon is already getting paid less for their time in the OR to make the patient flat, and they’re getting paid per procedure – NOT per hour – they seem to have every incentive to spend as little time as possible working on the patient, and potentially to do a hasty, incomplete job. And they know that they won’t be getting any further business from this patient who doesn’t want recon. Unless… unless they need another surgery to be truly flat.

Payment is not the only factor at play here. But it’s clear from the reimbursement perspective that plastic surgeons are highly disincentivized to provide a flat result in one surgery.

When my surgical oncologist recommended bringing a plastic surgeon onto the team to do a flat closure for me, I was completely unaware of these conflicts of interest. I have since anecdotally observed that women who used only one surgeon, the surgical oncologist, tend to have better and more completely flat results, than those of us who used a plastic surgeon. How sad is that? That we have worse outcomes with the specialist, than the generalist. Because of money? Is it that simple?

This is why we need buy-in from hospitals and surgeons. And we need solid data on this problem, bait and switch mastectomy surgery. How often does it happen? Under what circumstances? What are the risk factors or contributing factors? And how can we counteract them?

If we are committed to stopping this battery against patients, this is where we end up. We need to characterize the problem, before we can come up with a solution.

References:

https://www.google.com/…/33013-4-simple-rules-for-co-s…/amp/

https://www.aapc.com/…/26378-observe-documentation-require…/

Shouldn’t CANCER be your toughest fight when you’re fighting breast cancer?

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I’m sharing this image with permission from the woman pictured. You can follow her on Twitter @clreid56

Shouldn’t CANCER be your toughest fight when you’re fighting breast cancer?

Breast cancer takes away so much from a woman. And it takes it by force – you either do the treatments, or you die from the disease. That isn’t much of a choice.

Breast cancer steals your health. Your vitality. Your sexuality. Your hair, your eyebrows, and your breasts. Your physical, mental, emotional, and financial resources. It can and does ruin your personal relationships as well. Friends and sometimes even family members fall away as you morph into someone new, someone sick and weak, someone ruined and desperate. Contemplation of your mortality is more than many people can bear. But you must bear it, alone. You have no choice.

You can recover some of these things, but not all of them. The truth is, you will never be the same again.

The only real matter of choice in the whole nightmare is the reconstruction decision. It’s the only component of breast cancer treatment where the patient’s feelings, opinions, AGENCY, affect the actual experience. To snatch this away is the height of cruelty.

It’s dehumanizing. It’s unethical. It’s wrong.

No one knows why some surgeons cross this line. So far, the vast majority of surgeons and hospitals won’t even admit that it happens at all.

I’m here to tell you. IT HAPPENED TO ME. It continues to happen every day, as we speak. And it will keep happening again, and again, until we fight back.

Join me on September 8th to add your voice to the growing chorus that says, “NO MORE” to this cruelty.

It happened to me and I can’t change that… but I DO NOT have to accept it. I WILL fight back. I WILL do whatever it takes to put a stop to it. To protect women. To protect our daughters.

Join me.

Kim Bowles
Not Putting on a Shirt

The Hippocratic Oath

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The modern Hippocratic Oath serves as a moral code governing the actions of today’s physicians.

As a patient whose consent has been violated by the surgeon I entrusted with my body and my life… I would love to know what transpires in the minds of surgeons who cross the line and decide that they can and will commit this violation.

Because if I knew, I might be able to stop it.

Thanks to Lonnie Workman for inspiring this post. I’ve always known that my surgeon violated his Oath, but I didn’t realize just how powerful the words of the Oath would be.

I call on the Cleveland Clinic, and on Steven Bernard personally, to acknowledge the wrong that was done to me under their charge. And to work with me to ensure it doesn’t happen again.

Kim Bowles