Have They Finally Got to You? - the Firing of Dr Gu

Introduction - Dr Gu's History of Activism Made Him Unpopular at Vanderbilt

We first wrote in February, 2018, about the plight of Dr Eugene Gu, a surgical resident at Vanderbilt University Medical Center (VUMC).  Dr Gu has a history of political activism, resulting in being  blocked on Twitter by President Trump after Dr Gu criticized him online, until a court forced Trump to unblock him on First Amendment grounds.  After Dr Gu posted a photography of himself kneeling in support of the protest of football player Colin Kaepernick, the mother of a pediatric patient apparently refused permission for Dr Gu to treat her child based on the kneeling post, and VUMC responded by suspending him.

Dr Gu Fired

The story reappeared in the media in June, first in the Duke University Chronicle, then in the Tenneseean and USAToday.  From the latter,

A Tennessee doctor who became a social media sensation because of statements on President Donald Trump, racism and Colin Kaepernick - and who later sued the president over First Amendment rights - is losing his job at Vanderbilt University Medical Center.

Dr. Eugene Gu, 32, a Vanderbilt surgery resident, said Friday that Nashville's biggest hospital is ending his five-year residency after only three years.

Technically, Vanderbilt has decided not to renew his contract with the hospital, Gu said, but he argues the effect is 'no different than being fired.'

Dr Gu argued that the reason he was effectively fired was that VUMC disapproved of his political views as expressed on social media.

'The take-home message here is that there is an unwritten rule for surgical residents and that is rule is, always make your program look good and always make your hospital look good, and often that means stay silent,' Gu said.

VUMC denied that:

Vanderbilt said in an email statement Friday that the decision not to renew Gu's contract was not a result of his criticism of Trump, his lawsuit, or his public opposition to racism. The hospital has said previously that all disciplinary actions against Gu relate to his work performance and professionalism.

'Regarding other allegations that Dr. Gu is making about the Medical Center, I would ask that you please consider these as allegations and nothing more,' John Howser, a spokesman for the hospital, said in the email. 'To date, we have not engaged in a point by point rebuttal of Dr. Gu’s many claims over the past two-plus years. At this time we will continue to maintain this stance.'

VUMC, however, has not provided any clear evidence of deficient performance or insufficient professionalism.  The Duke Chronicle article noted arguments that Dr Gu made suggesting that it may not have had much such evidence.  First,

After an appeal, a May 17 letter to Gu from VUMC General Counsel Michael Regier—delivered at the request of Jeffrey Balser, president and CEO of VUMC—cited a 'lack of sufficient improvement in performance and conduct in key areas' after the probation. The letter, which was obtained by The Chronicle, indicated that the most "significant areas of concern" were 'patient care, communication, and medical knowledge.'

However, Dr Gu cited one example of a criticism of his performance that seemed rather trivial.

when he was serving on consult call, meaning he would respond to any surgical needs throughout the night. There was a patient for whom he was supposed to identify the course of treatment—which he did, correctly, as he did with the imaging and other relevant details. His colleagues, nevertheless, 'nit-picked' Gu about 'every little detail on the case'—claiming he didn’t 'dot all of his i’s and t’s' by not providing the patient’s height and weight—which Gu said were irrelevant.

Also, he noted that

Kyla Terhune, the residency program director for general surgery, was two-faced in her interactions with him. A text message obtained by The Chronicle showed that Terhune wrote 'Nice presentations' to Gu after he spoke at the Veterans Affairs Medical Center Tumor Board. He said she complimented him for his performance after going through two surgeries for him. But when it came time for performance review, Terhune said his performance was 'terrible' in those same instances, Gu noted.

Given the local and social media attention this story has received, one might wonder why, if VUMC had such a strong case against Dr Gu, it has avoided ever airing any details about it.

Furthermore, the article noted an apparent anomaly in the narrative of how the patient's mother came to complain about Dr Gu.

Before the story broke, VUMC declined to comment more than a dozen times, saying that it does not comment on personnel matters. After it was published, Howser wrote in a statement that Gu did not need to change his political views.

'Dr. Gu has never been told that he must change his political views or the substantive content of his personal participation on social media platforms,' the statement read. 'He has been advised of the need to adhere to VUMC’s social media policy, which requires that persons who are identified as representatives of VUMC clearly state that their views are their own. He has also been advised that resident physicians should be professional and respectful in their interactions and communications with and about one another.'

In the kneeling photo, one cannot make out that his badge says Vanderbilt Medical Center on it, even when zoomed in on. Gu's Twitter bio had no reference to Vanderbilt, though he had tweeted about Vanderbilt seven times prior. Twice, he tweeted that his views communicated on Twitter do not represent VUMC.

Yet Vanderbilt, after first suspending Dr Gu, ended his residency prematurely.  Since surgical residency normally lasts five years, it seems reasonable to say Dr Gu was fired, and that such Vanderbilt's action will likely damage his career.  Since Vanderbilt has not provided any convincing evidence that Dr Gu was incompetent or unprofessional, one is left with the nasty suspicion that it fired him because refused to stay silent about political beliefs that did not accord with those of Vanderbilt leadership.


Discussion

This story suggests that in our current political era, health care professionals, particularly trainees or others at the bottom of the totem pole, may be increasingly beholden to the political sensibilities of their bosses, and hence increasingly wary of espousing political views that run counter to those of their bosses. 

While it is reasonable for residency programs to require their trainees to be professional, since when did "professional" mean stifling political views that might offend hospital corporate leadership?

As we wrote in February,

 It may not be unreasonable to expect physicians and physician-trainees, as medical professionals, to avoid getting into political arguments with patients.  However, it is unreasonable to expect physicians to avoid making any public political comments that could ever be expected to offend any patient or relative.

And this case also raises the question of whether it was the patient's mother's offense, or the Department Chairman's offense, that mattered.

Attempts to censor political speech in academia are unfortunately not rare (see the website of FIRE, the Foundation for Individual Rights in Education, for many examples).  However, they have not seemed to be that frequent in medical education. (Our most recent example before this case was from 2015.)

I wonder, though, if the ongoing attacks on free speech and the free press (e.g., look here and here) by the current President and his cronies are emboldening censorship in US society.  The President does set the tone and agenda for the country.  A president who personally threatens free speech and a free press will encourage other would-be censors to crawl out of the woodwork. 

We will only be able to restore the freedoms promised in our Constitution, and ostensibly inherent in the nature of academic organizations, if we can get a new president who upholds the worth of these freedoms, and actually will preserve, protect and defend the Constitution of the United States.

Musical Interlude

Some lyrics from Dr Wu, Steely Dan, by Fagen and Becker

Are you with me Doctor Wu
Are you really just a shadow
Of the man that I once knew
She is lovely yes she's sly
And you're an ordinary guy
Has she finally got to you
Can you hear me Doctor

Are You With Us, Dr Gu? - Vanderbilt Suspended Surgical Resident Allegedly Due to Patient's Mother's Compaints About His "Taking a Knee" on Social Media

In the US, our political situation seems to be leading to new threats to free speech in academic medicine. 

Background: Dr Gu's Activism 

 his story was first reported by The Chronicle at Duke University, and here it is in chronological order

Congressional Subpoena about Fetal Tissue Research

Dr Eugene Gu is a pediatric surgical resident at Vanderbilt University Medical Center (VUMC).  He has a history of political activism starting at least since he was a medical student.

As a third-year student at Duke Medical School in 2012, Gu earned a Howard Hughes Medical Institute fellowship, allowing him to perform fully-funded research at Stanford Medical School. There, he worked with stem cells.

In particular,

he performed the first successful fetal kidney and fetal heart transplants in immunocompromised rats—a project funded by family, friends and small angel investors, he said. The ultimate goal was to help babies with congenital heart and kidney diseases.

In order to do this research,

Gu obtained the tissue from third-party StemExpress, not directly from patients.

He was rewarded with a congressional subpoena:

in March of 2016, Gu was subpoenaed by Congress for his work.

Rep. Marsha Blackburn (R-TN) put the subpoena into motion after manipulated videos tried to 'make it as though Planned Parenthood employees were selling fetal tissue in violation of federal law.'

Several subsequent investigations found 'no evidence of wrongdoing' by Planned Parenthood.

Congress said it subpoenaed him and other researchers at this time to 'get the facts about medical practices of abortion service providers and the business practices of the procurement organizations who sell baby body parts.'

Gu called it a 'witch-hunt' along with StemExpress CEO Cate Dyer in a joint op-ed in Nature.

The Association of American Medical Colleges issued a statement supporting the sort of research Gu was doing, signed by dozens of top medical schools, including Duke and Stanford.

Lawsuit After President Trump Blocked Dr Gu on Twitter

Dr Gu was not shy about replying to President Trump on Twitter.

Gu said the tweet that got him blocked by the 45th President of the United States poked fun at his infamous 'covfefe' typo:

Covfefe: The same guy who doesn't proofread his Twitter handles the nuclear button.

— Eugene Gu, MD (@eugenegu) June 18, 2017

'Trump often announces changes in national policy exclusively from his personal Twitter account,' Gu said. 'It has become a de facto town hall in the modern era of social media. Not being able to participate in the conversations underneath his tweets is like being silenced from the public sphere.'

This lead Dr Gu to become party to a lawsuit against Trump for blocking him and other Twitter users from this public forum.

The Knight First Amendment Institute filed a complaint on behalf of him and six other Twitter users blocked by President Trump in the Southern District of New York July 11. The group alleged that preventing citizens from accessing his account, a 'public forum,' was in violation of the First Amendment.

Dr Gu Suspended

After having demonstrated that he was not in agreement with President Trump and some of his supporters on a number of issues,

The now-Vanderbilt University Medical Center (VUMC) resident was placed on paid administrative leave for nearly two weeks on Nov. 9. He says it might have to do with a patient’s mother complaining that he took a knee on Twitter to protest white supremacy.

She wrote two public Facebook posts identifying herself as the patient’s mother that kicked Gu out of the room and prevented him from caring for her son because of Gu’s actions. She did not respond to multiple requests for comment from The Chronicle.

The Chronicle journalists did a little digging,

According to emails obtained by The Chronicle with the name of the patient and their mother redacted to protect patient privacy, VUMC administration officials discussed investigating all the mother’s complaints regarding his social media posts on Nov. 8. That day, Seth Karp, chairman of the department of surgery, requested that someone document the mother's complaints about Gu and get them to him by the end of the next day, Nov. 9.

One day later, Gu was placed on administrative leave.

VUMC did not return more than a dozen requests from the Chronicle for confirmation that Karp is involved in personnel decisions over more than a week, over email and the phone.

A later article in The Chronicle noted

on Monday, VUMC denied that he was placed on leave due to his kneeling after a wave of social media criticism and reports from major news outlets covering The Chronicle’s story.

'The assertion that Dr. Gu was disciplined because of his expression of political or social views in social media is untrue,' the new statement read. 'All of VUMC’s actions relating to Dr. Gu’s progress as a surgery resident have been and will continue to be based on his performance and his adherence to VUMC policies.'

The VUMC statement further said:

He has been advised of the need to adhere to VUMC’s social media policy, which requires that persons who are identified as representatives of VUMC clearly state that their views are their own. He has also been advised that resident physicians should be professional and respectful in their interactions and communications with and about one another,...

How Dr Gu might have violated the medical center's social media policy, or how his tweeting might have amounted to unprofessional or disrespectful communications with colleagues was not made clear.

According to his Twitter account, Dr Gu is still a resident at Vanderbilt but is seeking to transfer elsewhere.

This case apparently was also covered in a single story in the Tennessean, and inspired a single op-ed by a medical student in the Toronto Star. Beyond that, it has been anechoic in the news media or scholarly medical literature.

The Toronto Star op-ed suggested:

This is a cautionary tale for any resident physician. Medical trainees are at the mercy of the hospitals that employ them because mandatory residency education is a prerequisite for board examination and certification. Without these, a physician cannot practice independently.

Due to this power imbalance, physicians-in-training are averse to any action that would put themselves at professional risk, including political advocacy that may be perceived as contrary to an institution’s value system. The stakes are simply too high.

The real question, however, is whether society wants its physicians to also be advocates.

Discussion and Conclusions

This case suggested that at least the leadership of one prestigious university medical center is very uncomfortable at best, with its residents publicly expressing certain political opinions, even clearly outside the confines of the hospital.  Whether the leaders felt licensed by the President of the United States, who had banned the person at the center of this case from following him on Twitter, is a reasonable question.

It may not be unreasonable to expect physicians and physician-trainees, as medical professionals, to avoid getting into political arguments with patients.  However, it is unreasonable to expect physicians to avoid making any public political comments that could ever be expected to offend any patient or relative.

And this case also raises the question of whether it was the patient's mother's offense, or the Department Chairman's offense, that mattered.

Attempts to censor political speech in academia are unfortunately not rare (see the website of FIRE, the Foundation for Individual Rights in Education, for many examples).  However, they have not seemed to be that frequent in medical education. (Our most recent example was from 2015.)

I wonder, though, if the ongoing attacks on free speech and the free press (e.g., look here and here) by the current President and his cronies are emboldening censorship in US society.  The President does set the tone and agenda for the country.  A president who personally threatens free speech and a free press will encourage other would-be censors to crawl out of the woodwork. 

We will only be able to restore the freedoms promised in our Constitution, and ostensibly inherent in the nature of academic organizations, if we can get a new president who upholds the worth of these freedoms, and actually will preserve, protect and defend the Constitution of the United States.

Another Academic Medical Leader (This Time at Vanderbilt) Named Corporate Director (This Time at Merck)

We have previously blogged about the apparently major conflicts of interest generated when a leader of an academic medical institution is also simultaneously on the board of directors of one or more for-profit health care corporations.

The Associated Press (here via the Houston Chronicle) just reported that Dr Harry Jacobson has been appointed to the board of directors of Merck and Co. The AP report also noted that Jacobson is on the board of Kinetic Concepts Inc. A cursory Google search revealed Dr Jacobson is a founder of Radiation Oncology Services of America (via the Nashville Business Journal) and was formerly on the board of the Renal Care Group (via PRNewsire).

Meanwhile, Dr Jacobson's day job is to be Vice-Chancellor of Health Affairs of Vanderbilt University. So here is yet another example of a top leader of an academic health care institution who is also on the board of directors of in this case three for-profit health care corporations, including one of the largest pharmaceutical companies in the world, plus two smaller local companies.

According to the Third Edition of Corporate Governance by RAG Monks and N Minow, a member of the board of directors of a public, for-profit company must "demonstrate unyielding loyalty to the company's stockholders." So it would appear that Dr Jacobson, like other top leaders of academic medical institutions who serve on the boards of for-profit health care corporations, has quite some conflicts of interest. How can he simultaneously demonstrate "unyielding loyalty" to a pharmaceutical company, a company that produces wound care therapeutics products, and a company that provides outpatient radiology services, and meanwhile be devoted to the health care mission of Vanderbilt University? But at the moment, nobody at the University seems concerned about it. And these kinds of conflict of interest have excited little interest, while many bytes and much ink and paper address the conflicts generated when medical students, interns and residents, or practicing physicians receive pens or mugs with corporate logos, or free pizzas (see this post). Go figure, and let the good times roll....