Ethics Case, Part I

An ethics case that we recently discussed. I’ll write more about this case over the weekend. Maybe some comments can enlighten the situation? Has anyone encountered this in real life?

The Case:

It’s 3:30 PM in the ambulatory surgery pavillion (who names these things, anyways?). You’re a third year medical student on your first day in the OR, and its the last case of the day. You’re with your attending on the GYN surgical team. You go to meet the patient for pre-op and introduce yourself as a medical student who is part of the surgical team today. You and the attending speak with the patient and re-confirm her consent for the procedure. You then finish your conversation (this patient is quite anxious about general anaesthesia, which is required since it is a laparascopic procedure in the pelvis) and the patient continues to be prepped by nursing and anaesthesia. You and the surgical intern follow the anaesthesiologist and the patient into the room, where she climbs onto the bed (ambulatory surgery refers to the method of entrance … no one ambulates OUT of the operating room) and the Milk of Amensia is administered.

As the patient preparations are completed, your attending does a pelvic exam which is standard for this procedure. The intern then does a pelvic exam. Then your attending, turns to you and says “Put on gloves.” Apparently the particular pathology of the case, is notable and important to be able to identify on pelvic exam (an uncommon, but not immediately life threatening finding). Your attending then tells you to do a pelvic exam.

You’re not sure what to do, and everyone in the room is staring at you because you’re holding up the team (usually no one pays any attention to the medical student unless they do something collossaly stupid like break the sterile field or faint). You hurry across the OR, grab a pair of gloves, and your resident shows you how to perform the exam. You are able to appreciate the abnormal finding on your exam.

Questions for thought:

Is there a problem here? What are your gut reactions to this situation? What are your ethical obligations at that point (to your patient, to your education, or to anyone/anything else)? Lastly, what would you have done? What should have been done differently, if anything?

To all medical students: think about this issue before your OBGYN rotation or your first trip to the OR.

Things to consider:

-A pelvic exam is required due to the nature of the procedure (would your reaction be different if it was ENT surgery?).

-Two exams have already been performed, the student’s exam would be the third. The operative procedure and approach is highly unlikely to change based on the student’s exam (would your reaction be different if the student’s exam was the first?)

-You are being told to perform a medical task by a direct supervisor.

-The patient is not able to give permission for the exam at the time that the student is ordered to do the exam.

-The student did not ask the patient for permission to perform a pelvic exam on them. The student thought they would be observing/shadowing based on the day’s prior cases (the pelvic exam is performed before the patient is cleaned and sterile-ly draped so sterile gloves are not used and scrubbing in is not required).

-The patient did not explicitly give permission for the senior physician to perform a pelvic exam, or for the junior physician to perform a pelvic exam (would your reaction be different if the senior physician had asked if they could perform a pelvic exam, but had not asked about the student?).

-The patient did not ask what the student or trainees would do during the procedure. The consent form does not specify that students or trainees will participate in the surgery. Both the resident and the medical student introduced themselves to the patient as part of the surgical team and used their titles (i.e. “medical student”, “resident physician”).

-The patient will never know that any pelvic exams were performed, unless someone tells them (although, due to the nature of the surgery, reading about the procedure on WebMD or equivalent lay-public websites should make it clear that a pelvic exam is required for this procedure) (does this matter?).

-The attending has a longstanding relationship with the patient dating back twenty years and delivered all three of her children (does this matter?).

-The attending is female. The intern is male (does this matter?).

-You are male (does this matter?).

-The patient has not stated any strong religious or cultural beliefs about medicine or sexual modesty, and none are obvious (does this matter?).

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3 Responses to Ethics Case, Part I

  1. AndromedaMed says:

    Hmm, interesting. I think that the consent forms for the procedure should have detailed what would happen while the patient was out. I know for my colonoscopy, it was made very clear what scopes were going to be put where, and who was participating in my surgery.

    But so long as the consent forms indicated that a pelvic exam would be done I think it would be fine.

    Especially considering the reason is not superfluous. It’s not like the attending is trying to embarrass the woman; they are trying to teach me about a diagnosis. Additionally, it’s not like I’m some stranger off the street. I am bound by HIPAA and a professional, same as the attending. And even further, the patient knew that students/interns were in the room with her. Did she think we were all going to leave once the surgery started? No, we are part of the attending’s team. I don’t think that needs to be explicitly stated or you’d go overboard. I mean, imagine if you had to give permission for every doctor, nurse or student to see you in the operating room. Those consent forms would take forever and there is no way the hospital could predict every doctor that might be needed. What if a complication happened and we had to call another attending quickly? Would he be unable to operate because she didn’t give him permission first? I don’t think so.

    Those are my thoughts; sorry for the novel.

  2. Thanks for the comment and for your thoughts. Some perspective on this hypothetical, as it would apply to our University Hospital:

    I agree that the consent form should explain what is done during the procedure and that this would solve most or all of the issue. At University Hospital, for instance, in the ambulatory surgery center we use a standard form for all procedures and the surgeon writes in the title of the procedure but nothing more. The consent form does not state that students/residents will be present in the room, although this is (in my experience) always stated to the patient and is clear since we introduce ourselves to the patient before the procedure.

    Furthermore, for argument’s sake, lets assume that the attending does not state to the patient that a pelvic exam will be performed (I imagine this would change the scenario considerably).

    Thanks for your thoughts. I’ll write up part 2 after I finish my literature review for a research project I’m working on …

  3. Pingback: Ethics Case, Part II | Drinking From The Fire Hose

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