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 …