Ethics Case, Part II

This is part deux of a three part ethics case (read part one here) dealing with the performance of pelvic exams on anaesthetised women by medical students without explicitly obtaining prior consent to perform the exam.

In our second year “How to Be a Doctor” class (it wasn’t actually called that), we discussed a case involving a pelvic exam under anesthesia. In that case, multiple students called into the operating room and instructed to perform loosely-guided pelvic exams on an anesthetised lady. After the operative case completed, the student was asked by the patient what had happened during her procedure. The question posed was “How would you reply?”

In responding to this hypothetical, and during the ensuing discussion, I was firmly against performing pelvic exams without explicit prior consent (i.e. pre-anaesthesia verbal consent for the student to perform the specified exam). My reasoning was that it was a clear violation of  patient autonomy, that it risked compromising your honesty (because you would be tempted to lie to the patient if asked directly, particularly since you never asked permission), and that there was little educational benefit (and a considerable, perhaps insurmountable, amount of benefit would be required to outweigh the violation of honesty and patient autonomy). It was difficult to draw the line and allow only one student exam because even that would trigger the risks outlined above. I adamantly said that I would refuse to perform such an exam if asked (and I couldn’t believe that in this day and age I would ever encounter this seemingly apocryphal situation). You can clearly see where this is going …

Before we get to the punchline, it’s worth noting that at University Medical School, before beginning the third year we are taught pelvic exams both on mannequins (not helpful), and by trained patient-instructors who guide us as we examine them (amazingly helpful). While we don’t get to do a large number of exams, we do have a couple of high quality experiences. I wouldn’t say that I was confident of my exam skills going into third year, but I would say that I knew how to do an exam, how *not* to do an exam, and what I was looking for (but not what abnormal findings would feel like).

So, my first OR day with the OB attending. Dr. Peters is a long time community obstetrician in a three-physician practice (all female). I had been shadowing her in clinic all week, which in reality meant that I tried to find a quiet corner where I could read. Only some female OB patients (~50%, and they were usually pregnant) who see female physicians want a male medical student observing their pelvic exams. Dr. P operates one day per week at University Hospital, and I was eager to go with her into the OR, both out of boredom and as I anticipated the excitement of operating (meaning observing).

Most mornings on a surgical service start so early that they can hardly be considered truly mornings. Usually, you beat the sun by several hours. On some of the longer days, sunrise is only glimpsed through the windows of another hospital room while hurrying to ensure that none of your patients’ bowels or bladders have misbehaved. But the ambulatory surgery center is a more civilized zone. Even the medical students get coffee (except if the Nurse Ratchets of the world have anything to say about it).

So I meet our first patient, Mrs. Barlowe, a very pleasant lady here for an exploratory laparoscopy. Essentially, she had been having some symptoms consistent with a previous medical condition (let’s say endometriosis, a condition where normal lining of the uterus grows in abnormal places such as on the ovaries, pelvic or abdominal wall, rectum, colon, etc.), and after meeting with Dr P, she decided to have surgery to see whether there were any identifiable tissues that could be ablated (burned) to relieve her symptoms. By the time Dr. P and I entered the room, Mrs. Barlowe had already been “consented” for her surgery.

“Consenting” a person can mean many different things. On the research projects I worked on during medical school, it means verbally reviewing an exhaustive (and exhausting) description of the entire study, and having the patient sign a line indicating that they understand the study. Signing a consent form in the research setting does not express or imply any obligation or commitment to participate; rather it serves as legal documentation that the study team has explained the study, including risks and benefits (if any), and the subject has had an opportunity to ask questions.

Before going to the operating room, however, “Consenting” is quite different. This is a planned, ambulatory surgery. The physician has already reviewed the surgery during the pre-operative visit, and the patient has obviously consented to the procedure because they chose to undergo pre-operative testing, and because they showed up for the surgery, and because they signed some other forms during the office visit.

What, precisely, the patient has “consented to” is not clear. Even when discussing bread-and-butter issues like risks vs. benefits . This issue has been studied: and a relatively recent study (Abed et al, Am J Obstet Gynecol. 2007 Dec;197(6):674.e1-5) found that while “consenting” patients, the least well-discussed feature of surgery was who will be present in the OR during surgery. So that’s not reassuring.

When I meet Mrs. B, I introduce myself as a third year medical student and explain that I am part of Dr. Peters’ team today. I say that I will be observing and participating (under close supervision) in her pre-op, intra-op and post-op care. She nods, and asks me a few questions about the case that I easily answer. After we prep Mrs. B and move her to the OR, the anesthesiologist immediately gets down to business. General anesthesia is administered to reduce movement of the diaphragm which could interfere with the surgery, and because having several liters of CO2 inside one’s belly is probably pretty uncomfortable even with epidural/spinal. The patient is placed in the dorsal lithotomy position, undraped.

Dr. P, a friend of the patient for twenty years, and a leading physician in our department of OBGYN, turns to me and says: “Put on gloves and do an exam after the resident and I examine her. Tell me what you think.”

My heart drops, but I try not to show it. They can’t be serious, this must be some kind of test. Maybe if I just stand here, they’ll forget about it.

Dr. P turns back to me. “We don’t have all day.” Nurses are scurrying around to prep the remainder of the table and cleaning Mrs. B’s laparoscope insertion sites. In the controlled frenzy of the operating room, standing still is no longer an option.

At this point, what would be going through your mind?

In a few short moments, this is my internal monologue:

1. Two weeks ago I distinctly said that I would not do this.

2. Maybe the surgeon talked to Mrs. B about this exam and about my participation during her pre-op office visit.

2a. No, she almost certainly did not

2b. But what if she did?

2c. Stop it, that’s a total fantasy. You know she didn’t.

3. Dr. P seems to be a moral, trusted and upstanding human being. Also, a woman. She is a pillar in her community with relationships spanning three decades. She has birthed generations. She must have her patients’ best interests in mind.

I start walking over to the gloves on the wall.

4. But I know that my exam is not a key part of patient care. Hell, it’s the third exam today. Would Mrs. B ever agree to this if she were asked?

5. Would she? Who knows. This is a teaching hospital. She signed a form. She knows that students and residents are present in the operating room. What does she think we are doing during her surgery – twiddling our thumbs?

6. I’m supervised by two physicians. This is a unique learning opportunity. I’m part of the team and part of the decision-making process (admittedly, the smallest part of that process).

Now I have to make a decision. This situation doesn’t seem like the perverse, malevolent caricature that I read about. It seems normal. I’ve been given a direct order. I’m well supervised. I will be careful and will appreciate this learning opportunity and will do no harm.

I put on gloves. Dr. P patient guides me through a bimanual exam (meaning one hand inside the vagina and one hand on the outside of the abdomen/pelvis). I appreciate (meaning that I do feel and understand) both the abnormal and normal features of Mrs. B’s vagina, cervix, ovaries and uterus. The exam takes about 30 seconds. The gloves go in the trash, and I watch as Dr. P and her resident go to scrub. Since this is a laparoscopic case I am told to observe, but not scrub. I help get the rest of the OR ready. Mrs. B is draped in a sterile fashion.

The rest of the day is a busy blur with other procedures (not requiring a pre-op pelvic exam), a half-day of clinic, and little time for talking. As it winds down, Dr. P and I are sitting in the office of her private practice. Many degrees hang from the wall, and every available surface is covered with pictures of the stereotypical good life: fishing trips, pictures with Bill Clinton, family portraits, letters from thankful patients, degrees and awards.

I ask Dr. P what she thinks of having medical students do pelvic exams on anaesthetized patients. She looks at me for a few long moments, and says that they are a necessary part of training. Since we’re part of the team, and part of the decision-making process, since we’ve met the patient, since we are supervised during the exam and there is only one medical student per operating room, there is no harm. Refusing to perform the exam would deprive students of a valuable learning opportunity and prevent them from being part of the team. And, she says, patients won’t feel any ill effects of the exam.

I don’t know what to think, I know that I feel every moral alarm bell in my head ringing loudly. I feel uncomfortable, deep in the pit of my stomach, about what happened in the OR. And so I get home, and I write, and have a beer, and think. I speak to trusted friends who are not physicians, women and men. I speak to my girlfriend, my parents, and even my dogs (best listeners ever!). Eventually, I blog about it.

I’m probably doing all this for two reasons: to get an answer so that I can make the best decision if confronted with this again, and to assuage my discomfort at having done something that I view as ethically problematic. Don’t worry, neither goal has yet been accomplished.

So, where do I stand now? Well, I think that the problem spans beyond than what I do, or don’t do, on OBGYN. This is a major cultural issue: the worst of NIMBY-ism (Not In My Back Yard). Every patient wants a well-trained physician or surgeon, but only a few patients would to let a physician or surgeon train on them. Something must give.

So what would I tell a patient in pre-op if I were ever faced with this situation again? How’s this:

“Hi, my name is [ThirstyScholar] and I am a third year medical student on [Dr. Whomever’s] surgical team. As a medical student, I will observe and assist in your care before, during, and after your operation. As part of your surgical team, I will examine your abdomen and pelvis while you are under anesthesia to help guide our operation. [Dr. Whomever] will supervise me and anything that I do must meet her exceedingly high standards. Do you have any questions about your procedure or about my role in your care?”

While I think this is important, extending this line of reasoning could lead to some very un-reasonable conclusions. What’s so unique about a pelvic exam? Do I need separate prior consent to place a Foley? What about driving a laparascope/camera? What about cutting or tieing sutures? What about palpating an internal structure? Or retracting an organ? What do patients understand when I tell them that I will be assisting during their surgery? What is the mean and variance of that understanding? Do I have to cater to the extremes of understanding or just cover the middle? If there is a line to be drawn, I have no idea how to draw it. And what happens during residency? Does all of this go out the window?

In the end, I think I made my decision to change my spiel based as much on emotional as moral/ethical grounds. I don’t want to feel the way I felt after that exam if I can avoid it – and I can avoid it. So I will.

2000 words later, I’ve got a plan. But I don’t know if its any good …

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12 Responses to Ethics Case, Part II

  1. Mingle says:

    If the patient doesn’t give you consent and you’re faced with a similar situation, how would you respond to the attending? Something like, “I’m sorry, but the patient did not feel comfortable letting me do anything but observe”?

    • I plan to convey the patient’s wishes to my resident immediately after I speak with the patient, before we meet them as a team. If the resident/attending decided to speak with the patient about it, they would then have the opportunity to do so. Honestly, we’re talking about women who receive regular OBGYN care at a teaching clinic (and have no restrictions on who they see) and who present to a teaching hospital for a planned procedure. Based on my experience with this population, I expect the vast majority of them to be okay with my supervised participation in their care.

  2. AndromedaMed says:

    What a thoughtful post! Thanks for sharing it with us.

  3. Ernest Lerner says:

    Having just finished my Ob/Gyn rotation, I was faced with this same situation in my first week. I was initially reluctant, but performed the exam a) because the default is to do what your attending tells you to do, b) because I was confident that I would not harm the patient, c) because I had met the patient and felt like part of her care team, and d) because she was already bloomers-to-sunday exposed, having entrusted herself to the care of the OR team. Afterward, I thought a great deal about why a pelvic exam gives me the impression of being more intimate or invasive than having my hands inside someone’s abdomen (during my surgery rotations, while I always let patients know in pre-op that I would be assisting Dr. X with their surgery, I was never more specific in asking their consent than that). In the end, I decided that it was not more sensitive, especially while the patient is under (which does not feel to me as bad as it sounds in my head). I did try my best to forge a bond with all the patients, and in later weeks, I had, by the time of their surgery, usually observed or performed a pelvic exam on that patient while she was awake and aware and giving proper consent. It’s a weird issue – especially how the anaesthetic state affects the moral hazard in the situation.

  4. T says:

    So, here’s one thing left out: What if you’re dealing with someone who’s a rape/sexual abuse survivor? You wouldn’t necessarily know, it’s not something that comes up on most pre-op questions and not something a woman would necessarily disclose. You risk leaving a woman with a feeling of violation she doesn’t really understand when she wakes up. Your doctor’s comment of “takes no harm” is not necessarily correct. No /physical/ harm, perhaps. Unless you thoroughly cleaned her inside and out, and gave her about a day of knockout time for tissue contraction, that woman will wake feeling stretched and lubed, which is potentially triggering for panic attacks before she’s even fully come out of anaesthesia.

    I like your plan of informing the patient. It may someday be the difference between a woman waking up and immediately telling herself, “It was an exam. I’m ok.” and a woman waking up and climbing the panic tree. I know that if I were the patient, I would appreciate the disclosure and courtesy, and would consent to being used as a teaching tool. It would be one thing to find out a student poked around my innards through the surgical incision, or stitched me up, or hell, even performed the laparotomy while supervised. That’s a necessary part of the procedure and they have to learn somewhere. To find out an unnecessary procedure was performed, that I hadn’t consented to or even been informed of – especially a pelvic? I would raise such wrathful hell that the hospital’s administration andlegal team would sweat blood before I was done with them and the doctor that had ordered it would probably want to commit ritual suicide, because unconsentual vaginal penetration meets the sexual assault criteria in all 50 states. If they made me feel violated, I would bloody well make them feel like violators.

    I’m genuinely curious: when men go in for operations, do medical students get instructed to do rectal or prostate exams on them while they’re out?

    • Thanks so much for taking the time to post an insightful comment.

      Even if a woman is a survivor of sexual abuse, she’s going to get a pelvic exam because it is indicated for the procedure (e.g. most GYN surgeons wouldnt perform most GYN surgeries without one). She’ll likely get one from the attending and one from the resident (since the resident may be performing most/all of the case, with supervision), but certainly at least one. And while I can’t (and won’t) speculate about whether, after gynecologic surgery, one can tell whether one has had multiple (appropriately performed, nonmalicious) pelvic exams vs. a single exam … I can say that from the perspective of physical trauma, a properly performed pelvic exam is the least traumatic portion of any surgery (just wait till you see a mechanical cervical dilation … or a tenaculum … ugh …). However, from the perspective of emotional trauma, I think you are making a great point and it gets back to why both meeting and informing the patient preop is key.

      As far as the role of students – let me just tell you: being in the OR is a uniquely vulnerable position for any procedure. And while I’d like to say that every person keeps that in mind at every instance …

      As far as rectal exams: they are standard of care for trauma patients as part of the ATLS secondary survey. These exams are often done by the intern or medical student, on both male and female patients. Rectal exams are performed, only when indicated, as part of the preoperative evaluation in several colorectal and urologic surgeries, on both males and females. They are often performed by several team members including medical students, particularly if there is pathology worth noting.

      Look, I don’t think anyone should think that a medical student will do a pelvic or rectal exam on a patient who comes in for a knee replacement or heart surgery. However, we probably will put in your foley if you need one (urinary catheter placed in the urethra) and we will shave you as needed for your surgery.

      For all the students who read this, I would make two simple points:
      1. it is not as hard or as awkward as you think to tell your patient preoperatively that you will be assisting in their care, and to enumerate specifically that you will perform a pelvic exam in the operating room. You shouldn’t solicit their refusal by seeming uncertain or unconfident – if they have a problem, they will tell you or another team member. The more you practice this, the easier it will get. About one in ten or twenty patients will have an issue.

      2. although it seems like the end of the world to directly disobey an attending, on this issue, it isn’t. I honored OBGYN and I directly told two or three attendings that I wouldn’t perform a pelvic exam on patients I hadn’t met pre-op. They looked at me like I was crazy, and made fun of me a bit afterwards. After I explained that I *wanted* to do the exams, that I was interested in learning how to do them well, and that I cared about the patient (as opposed to being afraid or uninterested or squeamish), I had no problems. Remember that, by and large, OBGYNs are some of the most passionate patient advocates that you will find in medicine. They have a very strong bond with many of their patients, and as long as you show that you are motivated by caring and not acting disinterestedly, they will likely understand.

      That gets back to a larger issue which I’d like to touch on at some point – it is easy to lose parts of yourself in medical school, with grave costs. Be careful about the habits and the company that you keep, and the mentors you emulate (consciously and unconsciously). Choose your own priorities. But that is advice for another day … perhaps a day farther from my shelf exam …

      • First of all, let me say that I just discovered your blog two days ago, and I am really, really impressed. I am currently a year behind you, with career aspirations similar to yours, but I must say that I think you’re likely head-and-shoulders above me when it comes to simple “Get-your-shit-togetheritiveness”. You write beautifully, and I look forward to reading more, both your writing as well as your recommendations. That said, I disagree with you on this one. Full disclosure: I, too, am a male; so take my arguments here with a grain of salt.

        With regard to “Simple Point” 1, I agree with you whole-heartedly that it is of utmost importance to introduce yourself to the patient preoperatively, and tell her that you will be assisting in her care. To that end, the place where I did my inpatient GYN rotation mandated that any medical student performing an EUA must first have met the patient and introduced him- or herself. But you and I part ways when you suggest that I should “enumerate specifically” what procedures I will be performing; I disagree, for two reasons: First, there is nothing inherently different about a pelvic exam under anesthesia than any other part of the procedure. In fact, the patient has specifically consented to an EUA as part of the procedure, and furthermore consented to the possibility that a medical student may participate in their procedure. So I’m not entirely sure what is to be gained by obtaining a separate, explicit consent in this case. Is it because the exam involves the vagina? If anything, I feel as though your approach (past tense though it may have been, now, and certainly well-intentioned) makes the issue more fraught than it was to begin with. Do we really need a separate discussion, in hushed tones, about the parts of the procedure that involve a patient’s privates?

        Secondly, since you value a patient knowing specifically about your role in the operation, doesn’t obtaining a separate, specific consent by “enumerating specifically” what you will be doing during the procedure limit you to only that for which you obtained the consent? Do you include in your speil the fact that you may also be performing foley insertion, prepping, draping, suctioning, ligating, uterine manipulation, palpation of internal structures, holding clamps, retracting, stapling, etc? If not, why not? And if you don’t include these things, is there not a similar moral dilemma?

        My suspicion, if you’ll forgive me, is that your need to have this conversation with patients is an expression of uncertainty on your part with regard to your relationship as a male medical student to female patients. Not that that’s abnormal, or even particularly bad, mind you. But I think it says more about you than about a particular moral issue in medical education. At least, in this particular instance. The morality of some parts of medical education is probably worthy of an entire blog, let alone a post.

  5. There is a subset of patients who do believe that pelvic exams ARE differently from suturing or palpating an internal structure through an abdominal incision. Based on some of the published data I cited, this subset is at least a significant minority if not an outright majority of female patients. Accordingly, out of respect for their autonomy, discussing EUA should be a specifically enumerated part of your conversation with the patient, in addition to your more general discussion of your role in their care.

    I certainly agree that my personal feelings about EUA initially brought this issue to my attention. I feared their disappearance – the longer you do something, the more normal it seems – and sometimes those feelings were important markers of a belief that should have been maintained. That’s why I tried to look at this from a patient perspective to guide my decision making. For some procedures, examination of sensitive regions is clearly assumed in the consent – breast surgery, rectal/anal surgery, etc. However, I think that honestly many GYN patients don’t know that EUA are being done. They wouldn’t necessarily say no- but they would want to be informed.

    One of the most important learning experiences of third year is that you can’t rely on ANYONE to do your thinking or collect your data. The same principle holds true for moral reasoning. In medical training we learn to do many things that violate broader social norms or taboos but are morally permissible, even required. For me, the unique moral issue of EUA is based on what (some/most/all) patients would want to know, not my own feelings. Accordingly, doing an EUA without informing the patient is not permissible.

  6. With respect, I don’t know that we know that. I’m not sure to which published data you refer in your response, but none of the articles cited in your post give me a compelling reason to believe that a majority of female patients feels one way or the other. It might be an interesting survey, and could probably get published. We can suspect all we like, but without knowing, it is, at the very least, premature to draw ethical conclusions. When you say: “For me, the unique moral issue of EUA is based on what (some/most/all) patients would want to know, not my own feelings,” what I read is that it is based on “what I THINK patients want to know”. By no means does it make it less valid for you, and I think you’ve found a great way to navigate a conundrum. But I also think that it is entirely possible and ethically consistent to reach a different conclusion than yours.

    From a purely medicolegal standpoint, I can see no reason why medically-indicated EUA by a medical student isn’t already covered under the global consent. From an ethical standpoint, I suppose I am a little confused why we should consider EUA a “unique moral issue” if it is medically indicated. As an example, if I am charged with inserting a uterine manipulator under attending supervision for a laparoscopic procedure, then an exam to determine uterine position would be medically indicated. If a patient has already consented to the idea that I, as a student, will be involved in her care, and may perform procedures under the direct supervision of the attending surgeon, then would that consent not also *implicitly* include examinations necessary for the safe performance thereof?

    In my interpretation, the true moral transgression in the original ethics case wasn’t the fact that the patient hadn’t specifically and discretely consented to a student-performed EUA, but rather that the attending invited other students that were unfamiliar with the patient’s case, had not met the patient, and were not involved in her care to perform repeated EUAs. To my mind, the issue here isn’t *what* the global consent covers, but *whom*. If a patient signs a consent that includes a clause indicating that trainees will be involved in her care, which trainees, exactly, does that cover? In my estimation, it covers only those trainees involved in her care, except as specifically consented by the patient. And for me, that’s the key. As is almost always the case with this sort of thing, however, you may disagree.

    Perhaps put another way, I think you have identified a major moral issue of inadequate global consent, and the articles you cite substantiate that. But I don’t believe that the inadequacy of the consent is specific to the issue of EUAs, but rather an overall general question of how much effort the surveyed surgeons put into ensuring patient understanding of the procedure, team, etc.

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