Sarah: In the maternity ward of a Toronto hospital one Saturday in 2016, babies were being born at an alarming rate faster than they should have been, and the short staffed crew of nurses was getting worried. Something was up, but nobody raised any concerns, these were, after all, patients of highly respected ob-gyn Dr. Paul Shuen, who was on call at North York General Hospital most weekends. It wasn’t until two nurses found evidence of wrongdoing and reported it, that doctor Shuen’s misdeeds were revealed, and he lost his medical license. This is a story of greed, ethical neglect, disrespect of women and of a medical establishment that tried to block this very story from being told. I’m Sarah Boseveld in for Jordan Heath Rawlings, and this is The Big Story. Michael Lista wrote about Dr Shuen in an article published in the August issue of Toronto Life. His incredible reporting has shocked a city. Thank you so much for joining us, Michael.
Michael: It’s a pleasure to be here.
Sarah: So I read this story with a pit in my stomach, I’m a woman in Toronto who has had a baby in a hospital in Toronto really recently, and I know I’m not the only one who read your story and was just horrified. But let’s start at the beginning. Who is Dr Paul Sheun and how is he regarded as a doctor in the city?
Michael: So Paul Shuen was, you know, by all accounts for 30 years, one of the city’s most respected ob-gyn’s. He was also a gynecological oncologist. What’s sort of unusual about that is that most gynecological oncologists once they sort of go down that road they; I was told about 90% of them give up their obstetric practice.
Sarah: So they’re not delivering babies as often because they’re dealing with cancer patients.
Michael: Exactly, but Shuen decided to keep his obstetrics practice; Since the late 1980’s he worked at the North York General Hospital. He also taught at the University of Toronto. I spoke to a number of his colleagues, all of whom said that, you know, he was widely admired in the community until just a few years ago, when nurses at his hospital started to notice something odd about the way he was delivering babies. They were often large numbers of women coming in, in labor on the weekend, more so than on a weekday, or at least not necessarily more so but just in sort of unusually high numbers.
Sarah: And were they all his patients or?
Michael: Yeah, so he would take call on Saturdays, and so this is sort of fishy, but the same day he’s taking call, a lot of his patients are coming in to deliver. And they were in a kind of labor that’s called precipitous labor.
Sarah: What does that mean?
Michael: So it means the contractions are coming too quickly, lasting too long. Sometimes they’ll get a condition called hyper stimulation of the uterus, and what those what that is a sort of very common sign of having been induced, but the nurses would look at these patients charts, and they would see that there was no indication for induction, that they hadn’t been induced. They would ask the patients themselves and they would say, no, no, I wasn’t induced. What it turned out is that Dr Shuen was also seeing many of these patients at his clinic the morning that they were later coming in in labor. This is very odd. And then what happened not once, not twice, but three times, nurses who were tending to these patients found the dissolved remnants of a powdery pill in their vaginas, and again, there was no indication for that.
Sarah: There should be a record of any medication given to you and as a patient you should know about it.
Michael: Right and neither of those things happened. Which means that whatever this pill was, it was given to these women without their consent, without notifying them and it probably had something to do with why they were coming in in these large numbers and in precipitous labor. So what happened was that the third time that this pill was found, the hospital tested it, and it triggered an investigation into what was going on, why were Shuein’s patients sort of arriving at the hospital like this, what was going on. And what they found was that this pill was a drug called misoprostol, and misoprostol was originally developed as an ulcer medication, and like lots of medications it was found to have these other effects that they hadn’t designed it for, and those effects include when it’s given to a pregnant woman, it softens the cervix and can cause contractions. Um…
Sarah: The product induction method, right?
Michael: Sure. I mean, yeah, except the only thing is that using it for that purpose is against North York General Hospital policy. It is used sometimes as usually is like sort of half the recipe of pharmacological abortion right?
Sarah: An abortion pill.
Michael: That’s right. But if you use it on a woman who intends to deliver her baby and is at term, there are terrible side effects. It can cause the death of the baby, and it can cause the death of the mother. And so, you know, there’s a black box label warning on it that it isn’t to be used for that purpose.
Sarah: And he actually admitted that he was doing it for a long time, and not only was he doing it, he had trained another doctor to do it. And he said something like why don’t you go after him? So I do want to rewind a little bit, though, and just give us a sense of sort of how and why this happened. If he had said he had been doing it for a long time are there early signs of when these misdeeds began to occur that maybe were found later?
Michael: So Shuein and would later admit that he had been doing this for years, is the way that he describes it. You know the problem with misdeeds like Shuein’s is that there’s very little evidence, right, because it’s not in the chart, it’s not being told to the patient. The only way that you can really know whether or not it’s happened is if you can find the pill in the patient and collect it. So we don’t actually know how long Shuein has been doing it for, except by his own admission that it had been for years. Another question is sort of like, you know, your question is why, like, Why? Why would he be doing this? There are sort of two explanations. The explanation that Shuein and gave was that he was doing these women a favor. That he was trying to get around the hospital is the way that he later put it to his sort of interlocutors.
Sarah: Getting around the red tape of the hospital as he called it, and certainly a lot of patients in the Canadian health care system you know, sometimes you’re frustrated that things aren’t happening as quickly as you would like them to happen, you wait around.
Michael: Right, and that’s what he sort of said, you know, like sometimes if we book someone, you know, either it could be canceled, it would have to be rescheduled, it’s a big pain in the butt, You know, there’s like this whole sort of sluggish bureaucracy you have to deal with and this is a way to sort of get around it. But what his lead investigator in the culture physicians and surgeons later said, is that he can’t rule out pecuniary reasons for having done it.
Sarah: What do you mean by that?
Michael: So he’s suggesting that Shuein could have been doing it for the money, but like even when I was reporting the story I was sort of like well wait, like in a socialized sort of medical world how could you do something like this for money? Well, so Shuein took call on Saturdays, it looks like he was doing this on the weekend and what we later found out through documents at the CPSO, for one of the years that we have information on this, 2015 to 2016, Shuein delivered almost 700 babies a year at North York General Hospital, which is more than any other doctor there. But what’s really odd is that 47% of the babies were born on the weekend. Shuein’s boss at North York General had sort of told Shuein that; Shuein was only allowed to do 50 deliveries a month, and that’s partly sort of; It’s in part a safety issue, and it’s also impart a sort of budgetary issue. But Shuein isn’t paid from that budget, right? Like doctors around the country, they are sort of like high powered freelancers, right? They bill for service, right? So they get a fee for service. So if you do X you can bill, you know, the provincial health insurer for having done it. It’s not just a matter of volume, though that’s true, right? If you deliver more babies, you can charge more for having done it, but there’s a strange sort of incentive built into when it makes sense for an ob-gyn to deliver a baby. If you deliver a baby in Ontario on a weekday, you can charge 400 something dollars. But if you deliver that same baby on a weekend, you can charge over $700, it’s about 250 bucks more. So that’s the reason why, you know, or at least according to his medical investigator, he couldn’t rule out that Shuein was doing this on Saturdays when he took call so that he could deliver those babies for a higher rate then he could, if he was delivering them on a weekday.
Sarah: So money aside, another major problem with his conduct, it seems, would be informed patient consent and another example which also shocked me, had to do with a vulvectomie, is that what it was called? What happened there? So this is not even necessarily delivering babies that he was sort of blowing past patient consent on, it was other matters too, what was going on there?
Michael: So this was an issue with his oncology practice. What happened was that when we were investigating the story we asked the College of Physicians and Surgeons for the evidence that was entered against Shuen sort of in the, what resulted in the loss of his license, and two of those documents that were released to us were the previous complaints that were lodged against Shuen and were found to be credible. What’s odd is that those were not available to the public, right? It used to be that when something from the complaints committee at the CPSO was found to be credible and resulted in a ruling against a doctor that that would not be released to you. So if you wanted to know if your doctor had any problems with something like consent, you could know, right? So what happened with this woman was that she had this rare malignancy called Paget’s Disease, and it sort of manifests as little sort of lesions on on the vulva. And so she went to Dr. Shuen, Dr Shuen said listen we need to do a partial vulvectomie, and she was really nervous I mean, as you, as you can imagine, right? You’re like sorry, excuse me? And so he said this is what you need to do, we need to do the surgery. So she said, I mean, okay, if you think that’s what’s best I’ll book it.
Sarah: And how many of us have been like, okay, the doctor knows best right?
Michael: What are you gonna say, right? Like, argue with your doctor, Right?
Sarah: Medical professional, well respected, right?
Michael: Sure. So she said ok, and then Sheuin said, listen if you want more information, you can go home and Google Paget’s disease. And so she did, and she looked it up, and she found that in some cases it could be treated with a cream. So she came back and she said, listen, you know, I read we could just use a cream, that’s what I want. Sheuin said that’s not gonna help for your version of Paget’s disease so you need to have the surgery, and more than that, even though the surgery was a month out, if she canceled it, she would have to pay 100 bucks cancellation fee.
Sarah: A month in advance.
Michael: A month. And she said, well, I mean, you know, I don’t want to pay the cancellation fee, my doctor says I should do it, so I’ll do it. So when she woke up from the surgery, she found that not only had it you know, been this partial vulvectomie that they talked about, but he also cut off her clitoris.
Sarah: That, to me, my jaw was on the floor. I was like, you know, is that her fault for not asking more like about that? The other thing that struck me in the story was, you know, and there’s no proof of this at all, there’s no way of knowing for sure, but like if he had male patients, would he have been so cavalier with his decision making, with the lack of informed consent? You know, I think there really is a concern in the medical community that women’s pain, women’s health is not taken seriously. Um, you know, and again, no way of knowing that but that kept running through my mind reading this story, and I don’t know how the patient’s felt who you talked to, if there was sort of an air of that at all.
Michael: It’s hard to know with Shuein, because he only ever; His patients were only women, and you know, you can sort of speculators as to why he sort of decided to do that. But you know what ended up happening is that this woman was devastated, and she complained to the college of physicians and surgeons. We got this document, we had to fight to get it and in it the complaints committee decided that while there was nothing wrong with Shuein’s surgical technique, it was this $100 cancellation fee that lead this woman…
Sarah: Not to mention like the dignity of a person anyway.
Michael: I mean, like, it just seems they…
Sarah: It’s an ethical breach.
Michael: Of course it is. And what they said was that, that $100 inducement directly led this woman into getting a surgery that she found devastating, that she didn’t understand, that wasn’t explained to her properly, and I mean, like, for a doctor to do that to a woman in that infinitely vulnerable position and leverage 100 bucks, you know, leverage her with 100 bucks. I mean, I found it shocking.
Sarah: And so you talked to a detective for this piece because I’m sure as your reporting you’re like, how has he not faced any criminal charges, and that was a line of questioning that you took. Tell me what this detective said in terms of what were possible charges for the scope of everything you found, certainly the documents that you obtained.
Michael: So there are no charges, no criminal charges against Dr Paul Sheuin that we know of. But many of our readers in the wake of the story sort of asked why, and as you mentioned, I did speak to a detective, just sort of wondering is it possible if there’s some criminal liability for a doctor doing this sort of thing to a woman, especially when it comes to the misoprostol. Giving this dangerous drug….
Sarah: Administering a drug, you know, like I mean out in the world a comparable thing could be something like putting a date rape drug in your drink.
Michael: So that’s what the detective said, was that the criminal liability that Shuein could face is assault. What you just mentioned, that charge is called the administration of a noxious substance, which is the date rape charge, at least for the drug portion of it, and if one of the mothers or the babies died after being given misorostol, then that could be homicide. We asked the hospital afterwards, you know, after they conducted their investigation, confronted Shuein, you know, he denied it all, he said I did not do this. Finally, he admitted it. And, um, we asked the hospital; Sorry was there any larger investigation that North York general did to determine how many of these women were induced? What the consequences of those inductions were? If there were any adverse outcomes which could include death, right? And the hospital said it reviewed a number of years worth of documentation and found no adverse outcomes. And for me, the problem was sort of like, well, isn’t the whole issue that that this stuff wasn’t necessarily in the documentation, right? So how would you know if a patient was given this drug if if the very nature of Shuein’s misdeed was that he wasn’t putting it on the chart. There was so much more stuff that we wanted to put into it because I spoke to a bunch of midwives, sort of about the stories as I was reporting it, and they pointed me towards advocacy groups that focus on doctors behaving just like this. There’s one organization called the White Ribbon Alliance, and I sort of told them the story and, you know, was just sort of asking for any help if they would sort of speak about it and they say, oh, we hear stories about doctors using misoprostol all the time, and I was like, what do you mean? And they were the ones who…
Sarah: Where’s that alarm sounding loud and clear?
Michael: So there’s a name that they use for this sort of behavior, it’s called obstetric violence. In Britain they call it birth rape, and there’s a sort of movement a foot to sort of bring awareness about this, and it comes sort of out of the tension that has existed for, like the last couple decades between midwives and ob-gny’s. I’m not saying, you know, that what Shuein has done is in anyway typical of the obstetric field. But you know what they sort of complain about is the over medicalization of birth that sees not just birth as like a medical emergency that needs to be treated in the same way that like a heart attack or, you know, a broken leg needs to, but that, like the sort of dynamic between a doctor and a patient is one where the doctor knows everything, he’s going to give you what he thinks you need, and that you know what you want from your experiences is that’s very sweet, but you know, like we’re here to get it done.
Sarah: Ok woman like growing a human body, have you done that dr? I mean, no, and like, I mean, I’m I’m a woman who decided to have a child in the medical establishment, and I know that I had an option to do it a different way, certainly, but uh, you know, I think pregnant women, but also other people who just go to the doctor have dealt with what feels like a culture sometimes, and there are amazing doctors out there who really put their patients first. But is there concern that there is a bit of an allowance for some cavalier behavior. You know, certainly Dr Shuein, he did apologize and, you know, he had some very interesting responses such as I’m doing this woman a favor, you know, and was very respected. So what do you think that sort of culture of, like, respectability around doctors and, you know, white coat syndrome that some people have, you know where it’s just they feel nervous when they go to the doctor. What role do you think that might have played, and might that actually be telling of some of the responses you had from the college, right who tried to block access to these this evidence.
Michael: So just to speak for a second about that sort of fight. When we wanted to figure out what Shuein had done, we saw a sort of quick little write up that the college had done about what the discipline committee found. They revoked his license, they made him pay a $40,000 fine, but the college has sort of been going through from what I understand a sort of slow, kind of like opening up. They had been criticized for being too withholding, and so, like for example, those cautions, you know, it used to be that those cautions, like the two Shuein had before before he ended up losing his license, it used to be that those were not public. Since 2015 those going forward are now public.
Sarah: Like public in the sense that maybe they post it on their website?
Michael: They post it on the website. After we read the sort of brief summary, we wanted to see the way the whole sort of proceeding had gone, we wanted to see all the documentation. I mean, like, you know, like doing any reporting, like, you know, it’s really easy to get that stuff.
Sarah: Well you wrote in your piece I think something like, which is a very telling line, you know it’s easier to get evidence against a murderer than a doctor.
Michael: It’s really not editorializing, like that’s a fact. You know, from my experience as a reporter that’s a fact, because what we had to do is, we had to file a formal motion with the CPSO to see the documentation. So we had to get our lawyer involved, it cost many thousands of dollars in legal fees.
Sarah: And how long does this take too?
Michael: Two months? And
Sarah: So this is a legal circus, you know, by all accounts, just to keep a lid on this.
Michael But what’s interesting is that technically, if you wanted to right now, like after we’re done this if you wanted to walk over to College Street and go to the CPSO and listen to a disciplinary hearing you could. So these are all public, so this is like a month’s long.
Sarah: They’re just not really gonna help you fight it.
Michael: Yeah, and so it was just a very odd experience, and like when it was all done, you know, the college ended up in the end after the independent legal counsel waited, and they ended up saying, You know what? We need to follow the open court principle and this stuff should be open.
Sarah: But you had to fight for that. This is a journalistic win in a way, but I that should have already been the case.
Michael: Yeah, and if you were one of Shuein’s patients and had read you know, read this thing online, that he had lost its license, and you wanted to see it, you would have had to go through the same process…. if we hadn’t done it right? Toronto Life was like, yeah, sure, you know we’ll put up the thousands of bucks, right? But you would have to get your own lawyer to go and do that, and it’s just like… that’s not what an institution like this in a democracy should look like.
Sarah: So just to sort of end, you know, how have his patients responded to this story if you’ve heard from any of them and also like, where is he now? You know he’s lost his license, he had this whole oh, I’ve retired image, put on everything. Where does that all stand?
Michael: Well we reached out to Dr Shuein, and he declined to speak to us through his lawyers. I guess the short answer is we don’t really know where he is.
Sarah: But he’s still enjoying, like, whatever pension or something you get when you retire.
Michael: He framed, as you say, he framed his departure from the hospital even though he had his privileges revoked, he framed it as a retirement.
Sarah: And the hospital didn’t do anything to block that.
Michael: No, not as far as we can see. The Ob-gyn department, a U of T newsletter, they have a newsletter, they wrote up like a sort of valediction for him.
Sarah: Did they maybe know at U of T about all this?
Michael: I don’t know. I’m not sure, but, you know, they sort of, like, wished them a good retirement and said that, you know, the tips and techniques that he taught generations of surgeons…
Sarah: That one person that he says that he told to do this, you know, they might still be practicing.
Michael: Yeah. You know, I think people are sort of seeing that this a failure of not just one man’s ethics, though it was that. But it was like the whole sort of system didn’t really work the way that we should expect it to.
Sarah: So are there any takeaways and improvements that could be made from your piece or what you found.
Michael: Hire more nurses.
Sarah: Hire more nurses, you are heroic. These women knew something was wrong, they didn’t see the documentation, they found the glove with the residue of the pill in it, and they got it tested. And I mean, would any of this have happened without them?
Michael: I think in the future you can sort of see that there could have been intervention of the hospital sooner, right? Why did it take three pills to be found before they were tested. One of those earlier times, you know, Shuein’s boss said in a note that we got you know, he said, the pill looks like misoprostol. They didn’t test it, but it even looked like it right? And then he asked, Shuein, and he’s like, listen, you are you doing this? And Shuein said, no absolutely not, I would never do that, you know? And you know he said, and the doctor said iin a note, in the face of Shuein’s denial, what is their I can do. Well, there was stuff you could do, you know, because you did it eventually, you tested it there’s no reason it had to go on that long.
Sarah: Or that a nurse had to fish in the garbage, to get it right? Incredible story. Thank you for coming on.
Michael: Thank you Sarah.
Sarah: Michael Lista is a contributing editor for Toronto Life. That was The Big Story. For more visit us at thebigstorypodcast.ca or on Twitter @thebigstoryfpn. Find us on Apple, Google, Spotify Stitcher or wherever you get your podcasts. Be sure while you’re there to leave us a rating and a review. I’m Sarah Boseveld, we’ll catch up again tomorrow.
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