An Open Letter to The American Society of Anesthesiologists: Amy J. Reed MD, PhD (1973–2017)
Honorable Mr. President and standing members of the American Society of Anesthesiologists,
I write this open letter to you about one of your society’s members, my wife Amy Josephine Reed MD, PhD.
Amy passed away on May 24, 2017, barely 44, from complications caused by a gynecological procedure, known as morcellation.
You may read in her voice, here.
Amy J. Reed was her high school’s Valedictorian, and a Phi Beta Kappa graduate of Pennsylvania State University. She earned her MD and PhD degrees from the University of Pennsylvania’s School of Medicine. She completed her residency and fellowship training at the Hospital of the University of Pennsylvania (HUP) in 2011 and was dual board certified in anesthesiology and Critical Care Medicine. Subsequently, she served as a staff anesthesiologist and intensivist at Beth Israel Deaconess Hospital in Boston — and then, again, at HUP.
I, and all her colleagues, will attest that Amy J. Reed loved being an anesthesiologist and intensivist — and she practiced her profession with passion, humility, patience, commitment and good humor.
Amy was one of your ranks at the highest and most accomplished levels of education and practice. But in October of 2013, she fell to a systemic error of negligence in surgical practice in a gynecological operating room in Boston’s Brigham and Women’s Hospital (BWH). Specifically, until Amy’s complication was publicized and a battle for women’s health began raging, most gynecological surgeons were assuming women’s uterine fibroids to be benign. And morcellation was thought to be a minor technical detail, despite the clear evidence of harm in the specialty’s own literature.
As a result of the campaign Amy waged after her complication at BWH, the FDA ultimately issued a warning, which virtually eliminated the use of the power morcellator from the GYN specialty in the United States and many countries abroad. The FDA estimates and confirms that on the order of one in 350 women with symptomatic uterine fibroid carry an occult or missed uterine sarcoma, which when morcellated by a gynecologist can spread or be upstaged with deadly consequences — as happened to Dr. Amy J. Reed and many others.
Immediately subsequent to the FDA query in July 2014, J&J, the largest producer of the Gynecare morcellator, withdrew its device from the global market. But another prominent brand of the device marketed by STORZ remains on the market and is in use in many operating rooms across the United States and abroad.
Today, despite the fact that power morcellation has mostly receded from gynecology in major medical centers, a vast number of GYNs and other professionals continue to believe Amy’s campaign for women’s health was nothing more than an emotional publicity stunt — and that the less than 1% chance of an occult malignancy in uterine fibroids is an acceptable risk to patients. But such responses demonstrate the degree to which utilitarian thinking in our profession is overriding the time tested principles of medical ethics. With literally hundreds of thousands of fibroid operation being performed routinely in GYN operating rooms in the United States and abroad daily, a less than 1% chance still translates into thousands of unsuspecting women being placed in avoidable iatrogenic harm’s way — that, is no negligible number of patients harmed from a specific, incorrect and totally avoidable practice.
Very certainly if a specific device or practice caused avoidable deaths intra-operatively at a rate of one in 200–400, there is no question that both surgeon and anesthesiologist would move to eliminate the danger. The difference, here, is that the deadly consequence of morcellation is not immediately visible. But, now that the facts are known and most GYNs seem to have no problem with this, can anesthesiologists ignore it and remain in an ethical practice space? The answer is, No.
It takes no amount of effort for any reasonable physician to understand that mincing up tumors with malignant potential inside a human body cavity is a prohibitively dangerous practice — because it risks spreading or upstaging a deadly process. In fact, it is a dictum of general and oncological surgery that all masses with malignant potential be resected en bloc and with good margins. All, but gynecologists, seem to respect that principle.
Unfortunately, despite the extensive level of publicity generated by Amy’s complication, a large number of gynecological surgeons continue to morcellate women’s fibroids, manually or using a power morcellator. Many use power morcellators from manufacturers like STORZ, which continues to sell the dangerous device without regard for the deadly oncological danger it poses to women.
Manual morcellation is no less deadly. Just last December 2016 I heard from a woman whose sister’s occult uterine sarcoma was manually morcellated by a prominent California gynecologist. She died of catastrophic abdominal sarcomatosis, as my wife did, almost exactly one year after an operation for a presumably benign symptomatic uterine fibroid in December 2015 — she left a 7 year old daughter and her husband behind. This, nearly three years after Amy had raised a very loud alarm, internationally, and even to this particular gynecologist himself. The message is that GYNs are not taking the dangerous oncological potential of fibroids seriously enough — they believe it to be an overblown hazard.
This brings me to the message I want to convey to the ASA leadership and all members: Every woman who falls to uterine cancer spread or upstaging by morcellation at the hands of a gynecologist is operated on by two sets of physicians — a Gynecology team and an Anesthesiology team.
It is true that in our specialized practice of medicine, we all mind our own business and respect the autonomy and expertise of our colleagues in other specialities. We are “silo-ed” from one another, both by choice and by necessity. And for the most part, this works well. Everyone does their part to get patients through complex operations successfully.
But Amy’s complication and her large scale public health campaign demonstrated that there are poignant and dangerous exceptions to this rule of engagement in patient care.
To be clear, when a GYN uses an anesthesiologist’s expertise to perform a morcellation on a woman, it is not only the GYN who bears the burden of responsibility for the patient’s well being, but also the anesthesiologist. And if the GYN fails to do so properly, then the anesthesiologist has the ethical duty to restrain the harm.
In addition to her 6 lovely children, the legacy of Dr. Amy J. Reed’s life is that many hundreds, if not thousands, of unsuspecting women and their families will be spared the deadly complication of power morcellation into posterity. As for my wife, it is an indisputable fact that Amy single-handedly eliminated a man-made cancer risk to women worldwide. But her message to you, her colleagues in anesthesiology, is even more profound. In fact, it is a call to arms none of you could ignore now.
Here, I ask that every member of the ASA who participates in a gynecological operating room where uterine fibroid tumors are being treated by a gynecologist, remember the name Amy Josephine Reed — and ask your GYN colleagues if they are sure that your patient is not another Amy Reed. Because I guarantee you that they will not be able to make such an assurance, which makes their intent to morcellate a dangerous practice that could harm your patient irreversibly.
Leadership comes in many forms. Sometimes it’s compromise and consensus-building that marks leadership. Sometime it’s vocal and sharp-edged dissent from an incorrect and dangerous norm that marks the leader.
In the case of a woman being morcellated by a gynecologist in your operating room, it is dissent and doubt about the validity of this surgical approach by your GYN colleagues that will mark your character and strength as physicians, leaders and professionals.
In the name of your colleague, my wife, anesthesiologist and intensivist Amy Josephine Reed MD, PhD I ask you to vocally query, and if need be terminate your GYN colleagues’ operations involving morcellation of uterine fibroid tumors in women. Because in the practice of our profession, the idea that accepting avoidable collateral damage to a minority subset of susceptible patients, for the real or presumed benefit of the majority, is simply unethical thinking. And such cognitive errors in our profession lead to unjustifiable iatrogenic harm and unforgivable deaths of unsuspecting patients. Do not enable this gynecological hazard.
Yours with respect and in friendship,
Hooman Noorchashm MD, PhD