Comment of the Week: Not in my hospital
Monday, September 6, 2010 at 8:50AM
By Jill—Unnecesarean
Sorry for the delay in posting the Comment of the Week.
In this comment, a medical student tactfully refutes the claims of the doctor whose 2003 interview was posted here. I am particularly interested in item number three on his list.
i am a male medical student at a reputable institution where this is practiced. however, this article provides a highly dramatized depiction of what actually happens.
1. only occurs in OB/GYN cases. only. no appendectomies (performed by general surgeons)
2. entire team meets the patient pre-op.
3. informed consent includes language informing patient of what the procedure entails, including pelvic examination
4. the “line of medical students” consists of no more than 2, usually 1 (and the part about the “male students especially” is complete BS)
5. a resident guides the student
most of this article is fear-mongering and in many places just plain incorrect. its not as if I don’t see the moral dilemma and understand people’s concern/outrage. that’s a discussion for you to have with your medical team prior to the procedure, but please don’t think that this article accurately reflects the atmosphere of a GYN OR. if it did, i too would morally object.
final point, i was taught during my 2nd year training session on the pelvic exam to treat the patients as i would want my own mother or sister to be treated. i would have no hesitation about referring my family to the hospital where i currently work under their current practices.
ps - not that its meant as consolation, but the same thing occurs with rectal exams in male GU patients
If you work at a teaching hospital or have been a patient at one in the last few years, please send us the verbiage in your consent form. Transcribe it, scan it or take a picture with your phone and send it to unnecesarean (at) gmail, please. We would like to see examples of forms in which non-diagnostic (educational) pelvic exams and other specifics are explicitly expressed in the form.
Moving past the comments here and in other forums discussing the practice along the lines of “Who cares? They’re asleep anyway.” and “But how will they learn?!”, there is an longstanding assumption that patients who go to a teaching hospital already know that medical students will be involved in their care and therefore know that students will be practicing something on them while anesthetized. I would argue that, unless it’s spelled out explicitly, many, if not most, people have no idea what that means. To take it one step further, it is reasonable to assume that some patients would really appreciate the chance to opt-out of certain things if they were explained clearly in advance. One can’t exercise their right to refuse if they don’t know what is happening.
Help educate the public by showing everyone what informed consent looks like at a teaching hospital in the U.S. and abroad in 2010. It’s one thing to say that one’s hospital always obtains consent. It’s another to show what patients sign off on.
Reader Comments (19)
I was just told by a ( spanish speaking) mother who had a difficult birth in a NJ hospital that they had a room full of people , all taking turns to do an exam, When she protested they told her .. " What do you care, you have an epidural." They did not stop.
This whole issue horrifies and disgusts me. I am almost nauseous from B's comment. That is rape, over and over again.
there is a whole discussion on the The Unnecesarean facebook page,,, more stories like that.
I understand the need of that med student to protest, but unless he knows for a FACT that ALL hospitals operate the exact way he describes, he's also full of BS. Perhaps his hospital is better about it... that doesn't mean they all are (this is the same sort of argument as "I had a great natural birth in a hospital, therefore anyone else can, too".)
Claiming someone should just "know" they'll have stuff done to them b/c they're in a teaching hospital sounds like a cop-out.
I would take this a lot more seriously if he had the balls to name his institution, and knew how to use the shift key.
this is horrifying........
Thanks for sharing this into. It's okay to protest if there things that you think are not proper but before you do such action, make sure that you can really justify yourself and be ready for the consequences. Most practices are common in all hospitals though they may differ in some aspects but we also have to consider that all of them follow a certain rule.
How many men would be OK with digital exams performed anally while they were under anesthesia for a non-related surgery? In fact, why aren't anesthetized male patients routinely used as practice for medical students who are specializing in proctology? Maybe they are and we don't know it, but I'm guessing that very few men, straight or gay, would accept the "you're asleep, why should you care?" defense when it comes to the idea of other men probing their nether parts while they're under.
I just can't get past the idea that we presume doctors are only going to perform procedures that we consent to, or that are required as part of our care (i.e. something goes unexpectedly, but you're unconscious so they can't obtain consent). Saying that consent to unnecessary vaginal exams is buried in a legal document someone signs isn't the same as meeting the woman, saying, "Hi, I'm going to perform a completely unnecessary procedure on you while you're out. Do you mind?"
I take it that no one has the documents Jill is asking for? I'm very curious to see what turns up.
Can I just make the point that he's a med school student and he doesn't even capitalize the first letters of his sentences. My child is in 2nd grade and gets a big red x for that.
I am a nurse and have always worked at teaching hospitals though never specifically in a GYN area. It's not specifically the topic at hand but relates to who provides care. I have witnessed surgical consents and watched how the medical teams interact with patients. For the most part, the patient population is completely unaware or even confused as to who is participating in or directing their care when in a teaching institution. It is common for patients to see medical students, residents in various years of their post-graduate training, the attending physician (if they are lucky) not to mention ancillary professionals such as respiratory, physical therapy, radiology etc. Some medical students and residents are very good at introducing themselves as such, but others are not and just rush in and start talking. In reality, the patient perceives that everyone in a white coat is a "doctor."
In regards to consent forms, I have never seen any mention of educational experiences while under anesthesia, but they will generally say something to the effect that Dr. X (who is the fully trained physician) will perform or SUPERVISE your surgery. In many cases, this means that the resident in training does the surgery and the attending is in the room. I have always wondered if the families would easily consent if they truly understood that Dr. X, the one they often know and trust, will not be actually doing the surgery.
At one facility, it was included in the patient's bill of rights that they had the right to refuse student participation in their care. At times it was frustrating, but it was honored in regards to both medical and nursing students. I think it would be good for all patients to be fully informed of how students and resident physicians are involved in their care, and specifically to know WHO will be operating on them not to mention what they will be doing.
I believe that most providers alter their opinions when they, or a close family member need hospital care.
As a provider, I strive to speak in language that clients understand. Even highly educated people, though, have given me the feedback that they don't understand what I'm talking about. What is common 'in the field', is NOT common to our clients. Just because we regularly speak the language to each other doesn't mean our clients understand it. Medical literacy is a growing field and informed consent is in this conundrum of being written to protect the hospital and provider medico-legally, not REALLY COMMUNICATING the process of the procedure to the client. Only the most saavy read through these lengthy and overwhelming documents, and only the lawyer-patients actually question them.
As a provider who learned to do pelvic exams on other volunteer students and paid volunteers, I see no explainable reason why an anesthetized patient is necessary to learn them. This is a warped view of learning and is indeed abusive. If some can learn without such an action, all can learn without. Ridiculous and should be mandated against.
Guess what I just learned? If you hit create post rather than preview you cannot go back and edit. So I am reposting with corrections. Duh.
Jill,
I have been off the grid for a while but this post points out several issues that warrant addressing. I am typing at 0430 without spell check so give some leeway. It is quite frequent that patients in our academic hospitals are examined by more than one resident or student in the clinic/ER/L&D/OR. This is not done to be disgusting or abusive, I hope, but to teach/learn. I have read the above posts and I agree that models are employed and utilized. I guess one could argue that paying these women is abusive or degrading or dehumanizing but some will find a way to discredit any method of teaching. Cadavers and non-biological (a term I learned from watching Transformers with my 12 year old) models are also used. Every days-of-yore med student and I would hazard to say most nursing students have at least heard of a birthing "phantom" which is a birthing model used up until the newer plastic ones became available. Why then all the exams on the living? Because the models are a poor substitute for the tactile and elastic properties of a living body. Substitute "cardiac bypass" for "pelvic exam" and it may make sense. Also it is quite rare for these models to have a large floating ovarian cyst to palpate or a cervical Ca fixed to the pelvic side wall. These are findings that present an opportunity to learn, to feel, that a model just will not have. It is where your provider will learn to diagnosis rather than miss it "in the field" so to speak (this gyn is very careful to never say "in the trenches", just a little too close to a pun). As there are usually one or more students on ob/gyn rotations, not to mention residents, significant findings are used to teach. In the clinics as a resident and now in my office I asked the patient if the student could examine them also if there is some unusual finding. In the OR, if the resident or student were not the same one as in the clinic then they would examine the patient under general anesthesia as well to see the correlation with the clinical findings and/or radiological images. This student might be med/rn/np or mwf. They all need to learn but it was never my experience all on the same patient. Does the fact/myth of excessive exams have any mythbusters? Unsure. I cannot only speak from my experience. It is actually an odd coincidence (juxtaposition in med speak) I have found and addressed this today for yesterday I had an interesting encounter. I questioned the reasoning for a pelvic EUA (exam under anesthesia) prior to an abdominal hysterectomy of one of my fellow gyns who is non-academic and does not rotate students as I do. I can see no reason to perform a PELVIC exam at this time on one of my own patients. You are opening the abdomen regardless. There is no finding that I can think of that your exam will yield that results in your modifying your treatment course. When I asked why he did this on every one of his patients he responded with "because the insurance pays a hunnert dollars for it and if you don't your a f**king idiot". Guilty as charged, I guess.
I am waiting to perform a tubal (behind three c/sections - not mine) after my moms normal, if op is normal, vag delivery. That self serving comment made I had a chance to review some previous posts about students and exams. About Dr. Gerber refusing to exam the pt having a D&C. She was correct not to touch her. There was no mention that she had any privileges at that hospital and i will make the leap that it was not an academic center. Thus any contact she had with the patient would have been unethical at best and illegal at worst. the nurse who made the offer was not correct to do so. The patient appears to have had no informed consent given for this exam. Now to Dr. Greger. First note he is a published author and his interview is typical of one in-sighting rage to raise interest in a book. His statements have EVERYTHING!!! to appeal to our disgust -sexual abuse, female dehumanizing, misogyny, male chauvinism, bad doctors, unconcern for the patient, bad boy docs (they did everything but intercourse oh my), good girl docs, and then tremendous doses of self righteousness and pious humility. I went through medical school and maybe I'm an idiot and that is why I did not have time to write a book. I did see and did perform exams under anesthesia (EUA) on patients that had every last one signed a permit acknowledging that this was a teaching facility and that students would be present in the OR and may participate in their care and exam them as part of their education. I never saw this done by any student regardless of school that was not on that rotation and directly involved in that patients care and even then only if a significant teaching/learning finding was present. Every patient had the right and the privilege to refuse this and many did and this was always respected. I trained at a southern hospital and did a residency in Chicago and the same respect was maintained there as well. Please refer to my above post. I cannot say this does not ever happen incorrectly. I just have not observed the feces that this guy is spouting. I hope I have never mistreated a patient in this way. In anyway. That would probably be a huge matter of opinion though. However, from my limited psych standpoint I see a possible diagnosis (Delusion of Grandeur) as would be typical of one who points the finger at all but themselves. I occasionally have to point a finger at myself, damn police think that's the fun part of the test.
I'm so glad "ob" is back...
ob wrote: "Because the models are a poor substitute for the tactile and elastic properties of a living body."
Live humans are the ideal but it's not just because they're alive from what I hear. I dug for this comment left by a nurse-midwife on another post:
Whether or not a woman would consent to vaginal exams while anesthetized is, in my opinion, completely irrelevant. The idea that medical professionals are learning how to perform them on a woman who can't give any verbal or physical feedback (for instance, "ouch!") is horrifying to me (though not news - i'm aware of this practice.) The only thing learning to do VEs on women with anesthesia might be good for is learning how to do just that - a pre-operative digital exam of the organ you are about to perform surgery on. To expect medical students to learn the actual art/skill of performing a humane routine vaginal exam, you need living, breathing, speaking, feeling humans. In midwifery school we learned with gynecological TAs who are just the most amazing people - skilled and sensitive to learning needs, who also protected one another (they work in twos). We also practiced our classmates and let them practice on us (this was completely optional), and then of course we had a preceptor right by our side the first many times we did them in gynecological office visits or in labor.
I thought that was educational.
ob wrote: "I did see and did perform exams under anesthesia (EUA) on patients that had every last one signed a permit acknowledging that this was a teaching facility and that students would be present in the OR and may participate in their care and exam them as part of their education... Every patient had the right and the privilege to refuse this and many did and this was always respected."
The big question would be whether or not it was spelled out explicitly in the permit. One thing I have seen come up in discussions is that because forms state that students will be involved, many assume that consent to *everything* is implied. Naturally, one can't truly consent unless they know what's going to happen. I tend to believe that most people would be fine with one or two students examining them as described, but that hiding it from them might induce ire. You've written before about communication and how informed consent is important to you on more than just a legal level, so I feel like I know where you're coming from.
I'll send you candy if you find me a copy of an informed consent form that specifically mentions internal exams by students under anesthesia. We can do our own mythbusting on the topic.
Also, regarding Dr. Hunnert Dollars... eww.
Dr. ob, thanks for posting. I am student physician Gerber.
I was at my core site where I am doing my training. However, I was not with my attending physician, and was not seeing a patient who was on my rotation service. The OR nurse was not a member of the teaching faculty. I clarified the story more in the comments on the original post, if you want / have the time to find my comments in the slew of comments on that post. Our school utilizes paid standardized patients to teach us about female and male exams, and as far as I know, no one associated with our formal education would invite us to do a nonconsenting exam on an anesthetized patient.
Thanks for supporting my decision.
I'll see if I can get a consent from the "Center". Dr. Gerber, you rule. I am going to see a threatened ab.
Since it was brought up by another commentor...I'll pursue this line of thought...is it *really* ethical for midwifery training courses to ask students to practice on each other? Even if participation is painted as voluntary...how voluntary is it, really?
I can say from my own experience that there is peer pressure to comply with the exams even if a person does not want to be examined. I recently participated in an 3 day introductory midwifery skills lab, and I did not realize until arriving at the first day of class that this was going to be part of the class. I'll admit to feeling panicked--I'm very "private" about my body. I do not particularly like having cervical exams done. I typically go 3 years between "well woman" check ups. I did not want to be a training model! But none of the other 4 women who were there the morning of the exams expressed any hesitation (another class member missed that morning because she was attending a birth).
As luck would have it, my period started the morning of the first class, so I used that as an "excuse" to get out of being a model. But I felt extremely uncomfortable, as if I was a "3rd wheel." I use a menstrual cup, so there was no trash in the bathroom waste baskets to support my "excuse," so I did wonder if people believed me. The instructor did not allow me the opportunity to insert a speculum even though two of the class members had expressed a willingness to allow multiple full exams. I don't know if failing to allow me to insert a speculum was a deliberate slight since I wasn't "fully participating," or just an over-sight. I didn't pursue it since in all honesty, I felt uncomfortable doing the bimanual exam on a fellow student, let alone putting a speculum in.