Medical Violence & Complicit Doctors - Finding the Way Back to Consent & Agency

[00:00:02]At the top here, I just want to say that we're going to be talking about consent and violations of consent. And if you're not in a place to hear these discussions right now, please take care and maybe we'll see you on the next one. Now, I want you to picture this. You or someone you love nervously arrives to the doctor's office for a gynecological exam. Uh, the nurse lays out your wispy paper covers and tells you to strip your clothes and put them in the chair and put the tissue paper cover on your bottom half and you sit on the table, paper crumbling, shifting, and trying to find the most comfortable angle and spot. when a doctor that you don't know well walks into the room and that doctor comes in a medical student in tow and begins your exam but it's painful and rushed and lacks any attention to your emotional state and after clenching your fists and biting your tongue you've had enough and you finally ask him to stop but he pushes your legs further apart and tells you that he's almost done Dr. Zed Jaw doesn't have to picture this.

[00:01:07]She was the medical student observing this interaction and it led her one of many experiences. It led her to write this important new book, Consented: A Doctor's Call to End Medical Violence and Reclaim Patient Autonomy. And there are several remarkable things about this book that fundamentally shifted not only how I see the world, but how I will view my own interactions with medical professionals going forward. And for anyone who might be watching this who, you know, hasn't experienced quite the violation that I just described, but who has felt rushed, like they didn't have a say in their care, like they didn't have the ability to address their concerns before, vaguely consenting or maybe not at all consenting to a treatment, I think that you will feel seen by Dr. Jaw's work. She also doesn't let herself off the hook in this book. This is an indictment of the system and how through education and training, people find themselves complicit in a system that degrades patient care. Uh Dr. Jaw is out here doing the work to change it though and I really hope that you enjoy my conversation with her. Dr. Jaw, thank you so much for being here today.

[00:02:20]>> Thank you so much for having me. You know, I have to say I have so much respect for you after reading your book and for many reasons, but one of them is that you don't let yourself off the hook in this book. You talk about the ways in which being in the medical training system influenced the way that you then went out and did your work. And I really related to that because I'm a licensed therapist and I remember my own training uh not as intensive as being a doctor.

[00:02:52]But um I remember it was like you talked about in the book training kind of the humanity out of you. We were very afraid to be in the room alone with the client because we wanted to sit close to the door and what if they attacked you and you can't touch them and don't don't cry in front of them. You don't want to get emotional and all these different training methods that kind of created a situation where you were disconnected from the humanity of the person sitting across from you in the room.

[00:03:19]>> Can you talk a little bit about before we get to the consent aspect of it? What is it that happens in medical training and education? You think where are some of the areas of breakdown where you have that distance created between you and the other person in the room just on a human level?

[00:03:37]Yeah, that's a great question. Thank you for asking that. So I and thanks for sharing your own experience as a therapist. I I think the main thing even as you were talking, I noticed that there was a division of of them versus us, right? as as if when we enter this exam room, when we put on our white coat, when we put on our therapy hat, therapist hat, we become this person that doesn't that that these these uh conditions, medical conditions or chronic suffering doesn't really apply to us anymore. We're above that.

[00:04:08]We do better. We can prevent it. We can cure ourselves. It's as if we don't we don't embody those human conditions anymore. Yeah. And so that there's a there's a real divide. And then the other thing when you think about medical education now first of all med medical education has always been really hard on the admission criteria right so who makes it to medical school it's the people who have had the privilege of being able-bodied they are not a they're not um just you know intelligent people hardworking people they also have had the opportunity to work hard on applying into medical school and almost doing nothing but that, right? Who has the time? It's not the people who have chronic illnesses.

[00:04:55]It's not people who are disabled, who are, you know, a lot of times we we we meet people who are also like athletic and like they're out there organizing things. They have all this free time to do all these things. So they're they also happen to be thinbodied. A lot of them have privileges people who are in like in in their family who are in medicine. So they have the insider advantage of that too. So, and then the other thing about medical admission and medical education in general is that our textbooks have always been written by people who are able-bodied, cisgender, straight, white men who don't look like you and I, you know. So when we try to apply ourselves to that criteria of professionalism of what it it means to be a good candidate of of medical school that's when we have to some somehow change ourselves to fit into that mold which a lot of times in that process we lose ourselves as well and the way we talk about our patients in our textbooks too as you mentioned you know we we we do these the free like labeling of people right like we suddenly you know instead of people who face difficulties in life who have um other priorities in life like you and I do, we call them non-compliant. We say they're difficult.

[00:06:10]So, we say that they don't prioritize their health and then we blame them for their illnesses. These are always these are all these unreasonable in dehumanizing things that we say about patients and those are written in our in in our textbooks uh either written or passed down generations of uh during the educational process and we some at some point embody that language and we start to adopt that language and I remember in my book I write about all these times when the first time I I I used those language myself or like you know I think about thinking back in time when I blamed the patients when I gaslit on my patients when I was fat phobic when I was you know all these things and so today I look back and I think gosh I how much harm did I do by embodying that and not questioning it. So this book consented really is my way to um reconcile with who I was before medicine and how medicine changed me into somebody else and how desperately I want to become that person who uh who I was and who I wanted to be before medicine had the time to mold me into something else. And it's such a powerful story and I think one of the things about it is many people can relate unfortunately to a lot of the experiences that you write about in here. um especially members of marginalized communities, especially women who are you know not believed who have to beg for pain management for basic procedures and um you know you cover a lot of that ground in here but you know you you start the book with an anecdote about being a medical student and it really kind of drops you in the story and makes you kind of understand where we are with consent and I'm wondering if you can tell that story of when you were a medical student and you were observing the gynecological exam as a medical student.

[00:08:04]>> Um, first time I met this patient was when she was already 39 weeks pregnant.

[00:08:10]She was a young woman and she had no support system. So, she was afraid herself as well. First thing that happened was that she was asked to strip down um and sit in the uh in you know half naked but with just a paper drape over her >> already a very vulnerable position.

[00:08:28]>> Yes. And she was 39 weeks pregnant. and she didn't know what to expect her first pregnancy and no one was supporting her right all of that and she was a young woman very young and um no one explained to her what was about to happen asked her you ready for your cervical exam to check your cervix and I don't even know did she know what cervix was what what was what was the expectation did she know what was going to happen no one explained to her so she was not consented at all right and so then my attendant came in I was tray trailing behind him uh the exam was so horrendous that outside of medicine you would never think this is okay. You know, basically a forceful vaginal exam uh not just fingers in the vagina but actually reached all the way to the to the end of the vagina where it opens up to u connect to the uterus and that's a really like really a severe depth. And then to fit your finger in something that's not open to assess how open, how ready it is. First of all, in a young healthy first time pregnancy with no sign of labor and no complication, this was unnecessary. But she didn't know that and I didn't know that.

[00:09:35]>> And um second of all, um not not knowing what to expect and having go having to go through a painful exam like that.

[00:09:43]What really struck me throughout the process was that multiple times she verbally and non-verbally said no.

[00:09:52]>> She didn't want it to go on. She didn't know what it was. And then she said no and was ignored. And then she closed her legs, which was her non-verbal way to say no to withdraw her consent. And instead of us withdrawing uh uh what we're doing and stopping or doing reassessing and you know asking what we can do to make her more comfortable um my attendant pushed her legs down with with with his elbows and kept going to the exam and instead of stopping he said oh almost done almost done >> right as if this was no longer a person who was having an experience that she was going to remember for the rest of her Right.

[00:10:34]>> But it was nothing but a task at hand, a check mark for us that we just got to do it and move on to the next task that we had to do.

[00:10:43]>> Yeah. As though stop and know or you know a visible indications that something is extremely painful doesn't mean stop what you're doing right away.

[00:10:53]It means like hurry up and finish it.

[00:10:56]>> Yeah. Faster. Go faster. You know, doesn't that sound like rape culture? I mean, isn't that what rape culture is?

[00:11:02]Um, of course, this this this is not a person who um set out in his career to do harm. This wasn't a criminal who was going to be persecuted, right? This was a person who thought that he was doing the patient a favor by checking their cervix. And this was a person who probably started off like me, a wholesome person who understood body autonomy, understood patients, right?

[00:11:28]And then somewhere along the way or every step along the way got that part of him trained out of him and now we're in this different reality. We thought this was normal and I of course that it was memorable for me because I didn't think it was normal until everyone else acted like it was normal. Well, and you talk about and you were even kind of going through it when you were telling that story. You can kind of pick up on the different types of consent that you kind of go through in your book because there's the more obvious one of someone saying stop and know, right? That you understand that this person isn't consenting, but you also kind of go through if a patient is confused, doesn't fully understand what procedure they may be consenting to, that that's also a problem. You talk about um kind of signature collecting versus collaboration and how that's an important part of consent too that you don't just want to get someone's signature on a form. They may not have understood the form, you know, and there's a lot of constraints that go with this including time, the workload, um you know, things that are on the doctor's plate as well, but when it comes down to consent, this is so essential. Can you talk a little bit about those other areas of consent that maybe people might not be thinking of things that aren't necessarily stop or know?

[00:12:43]>> Yes. Yeah. Thank you for asking that. I think that that's sort of the essence of my book which talks about the number one thing that makes what we do part of medical rape culture is our our um uh how we deal with constant how the rest of the society is moving toward a constant culture while medicine is sort of stuck in the in the history. So um in my opinion medical consent isn't just about informing patients but also about this ongoing conversation right it has to be it cannot be just a legal signature it has to be a trustbased ongoing conversation where a patient can ask questions they can withdraw cons their consent for any reason at any time and we must respect that right that's what I think authentic medical uh patient consent should be but I in my book I I I dissected the the the the the anatomy of a u um um of a bad consent which I define to be um four different types. We got the non-consent which basically just means that uh patient didn't give consent and we did it anyway. And then number two force consent which means patient explicitly said no and we still force them to do it. And then I think those are a little bit less common these days uh because of how because of famous lawsuits in the medical history which unfortunately lawsuits were what pushed medicine to go to informed consent and patient autonomy. Yeah. somebody had to force our hands to really understand these two concepts in in which makes it possible or makes it I I suppose reasonable um that medical consent today is more about legal protection because of these famous lawsuits without without asking questions about it. But I think the less the third and the fourth type of of uh bad consent are a lot more common today might be even the norm of consent today.

[00:14:32]The third one is called inadequate consent which means patient was not given sufficient information to make a real decision. Either we were trying to convey one option to be a better option for patient for whatever reason or patient were not given all the possible alternatives including what happens if you don't forego if you don't go uh undergo this procedure or whatever is going to happen. what happens when you choose to not engage that should totally have been a choice at any point.

[00:15:06]>> Um and then the last type which I think is the main uh type of bad consent today is called contractual consent which is what you were talking about treating consent as legal document to protect us >> right >> but not the patient. And so this was be this is a put your signature here, sign your name, date and then forever forever holds your peace, right? So it's the same way when you download an app, you click yes and then you don't ever you don't ever go through all of that. But at least an app, you can delete it. You can you can still unsubscribe. But so you know medicine we're talking about sometimes even procedures where you have to it's a decision that you make that affects for the rest of affects you for the rest of your life. Absolutely. And so this one type of signature where patient cannot realistically withdraw anymore and it's one and done. That's what that's what contractual consent is and it doesn't do anything to protect the patient except for legally protect um us.

[00:16:04]>> And you talk a lot a lot in the book about systemic issues that kind of play a role especially in those latter two types of consent that you just distilled there. And I mean some of that is the workload like we talked about earlier, some of that is the time constraints. I know there's many times in the book where you would be talking about looking at the clock, you know, you have this many patients, you know, you have this many people that you're supervising and they have this many patients and it sounds enormously stressful. So when you're thinking about, you know, doctors trying to implement this approach to, you know, take on board the education that you are providing in this book that you give to the people that you teach.

[00:16:45]What do you do about some of those systemic constraints about the stress of the case load, the the time constraints, how people are rushing to do one thing after another? How can you kind of realign even within this broken system to ensure that this is a priority for people? We have many things so backward in order to facilitate a procedure-driven um productivity driven um specialty like structure uh framework. we must have someone who helps the patient put it together and that someone is the primary care clinicians um and especially in the rural area who is here to hold the whole person together because if we send the person to the kidney doctor they're going to treat the kidneys and when they talk about the heart and they're going to be like go to the cardiologist and the you know people have different priorities because their departments are different but who's the one who who collects all the assist patients down and say, "Okay, I understand these are recommended to you, but let's talk about who you are as a person and where are you in your life and who do you have at home to take care of you after these things are done?"

[00:17:58]>> Um, and then with all of that information, would you still do it? And if you were to do it, which option would you like to pick? And and where would you like to go? You know, who who who the who does that? It has to be primary care physician, primary care clinicians.

[00:18:13]But the primary care clinicians are the ones not only have the one of the highest uh discrepancies in terms of demand and supply uh but also um you know the hierarchical medical education uh treats primary care as the second choice. you know, um, primary care physicians, uh, make much less money than specialty, uh, uh, clinicians and they are, um, uh, they're given a lot higher patient load and they are they face a lot more insurance denials and they they they have a lot more, um, uh, structural tasks that they have to go through and also they are respected much less in the hierarchical environments that is medicine we know today in the United So if that doesn't change, none of the things that I talk about, especially in the the end of my each chapter, I kind of imagine boldly a future what it what uh radical um uh healthcare personalized healthcare looks like. But every single chapter or I imagine a better future is based on having a robust primary care um department which is the department of the whole person and that just has to happen first in my opinion >> and it and it's tough right because you as an individual you are making a difference you're writing a book to educate people you educate people in you know training um students that are coming up under you and those are important things there was a an anecdote in the story in the book where you talk about training students and you told them the story that you just told us about the doctor continuing the gyological exam after the woman said you know stop and expressed that she was in pain and you asked them you know what would you do in that situation and they all said you stop and so there's at least this knowledge base now that can give us some hope in the training of understanding that piece of it also seems like you know you as a doctor entering the room you are prioritizing consent. You're prioritizing look at some looking at someone as a whole person, the whole story, trying to get to know them even though those systemic limitations still exist on you. And so that means that there are other physicians that are also doing that and I think that that's hopeful too. Do you notice that when you talk about this that you are met with a lot of physicians who say to you, "I noticed this. I'm so glad that you're speaking this. I try to put this into practice.

[00:20:41]this is what I'm doing to ensure that I'm putting this into practice. What has the response been?

[00:20:47]>> Yeah, that's a great question. You know, I I was quite nervous about this book coming out because I worried that I was going to be pitted as an outsider uh now outcast by medicine by people within medicine now. But I I sort of encounter the opposite. I think all of us sort of experience on a daily basis the toll of the systemic oppressive forces and capitalistic forces that are at play. Yeah.

[00:21:13]>> And all of us all of us feel it and we are the person we are the faces of medicine and when things don't go well and when patients uh outcome don't go well when patients are unhappy with the system they don't know who to look for to blame uh in the system. They the system is not a person. Yeah, >> right. But we are people. So they come to us and they they u blame us and you know and we blame them. And so in a way, aren't we all pitted against each other?

[00:21:40]It's isn't this whole system um the lack of consent culture and the problematic culture of medicine? Doesn't that doesn't that harm all of us? And and I think the answer is absolutely yes.

[00:21:52]Right? Like it it harms all of us. It prevents us from becoming the person we thought we were becoming when we enter medical school, right? The person we wrote about in our personal statements, the the person that we imagine ourselves to be um to convince the medical schools to accept us as the future doctors, right? Isn't that that's who we want to be? And the system prevents us from getting to be that person which is harmful. And then we eventually become socalist and we gaslight patients. with blind patients. This is it. This isn't who we want to be. I think systemically we all feel that we just not everyone has a language to speak that. Um I talk about this invisible monster uh in a nightmare in my book. And I think you know in the book one day I woke up I realized that I was the monster. And I think in a way what I was trying to do of course I want to be vulnerable. I think the only reason why anyone would pick up someone's book um and like it and read it until the end is if they see the real person behind the writer, right? So, I um want to put myself out there. I think that's the only way to tell the truth. That's one one reason why I did that. But on the other hand, I think without putting myself in the book, implicating myself in the book, it's hard for people who are so much more advanced in their medical training and the medical career to remember what it was like uh when they first started.

[00:23:27]And I'm hoping by putting my vulnerability out there that will remind them gently, hey, wake up. Let's let's stop this nightmare together. What can we do to move forward? And as I as the book comes out, more and more people are reaching out to me, especially in healthcare, to say, you know what, I've always thought about that. And I I I wonder that's why I'm so burnt out. I wonder why I wonder that's this is the problem. And so having a language to talk about the things that we suffer together within medicine and al in in outside medicine I think that's been a really healing process for uh many of us and many um colleagues and uh when I say colleague I don't mean the people co-workers I mean you know people in medicine have reached out to me and said you know I'm going to recommend this book to my colleagues which is going to be the hard step to to get people to convince people that they should read another book about medicine, right? But once once people once people do and they see themselves in it and they see um they see um who they wanted to be in it, um that's when we can wake up together and dream a better future. And so in my opinion, it's been a tremendous personal growth. It's a reckoning of course, but it's also invitation u for others to join us. And I want to reassure um a little bit or give a little bit hopeful notes to your listeners and your audience that there are so many of us who think the same. Yeah, there are more and more people like us too and as we work this work, we're going to convert more people to join us as well. I think I think I think a revolution is coming within medicine. I think we're radically moving toward constant culture if the rest of the society would help us out.

[00:25:12]Um, but first step first, we have to see each other like human beings.

[00:25:18]>> Yeah, absolutely. And I love that. I mean, it's it's really what I loved about the book, and it I know I phrased it earlier like you didn't let yourself off the hook, but I think it's so important to just be honest and speaking broadly about culture and as human beings, we're generally afraid to admit when we've made mistakes. But I know back in my training, like having my supervisors tell us about mistakes that they made with clients, those were some of the most impactful educational moments. I know for me in sharing the early mistakes that I made with my first clients and not being human enough and just being afraid to relate because of the training that caused me to have, you know, some of my defenses up that I did not need at all, but I didn't know that because you have to unlearn some things when you go through training once you're actually out in the real world.

[00:26:02]>> And it's just nice to hear people admit, you know, these are the things that I did early on when I didn't know better.

[00:26:08]Now I know better and I'm implementing those things. Let's see. Maybe you have some advice for medical students. I have a good friend who is a medical student.

[00:26:15]What about medical students going through this process right now where they're in the middle of being ground down and having their humanity kind of um you know stripped from them? What is what is the advice you have for medical students to not to not lose it entirely?

[00:26:30]Um, I think sometimes I think about that as like what would I tell myself? Um, if I could talk to myself as a short coat, short white coatwearing, timid medical students, a new immigrant, a young woman, I think I would say that um it's okay that you're going through this. Um, I know the reality kind of breaks a little bit when you come into medicine and then, you know, at some point you're going to lose some of it, maybe a lot of it, and then you're going to one day think back and and look back and and and and flabbergast on how who you've become. But really, when you look back on yourself, give yourself some grace that this is so much systemic historical forces at play that's against your humanity. It's not you. You're not the weak one. Um, but when you do wake up, which you will because that's what because it's 2026, we have to, right? Um when you do you you can invite other people along and you can you can be the person who who um had the theme of humanistic approach uh in medicine and medical students right now um are the humblest they've ever they're ever going to be because medicine isn't going to make you more humble as you go along.

[00:27:59]Um, so hold on to that humility, that humanism as much as you can. Um, and then if you're an educator, you know, when you see that humility, don't punish that. Let's encourage that. Let's it's okay when our medical students don't know. It's that doesn't reflect on us who we are as teachers. It just means that we cultivate an environment where we allow our learners, our trainees to admit that they don't know. And isn't that a lot more valuable of a lesson than knowing everything which is not possible?

[00:28:32]>> I think so. Um I think that's really important is keeping that intellectual humility and knowing the limits of your knowledge and acknowledging the limits of your knowledge and we all have those and it's so important. Um there's so many things that I could talk to you about but I don't want to take too much of your time. So I'm going to finish with the final question which is kind of on theme for a lot of the things that we've been talking about here. Um, you know, something I encourage a lot with the conversations that I have here is for people to keep an open mind, for them to, you know, change their mind as the evidence changes or as their understanding of the evidence changes.

[00:29:05]And so, in the spirit of that, I would like to ask you, Dr. Ja, >> what is the most recent thing that you changed your mind about?

[00:29:14]>> Yeah. So I thought about that question too because I was traveling and I had this uh I was having dinner with u a small group of people. It was this immersive um dinner experience in Norway and uh we were together for like three and a half hours and sitting next to me were people from other parts of Europe.

[00:29:32]I think a couple from Sweden who are doctors and uh and uh a couple from Norway who what one of them is is a nurse. And so we started talking. They asked me at some point how much I made uh money-wise as as a as a doctor in America, right? Realistic question. We should talk more about money for sure, especially women in medicine. Um so I told them about about it and then they were like stunned how much money we we make compared to what they make. And then they kept asking me, they're like, "Okay, how about student loans?" And then I tell them, "Well, you know, on average 250,000, maybe even more. two doctor two young doctors near each other. You might be looking at a whole million dollar of student debts that you're going to spend the rest of your life uh repaying. And then they asked me about the hierarchical culture of medicine. They said we've heard horror stories about from our American friends about their medical education. Is that true? And then what about the fact that you guys don't have three to four weeks of vac paid vacation that your bosses force you to take every every summer or else they they think something is going on with you. Um, do you have to to earn like your PTO? Um, and then you know like uh do you have to see 25 to 30 patients a day? Like how about like do you ever sleep? You know, as they were asking more and more questions and then then that's when I realized you know what I don't think I I I I don't think that they think we're so great. I think that they pity us. I think they feel bad for how much we work as Americans in general, especially American doc, physicians in and people in >> we have this hustle culture in America today, right?

[00:31:06]>> In a way that is a punishment system where the more good work that you do, you're rewarded or slashpunished with more work and harder work for you to do.

[00:31:18]And with no check and balance, especially medicine, this grind culture, this hustle culture, and we take so much pride in it. That's another piece of advice I want to give people in medicine is that we need to somehow abandon this hustle culture. We should we should stop taking pride in how tired we are and how exhausted we are. It is not a reward system. This system is really exploitation disguised in ambition like personal professional goals. Right? So that's what I recently changed my mind about. I think I'm going to start to do more slowing down in my life and take a little bit more pride in how much I live in the moment or right now I don't quite live in the moment yet but I'm going to work toward that and then yeah after after the next book project relax >> so that's what I recently changed my mind about we need to slow down. Yeah, I I agree with that. But it also and I guess not to tie back to work, but this is also my impulse because I can't disconnect, but it makes you better at your job, right? I mean, it makes you able to show up for people and be be that physician that you wanted to be when you applied to medical school. So, I think it's an important reminder even separate and apart from work, even though that's my tendency to tie it to work because I have the same issue.

[00:32:35]>> Well, thank you.

[00:32:36]>> Relax. What is that?

[00:32:38]>> Thank you so much for that response. Um, I think we can all learn a lot from that and we can all learn a lot from your book. So, I highly recommend that everyone grab a copy. There will be a link to it in the description below. But I want to say to you, Dr. Ja, thank you so much for your time. Thank you so much for your work. And thank you for being here today.

[00:32:55]>> Thank you. And thank you for providing a platform where people can have authentic conversations and having the openness to talk about different issues from different perspectives.

[00:33:03]>> Thank you.