I have read some articles and heard from other people that at some hospitals women are given pelvic exams (without their explicit consent) when they are under general before surgery (a surgery that may not be related to anything gynecological). Is this true? I haven't started med school yet and am interested to know if this is a common practice in the hospital. for those that have been on surgery rounds, is this something that is seen often or at all?
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I've been apart of these, and all women have given explicit consent for the pelvic exam under-GET performed by attendings, residents, and/or med students. I have NEVER seen one of these done for non-gynecologic surgeries and never saw one done during my time on the Surgical Oncology service and find it unbelieveable that they would be (ie resection for gastric ca, mastecomy, etc). The only time that I can think of in which one might be done in a semi-related setting is if a woman has a colon adeno ca which may have directly extended to the uterus/parametrial tissues, and even in this case its gonna be the GYN Onc and residents/fellows and NOT the surgical oncologist or colorectal surgeon that does the exam to determine clinical staging.
http://www.obgyn.utoronto.ca/undergrad/Policies/Pelvic-Exam-Policy.htm
Here is a link to torontos policy, and I believe that is similar to most places policy now. It is usually described in the consent forms, but I wouldn't be surprised if people just gloss over it and patients don't really know, which is unfortunate. The thing is a lot of patients will consent to it if asked explicitly and don't mind, its just whether people will ask or not. The other thing is that a lot of the other procedures like foley's and central lines, and that sort of stuff are done by students while the patient is under anesthesia, the only real difference being is that the pelvic exam isn't directly involved in the care.
Here is a good article too about the whole controversy.
http://content.nejm.org/cgi/content/full/356/9/889
Here is a link to torontos policy, and I believe that is similar to most places policy now. It is usually described in the consent forms, but I wouldn't be surprised if people just gloss over it and patients don't really know, which is unfortunate. The thing is a lot of patients will consent to it if asked explicitly and don't mind, its just whether people will ask or not. The other thing is that a lot of the other procedures like foley's and central lines, and that sort of stuff are done by students while the patient is under anesthesia, the only real difference being is that the pelvic exam isn't directly involved in the care.
Here is a good article too about the whole controversy.
http://content.nejm.org/cgi/content/full/356/9/889
After completing a surgical residency and fellowship, I can say that never did I do or hear about someone having general surgery getting a full pelvic exam. That doesn't mean that exams under anesthesia are not warranted (we do plenty of those for perianal reasons) or done, but in general those exams are the realm of the Ob-Gyn, not general surgery. I have opened the introitus when looking for the opening of a perianal fistula and of course, for procedures for recto-vaginal fistulas.
That said, if one was contemplating needing to do a pelvic exam, it should be contained on the consent form. Every consent form I have seen contains a phrase like, "I authorize Dr. X and his designated team/assistant, etc. to perform operation X..". Therefore, the patient is giving consent for the attending as well as others to perform the procedure named. It would be unethical to perform a pelvic examination on a patient without reason...those reasons are either:
a) standard part of the proposed procedure
b) findings during the consented procedure which necessitate a pelvic examination. All consent forms include a statement as well which say, "I agree to other procedures which the surgeon deems necessary" which covers the surgeon in case of unexpected findings.
There's a similar thread around here on this very topic (Clinical Rotations or Pre-Allo forum, I think). At any rate, while pelvic examinations for anesthetized patients who don't warrant them probably do happen, I would <hope and expect> that they are rare.
As a student, you have the right to refuse to do anything which makes you uncomfortable - this would be an appropriate reason, IMHO.
That said, if one was contemplating needing to do a pelvic exam, it should be contained on the consent form. Every consent form I have seen contains a phrase like, "I authorize Dr. X and his designated team/assistant, etc. to perform operation X..". Therefore, the patient is giving consent for the attending as well as others to perform the procedure named. It would be unethical to perform a pelvic examination on a patient without reason...those reasons are either:
a) standard part of the proposed procedure
b) findings during the consented procedure which necessitate a pelvic examination. All consent forms include a statement as well which say, "I agree to other procedures which the surgeon deems necessary" which covers the surgeon in case of unexpected findings.
There's a similar thread around here on this very topic (Clinical Rotations or Pre-Allo forum, I think). At any rate, while pelvic examinations for anesthetized patients who don't warrant them probably do happen, I would <hope and expect> that they are rare.
As a student, you have the right to refuse to do anything which makes you uncomfortable - this would be an appropriate reason, IMHO.
When I was doing OB/GYN as a med student, the attending would have me do a pelvic right after the patient was under and before we started surgery. Of course, we were doing GYN-related surgery and he wanted me to note the difference before and after a cystocele or rectocele repair. We didn't exactly get permission but it was for teaching purposes.
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That was my experience as well. It's suprising how worked up some people get over the issue. You will be naked on a brightly lit table for all to see. A medical student will put a tube into your bladder. We're about to flay your belly open and remove your uterus and ovaries. But to do a pelvic exam! What a violation!
If you get into this habit of being deathly afraid of the patient's feelings about an internal exam you will never learn how. I'm not saying that you should be a jerk about it, but you owe it to your future patients to get some idea of what stuff feels like.
It's my understanding that this is how it is handled in gyn surg at my program as well. I was never asked to do one while a patient was under general.
I can understand patients objecting to having one done when it is not indicated for the surgery, however. It's an invasive procedure in the patient's point of view and if unnecessary, should not be done.
I am cringing a little at this thread. As a female student not yet in the medical field, I am disturbed to hear that by consenting to surgery, I risk having someone literally in my vagina without consent for purposes that benefit only the providers, and not me. Are patients really viewed as a teaching tool rather than a human being? That I will be splayed and sliced during the procedure doesn't mean that additional indignities are acceptable.
It's still my vagina, even if I am naked and unconscious. I didn't lend it to anyone to practice techniques.
It's still my vagina, even if I am naked and unconscious. I didn't lend it to anyone to practice techniques.
DermViser, I'm not sure I understand what the lost relationships and other negative aspects of entering the medical field have to do with not wanting to be used as a teaching tool unless I have specifically consented to this activity.
You have though. "if the surgeon deems it necessary."
" Hey I think it's necessary to do a pelvic exam." <- after this statement or thought, it's completely valid, legal and ethical to do a pelvic exam. It's not like people are doing this stuff to play around.
It's a part of the physical exam. It's not a big deal for providers, and it's certainly not sexual. It is done to confirm findings and, yes, to make sure we know what that pathology feels like.
Just like a good abdominal exam is done before an abdominal procedure, a good joint examination is done before an arthroplasty, a good rectal exam is done before an anorectal procedure, a good oral exam is done before an oral or oropharyngeal procedure.
You should probably also be aware that immediately after doing a pelvic exam, the gynecologist is probably going to spend the next few hours operating around the reproductive tract. So a pelvic exam is probably the least invasive thing that happens that day.
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In my experience, I have only seen Pelvic exams under GETA when on the Gyn service and they were all clearly done with a purpose (ex. To confirm laterality of an adnexal mass, palpate a cervical mass to be resected, etc.). Never seen this done for a General Surgery procedure though.
Quote from glorytaker<<When I was doing OB/GYN as a med student, the attending would have me do a pelvic right after the patient was under and before we started surgery. Of course, we were doing GYN-related surgery and he wanted me to note the difference before and after a cystocele or rectocele repair. We didn't exactly get permission but it was for teaching purposes.>>
It says here that the attending wanted the student to note the different before and after the surgical procedure. That states that the med student was doing the pelvic exam to familiarize him/herself with the particular anatomy and how it felt before and after the procedure. That is of no benefit to the patient if the attending also does a pelvic as part of the surgical procedure.
It also says in the above snip that "We didn't exactly get permission, but it was for teaching purposes."
As a patient, I do not have an obligation to be a live dummy for any person to hone their skill of feeling organs. It seems that medical professionals become desensitized to the fact that a patient deserves respect. Inserting an object or a part of your body into another individual's body for purposes beneficial only to the first party without express consent is a violation. That it's the least invasive procedure to happen to the patient that day does not make it any less of a violation.
It says here that the attending wanted the student to note the different before and after the surgical procedure. That states that the med student was doing the pelvic exam to familiarize him/herself with the particular anatomy and how it felt before and after the procedure. That is of no benefit to the patient if the attending also does a pelvic as part of the surgical procedure.
It also says in the above snip that "We didn't exactly get permission, but it was for teaching purposes."
As a patient, I do not have an obligation to be a live dummy for any person to hone their skill of feeling organs. It seems that medical professionals become desensitized to the fact that a patient deserves respect. Inserting an object or a part of your body into another individual's body for purposes beneficial only to the first party without express consent is a violation. That it's the least invasive procedure to happen to the patient that day does not make it any less of a violation.
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I'm starting to think that you are one of those anti-medicine hipsters trolling, but I'll answer this question seriously anyway. Remember, this student might someday be repairing cystoceles/rectoceles. How is he supposed to know how to fix it if he doesn't even know what a rectocele is? As medical students aren't we supposed to learn certain things like, oh, I don't know, ANATOMY? Then again you aren't in medicine.
Uhm, why can't consent for a student to examine the patient be obtained prior to anesthesia?
Trolling? Too old for that nonsense here!
I'm actually a psychology/sociology student training for a second career as a Youth Intervention Counselor. This is a subject that has come up quite a bit with the adolescents I've met during this training. I came to this site to see if I could learn more so that I could offer informed answers to the young people I serve. I was surprised to notice the paradoxical undercurrent here (and on many other sites that cater to medical professionals) that patients seem to be regarded as almost an obstacle to giving medical care. Do medical professionals really feel that patients should just 'get over it ' and accept additional handling simply because a total stranger needs to use us?
Yes, you absolutely are expected to learn anatomy. That does not mean that by seeking medical care, I lose my identity and become simply a handy body for you to learn upon. I don't want anyone practicing anything on any part of my body without my consent, no matter what it is that students need to learn.
It's ironic that as a patient, I am expected to be willing, compliant and to ignore my own feelings about what shall be done to me while hospitalized or receiving care.
Is it really unreasonable to expect that my body will not be used by anyone who cares to use it? What students must learn is not a debt that must be paid by those who are in need of treatment.
I did not come her to argue or disparage. I'm here to learn, and don't wish to offend anyone.
I'm actually a psychology/sociology student training for a second career as a Youth Intervention Counselor. This is a subject that has come up quite a bit with the adolescents I've met during this training. I came to this site to see if I could learn more so that I could offer informed answers to the young people I serve. I was surprised to notice the paradoxical undercurrent here (and on many other sites that cater to medical professionals) that patients seem to be regarded as almost an obstacle to giving medical care. Do medical professionals really feel that patients should just 'get over it ' and accept additional handling simply because a total stranger needs to use us?
Yes, you absolutely are expected to learn anatomy. That does not mean that by seeking medical care, I lose my identity and become simply a handy body for you to learn upon. I don't want anyone practicing anything on any part of my body without my consent, no matter what it is that students need to learn.
It's ironic that as a patient, I am expected to be willing, compliant and to ignore my own feelings about what shall be done to me while hospitalized or receiving care.
Is it really unreasonable to expect that my body will not be used by anyone who cares to use it? What students must learn is not a debt that must be paid by those who are in need of treatment.
I did not come her to argue or disparage. I'm here to learn, and don't wish to offend anyone.
Probably because nobody would say yes and students would never learn. I'm going to stick a rigid metal scope, a foley into your vagina but my fingers are off limits. Makes sense I suppose.
There are teaching hospitals and hospitals without students. If you do not wish to be a teaching tool, it would make sense to seek out hospitals without residents or medical students. If a patient goes to a teaching hospital, it is kind of implied they will be used to teach students, no?
Sorry, but you INHERENTLY agree to that when you're seen in an academic teaching hospital. You agree to have residents and medical students participate in your care, not just an attending. If you just want an attending, then you are free to go to a non-teaching hospital. That's the deal.
If you have so much of an issue with students learning from your case, why don't you go to a non-teaching hospital for your care?
This hypothetical student is going to be assisting in an operation on you, and in your scenario he would doing it without knowing what he's operating on, where it is in relation to other vital organs/vessels, what it feels like, how big it is, etc. He's not "feeling you up" for the hell of it, it's vital information essential to the surgery.
Yup, that explains the "clutching of the pearls" response then.
This is a member of the new generation of patients. They think they are entitled to the best care, usually subsidized to some extent at the teaching hospital, but want to dictate terms. It's all part of this "customer satisfaction" crap, and the mentality that the patient is a customer who is "always right." It's a terrible paradigm and obstructs care.
It's debatable whether it benefits you directly, but it does not only benefit the provider. It benefits the future patients of said provider. And, again, this is generally included in the consent form, and is only, as far as I know, done during GYN procedures, not general surgery. You're not going to have a pelvic done for a cholecystectomy or appendectomy.
While I can understand where your outrage is coming from, by going to a teaching hospital, you are consenting to being treated by medical students and residents, who are there to learn. If you aren't comfortable with that part of the arrangement, don't go to a teaching hospital, or explicitly state that you do not want a medical student participating in your care. How else do you expect us to learn?
And again, as part of the consent form, you are consenting to necessary exams and participation of medical students in your care. Providers are careful to only include the parts of the physical exam that are relevant to the operation being performed. If that involves female anatomy, then a pelvic exam may be done.
No one is learning anatomy by doing a pelvic exam first of all. Secondly, there are many people who feel like you do and if you feel like this just don't consent to a student examining you. No one is forcing you to do this. You don't have to ignore your own feelings.
And you may not understand exactly what happens in real life. Its not like you are unconscious and the whole entire med school comes and gives you a pelvic exam. It may be 1 or 2 students in the OR. It's really not a massive deal.
And for the bolded part, this is a matter of the doctor. Some docs hate when the patient says no and some docs understand. If its something to do with being naked i totally understand if the patient wants privacy.
Students are expected to be docs in a few years. Don't feel like your body is being "used" it almost sounds as if the student is doing it for their own benefit, which they are technically, but ultimately its not the benefit for themselves is it? It's for who they are going to treat in a few years. The more times anyone does something obviously the more comfortable they will be later.
How can you expect students to learn if sick people aren't willing to be examined by students?
I think there's a general disconnect between what a pelvic exam actually is and the perception of a pelvic exam. It's certainly not some sexual thing that the student/physician enjoys doing. It's a medical exam. I don't know of many people that do not wish to have an exam done on them to investigate a problem in that area. As said, these aren't going to be done when your ear is infected. Not many people say no to you looking into their mouth when their throat is swollen. It's more personal yes, but that's due to the location of the potential illness. I don't think many people are going to risk their health in order to "protect their body" from a pelvic exam.
Look... I'm a student, and I've been a patient a lot. Would I expect to get a pelvic exam, possibly while under anesthesia, if I were having a uro-gyn surgery? Yes, it's medically necessary and if a student did it he or she would learn something. Would I expect to get one if I were in to have a torn ACL repaired? NO, and it's situations more along that line that have gotten this practice justifiable flack. It's an unnecessary, invasive exam then and the secrecy that it goes on just makes it look even worse.
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I'm sure there are some here and there, since there are perverts in every field of the world as well as medicine (as evidenced by a couple other threads on this subject in this forum).
Physicians have a covenant with the public. We are trusted to be competent and be able to heal the sick. Competence is acquired with knowledge and knowledge comes with experience. You can't expect people to magically become medical professionals out of nowhere without actually doing things. No one is disrespecting you or your body.
Exactly. I was kind of trying to use the Socratic method to get the person I quoted to arrive at that conclusion. There is no autonomy-violating pelvic exam epidemic occurring in America's teaching hospitals.
Is a pelvic exam under anesthesia any more invasive than me teaching a student how to explore the abdomen at the beginning of a laparotomy? Or having the student palpate the abdomen to "feel the olive" in an anesthetized baby with pyloric stenosis? Or letting a student feel the beating heart before we go on pump for a CABG? Or cradle the transplanted kidney in their hands before we sew it in?
No. The only difference between the pelvic exam and any of these other educational experiences in the OR is that our society has made the genitals culturally taboo.
No. The only difference between the pelvic exam and any of these other educational experiences in the OR is that our society has made the genitals culturally taboo.
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Yep, plenty. It used to be much more common, before medicine became less paternalistic.
Ultimately, patients should (except for very narrow circumstances) always have a right to refuse procedures even in a teaching situation. I once said no to having a student remove my chest tube; for whatever reason the thought of the procedure was really frightening me and I wanted to be in more experienced hands. That no was respected about something far less personal than a pelvic. Just be upfront, and actually get consent.
I've never heard of it happening outside the context of a urogyn procedure.
And I actually don't let students pull chest tubes haha. Once you've had one reaccumulation pneumo you learn to take that seriously.
Doesn't make any sense to me either - shouldn't the Ob-Gyn rotation be pretty sufficient? - but it happens.
Nice to know much-younger-me's instincts were on the right track!
On your first point, false. The women in my family have always consented to teaching baby docs for the reasons highlighted in the thread, and because I figure if I'm going to be learning I should be willing to teach. I often seek residents for care, and will talk to medical students as long as they'd like me to, and I know I'm not the only patient who feels this way.
Second, since teaching hospitals tend to be cheaper/more accessible, doesn't that kind of introduce some hinky, Belmont Report-violating undertones to this discussion? What if the patient is unaware that their hospital is a teaching center? Or is not covered at a non-teaching center? I definitely understand and respect the need for students to learn, but the tough sh!t attitude about strangers inserting anything into a vagina, which is a sexualized and personal space regardless of how clinical the exam might be, is surprisingly abrasive.
It is not like booking a room at a hotel; patients must go to the hospital where their doctor has privileges. Like many others who are not yet medical students, I was not aware that our hospital was a teaching hospital until it was too late. It is very likely that others are caught off guard in the same way.
Part of patients' frustration is not knowing what may be asked of us or taken without asking.
"No patients" was an exaggeration. But surely you can agree that if you asked every patient explicitly, "do you want a medical student learning by examining you and performing procedures", or any other way you want to word that sentiment, the # who agree would be a fraction of what it is now.
I don't have any data to address your second point. I would not have thought so though. There are a lot of community clinics with sliding scale clinics which don't have students. And teaching hospitals, in my experience, are so inefficient that I can't imagine they can afford to charge a lot less. And yeah, tough **** is my pretty much my attitude towards most things, not just this topic. I get that the genitalia are very, very private for most women. I got kicked out of plenty of patient rooms on OB/GYN by virtue of having a penis, which resulted in a poor learning experience compared to female students. I'm not going into OBGYN so I didn't particularly care, but there are male students who will be and if I'm weighing the pros and cons of having poorly trained womens health physicians versus having written consent and not explicitly addressing the medical student involvement orally, I'm going to lean towards getting students proper training every time.
That said, if a patient explicitly says I want no students then obviously that wish is respected (and eI've never seen anything violating patient wishes).
I don't mean to have a "tough ****" or callous attitude.
However, I would definitely say that there is a LOT you can potentially learn from examining an anesthetized patient. Paralytics make for a very good physical exam. And it's one of the few chances some students will get to examine pathology rather than examine normal findings.
I guess for me, what it comes down to is the nature of your relationship with your surgeon, and whether there is trust and respect. I respect my patients and the tremendous obligation I am under when I cut them open. I wouldn't do anything to violate that respect - either myself or by letting a student do something. I hope that my patients trust me in that regard - they obviously trust me enough to let me operate on them. But I do let students learn as a part of the operation - and I discuss with the patients ahead of time that there will be students there and that they will be actively participating. I also have no issue asking a patient for their permission to have a student perform a genital, rectal, or breast exam while they are awake.
I think you've missed the "consent form" point. Hit Ctrl+F and search for "consent" and note that it has appeared dozens of times in this thread.
Can you explain what you mean by "until it was too late"? Are you waking from anesthesia and seeing a student there? The frustration is understandable. How would you want this addressed? It's on the paper you sign, and patients can see medical students and residents wandering around and probably talking to them. Do you want it to be a mandatory part of the informed consent process (which is already overwhelming for a patient)?
Doctors can have privileges at several hospitals. Also, you usually see your doctor several times as outpatient followup visits before heading into major surgery.
If you didn't notice residents or medical students walking around in a teaching hospital, then you need to open up your eyes more. Most people notice this type of stuff.
Wait, covenant with the public? I have never heard of this and did not enter into such an agreement. It is absolutely disrespect to me and my body to practice any procedure on me without clear consent. That models are needed does not mean that patients should lose the right to refuse participating as a model.
At a Planned Parenthood office, a student nurse came into the exam room with the NP to observe my exam. I refused. The appointment is unpleasant enough without a stranger there looking at my body as if it were an anatomy book. How invasive. She couldn't even bother to ask, but simply showed up planning to breach my privacy for her benefit. It is for her benefit. She is the one who wished to become a nurse.
There seems to be a disconnect here that because medical students need to learn, patients have an obligation to cast aside modesty and autonomy and allow themselves to be used.
When I became a phlebotomist, I told every single patient that I was a student qualifying to become certified, and asked in the form of a question (never a statement of what I would be doing to them) if they would allow me to draw their blood. Some patients refused, as they had every right to do.
DermViser, how are patients to notice who is walking around in a hospital, or know what their role is there? Most patients spend very little time there when they are well.
Most patients at teaching hospitals interact with residents and med students (short white coats) all the time when they're there for their care.
Not necessarily. I spent close to two weeks as an inpatient at a teaching hospital, and met only one student in that time. Unless it's explained, the short coat means absolutely nothing to a lay person.
If you consider it invasive and offensive that a student had the audacity to enter the room....
Then yeah, I'd say we have a disconnect here.
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