"I was completely shocked by them."
Neurologist Dr Kate Ahmad was preparing for a 'women in medicine' teaching presentation when the images landed in her inbox.
Dr Ahmad is a neurologist at Sydney's Royal North Shore Hospital. She also serves as Vice President of the hospital's Women's Society.
She'd decided to reach out to other women across different fields, to get a sense of what working life was like for them.
What she got back - in one case - was a set of photos of pages from an orthopaedics textbook originally published in 2002. It was a student who'd been issued the textbook as recently as 2015 who had flagged them with her.
Someone actually emailed me and said this is the orthopaedics textbook that we were assigned in medical school.
The student was apparently 'disgusted at the time', but didn't do anything about it. Dr Ahmad says she felt the images were something that needed to be made public.
'Advanced Examination Techniques in Orthopaedics' had issued a second reprint, published in January 2014 - but even those updated photos raised questions. In one photo, a sports bra had been swapped for a push-up bra.
"In a way those images are just as bad as the first," Dr Ahmad told The Feed.
It's unclear if - or how many - Australian institutions are still using the teaching material.
The images received near unanimous criticism online.
Key concerns included the items of clothing (or lack of) the patient was wearing, the poses - and the fact that nearly all images included a male doctor.
Criticism also came from other orthopaedic surgeons.
Dr Ahmad notes a number of medical fields still aren't attracting female doctors.
Interestingly, orthopaedics is one of them.
The National Health Workforce Dataset (2016) reports that 96.9 per cent of orthopaedic clinicians were male. Just over three per cent were female.
These sorts of textbooks, Dr Ahmad warns, could discourage even more women from certain surgical fields.
Dr Ahmad was also concerned the images could affect feelings of safety - for both the medical professionals, and patients.
"You look at that book, and you see that objectification of a woman patient when that woman's in a vulnerable position, and you're supposed to be able to trust the clinician looking after her."
She warns it could also erode trust in male orthopaedic surgeons.
Dr Ahmad says representation of women - like this in textbooks - is just one of many issues female clinicians face.
"The other stories that people had sent through to me were completely appalling," Dr Ahmad told The Feed.
"It shows that there are still significant problems for women in medicine in the way that they're treated."
Dr Ahmad says she's heard from a number of junior doctors who've had sexual comments or inappropriate propositions from people in positions of power.
The common one is if a women is kneeling, there have been lots of inappropriate comments made regarding what kind of things she could be doing.
There's also a stigma and discrimination around pregnancy and female clinicians taking time to have children.
"There have been comments like 'there's no point having women in medicine because they're just going to get pregnant have children and not work full time."
She warns that male dominated specialties - like orthopaedics - can also give rise to a 'boys club' culture that can make it difficult for junior doctors to speak up.
"You're likely to be first not believed or told you can't take a joke, or pushed out because you don't fit in the culture of the area."
Cambridge University Press responded to the discussion on Twitter.
They say they acquired the initial textbook after it was published, and requested a second edition be printed.
"To demonstrate examination techniques effectively the reader needs to be able to see skin, muscles and bony features where appropriate," they explained.
Cambridge conceded that the second edition images were 'still out of place, given the subject matter'. They're now printing a third.
Dr Ahmad says it's an 'inadequate' response - but she's not surprised.
This has obviously gone through many layers where people have said this is okay.
She's hopeful the third edition will improve representation: not just of women, but of more 'typical' orthopaedic patients and clinicians.
"We need [to see] real life."
