Pelvic exam during general anesthesia ??

[VisionaryTics]

If the patient is awake when you know you're going to be doing it, absolutely. Sometimes, emergencies come up and we need to do something else while the patient is unconscious and, obviously, in those cases, you do what you need to do to save the patient, but in that case, 99% of the time, it's not the med student doing it.

As has been discussed before, intubating and suturing are not the same as pelvics.

I'll ask you again since you sidestepped the question, what about foleys? 99% of patients have no idea that a medical student will place a tube in their bladder.

Also, I think suturing the face or neck is a pretty sensitive matter.

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[Elisabeth Kate]

I'll ask you again since you sidestepped the question, what about foleys? 99% of patients have no idea that a medical student will place a tube in their bladder.

Also, I think suturing the face or neck is a pretty sensitive matter.

The only time I placed foleys (a handful of times), I got permission beforehand. Name me one med student who walks in and stitches a face or neck without permission. I suppose on a surgery rotation, that question might be relevant, but I didn't deal with face or neck injuries on my surgery rotation. The only time I encountered a patient who needed stitches on the face was in my ER rotation and you better believe I asked permission before I touched them.

 

[mvenus929]

As has been discussed before, intubating and suturing are not the same as pelvics.

I dunno. Intubating is a pretty traumatic thing to do, we just don't think much of it because patients are almost universally asleep when they do get intubated. I'd far rather have a pelvic exam when I'm awake than be intubated when I'm awake.

 

[Winged Scapula]

I feel the need to clarify because it appears that my earlier comment (post #189) is being used to bolster an argument.

"Secondly, patient autonomy includes the right to refuse care and who provides it. Simply being admitted to a teaching hospital does not require that a patient be treated by a medical student or resident physician. The attending of record may require that as a stipulation of his/her care and the patient then can decide whether or not to seek care elsewhere (as I have had attendings do in residency - in essence tell the patient that they could go elsewhere for their care because the students and residents would be involved.... But bottom line: attendings absolutely have the right to refuse treatment to patients who refuse to accept care from trainees."

In regards to those who felt the above statement by me was an opinion, let me clarify that this is actually Policy as stated by the VAMC and another academic tertiary care center where I am on faculty. Thus it does not represent my opinion but rather hospital policy and a consensus statement.

While patients should have a reasonable expectation that they will be examined and treated by a medical trainee if they are at a teaching hospital:

1) evidence exists that the reasonable patient does not always know what a teaching hospital is or who is involved in their care or what their appropriate roles are;

2) this does not mandate that the care received must include trainees; this should be interpreted as a statement that trainees do not have the right to expect that they will be involved in the patients care.

The patient has the right to refuse a trainees involvement.
I have the right as an attending to require medical students and other trainees to be involved in the care of any patient I deem appropriate. If the patient does not agree, I either refuse to treat the patient or remove the trainees from the case. Let's no confuse this with some personal opinion I have.

In regards to consent forms, they all mention that the procedure will be performed by Dr X and their associates/assistants and may include anything I deem medically necessary. I will agree that they are vague however the standard that they are held to is that of a reasonable person and the standard practices of a physician in that specialty. Therefore a pelvic exam by the attending and their trainees is reasonable if one is doing a hysterectomy, or rectocele repair etc. This includes placing Foleys, starting IVs etc - I do not need to clarify who is doing it. It would not be reasonable in most peoples estimation to do a vaginal exam someone is under anesthesia for a thyroidectomy for example. You do not get free reign to do anything just because the consent form doesn't list every possible procedure or everyone in the room.

 

[Elisabeth Kate]

I dunno. Intubating is a pretty traumatic thing to do, we just don't think much of it because patients are almost universally asleep when they do get intubated. I'd far rather have a pelvic exam when I'm awake than be intubated when I'm awake.

As noted several pages ago, there is a difference psychologically and emotionally in intubation and pelvic exams.

My apologies @Winged Scapula for stating that it was your opinion rather than policy.

 

[Flamen04]

This thread should just die

 

[Winged Scapula]

As noted several pages ago, there is a difference psychologically and emotionally in intubation and pelvic exams.

My apologies @Winged Scapula for stating that it was your opinion rather than policy.

No worries - you weren't the only one who thought it was my opinion. I wasn't clear earlier.

 

[Anastomoses]

This is ridiculous. No one is advocating what you're describing (rape). We're talking about a medical professional (med student/resident) performing a medically indicated procedure (pelvic exam) for the purposes of learning in a patient that has already signed a consent form.

Oh, the consent forms state that the patient's private parts can be used for learning purposes by students? I mean, if it does...then I'm all for it.

As Elisabeth Kate stated above, a med student's learning and the benefit of someone's pathology to learn just does not trump their desire to keep their care to the minimum required and by the probing hands of actual professionals. If the patient is generous, they can be asked to sign a release saying "it's okay to feel around my pathological vagina for your education purposes"; otherwise...I'm not sure where the overentitlement is coming from.

If you really need consenting pathological pelvic exams, offer money/incentives to those who don't mind.

And for the babbling brook that is @DermViser, there will be many many pathologies that a rotating student isn't going to "feel up".

When the phrase "medical trainee" is being used in this thread, are we discussing residents or medical students? I think we all know there's a difference between a resident practicing their intended specialty and a student on a 6 to 8 week rotation. Just want to make sure we're discussing the same thing.

I also think some people are lumping "any medical trainee involvement" with "probing the crevices of my private parts, despite being unqualified and offering nothing to my health"

 

[tco]

This thread reminds me of a time during third year that a patient came in on my OB rotation to deliver (sidebar - no insurance) and absolutely refused care by any males. This included the attending on overnight coverage. IMO, we should have told her to buzz off, but instead they called an attending at home (!!!!!!) and woke her up. She agreed to come in and deliver.

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[tco]

The attending they called was a random one. They don't have a schedule set up to "Call in case of entitled patient."

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[TooMuchResearch]

If the patient is awake when you know you're going to be doing it, absolutely. Sometimes, emergencies come up and we need to do something else while the patient is unconscious and, obviously, in those cases, you do what you need to do to save the patient, but in that case, 99% of the time, it's not the med student doing it.

As has been discussed before, intubating and suturing are not the same as pelvics.

Good point. If the intubation is messed up, the patient can die.

 

[DermViser]

And for the babbling brook that is @DermViser, there will be many many pathologies that a rotating student isn't going to "feel up".

And what's your point? No one is talking about doing a pelvic exam on a woman who is here for breast cancer.

 

[SouthernSurgeon]

When the phrase "medical trainee" is being used in this thread, are we discussing residents or medical students? I think we all know there's a difference between a resident practicing their intended specialty and a student on a 6 to 8 week rotation. Just want to make sure we're discussing the same thing.

I also think some people are lumping "any medical trainee involvement" with "probing the crevices of my private parts, despite being unqualified and offering nothing to my health"

I think some of this is a very narrow view. I don't mean to marginalize the concerns about the pelvic exam in specific - and have said as such above.

But this kind of oh the student is just on a 6 to 8 week rotation" - they don't need to actually learn how to do this, attitude is emblematic of some of the issues in medical education.

The idea that all actual specialty learning should/does occur in residency is why intern year is increasingly being marginalized and we find that we have to teach our interns the very basics of patient care rather than actually allowing them to practice the more specialized aspects of a field.

Every student should learn how to do a competent bimanual exam and be at least comfortable enough to recognize gross pathologic findings on said exam. For one thing, every student who goes into a primary care field should be comfortable doing them as a part of their practice. It's sad that there are a ton of medicine docs out there who refer otherwise healthy women to an OB for a routine pelvic exam - it would be easier, more cost effective, and more convenient for the patient if that doc felt comfortable doing the exam right there in clinic themselves.

 

[Elisabeth Kate]

Every student should learn how to do a competent bimanual exam and be at least comfortable enough to recognize gross pathologic findings on said exam. For one thing, every student who goes into a primary care field should be comfortable doing them as a part of their practice. It's sad that there are a ton of medicine docs out there who refer otherwise healthy women to an OB for a routine pelvic exam - it would be easier, more cost effective, and more convenient for the patient if that doc felt comfortable doing the exam right there in clinic themselves.

I don't think anyone is denying that. I, for one, agree with everything you said. I just think that a patient's informed (explicit) consent should be priority. Our need to learn doesn't trump a patient's right to control who examines/penetrates their body.

 

[SouthernSurgeon]

I don't think anyone is denying that. I, for one, agree with everything you said. I just think that a patient's informed (explicit) consent should be priority. Our need to learn doesn't trump a patient's right to control who examines/penetrates their body.

And as I've said I don't have an issue with that. And every case I've been involved in - "exam under anesthesia" is explicitly stated on the procedure consent form

 

[Psai]

I don't think anyone is denying that. I, for one, agree with everything you said. I just think that a patient's informed (explicit) consent should be priority. Our need to learn doesn't trump a patient's right to control who examines/penetrates their body.

You keep arguing against a point that no one is making which seems to be your modus operandi. No one is taking away a patient's right to control anything.

 

[Elisabeth Kate]

You keep arguing against a point that no one is making which seems to be your modus operandi. No one is taking away a patient's right to control anything.

And you keep blocking out anything that destroys your argument, which seems to be YOUR modus operandi. The lack of explicit consent is the premise of this thread, so to suggest it's a point that no one is making is really quite curious.

 

[Psai]

You're just arguing to argue.

 

[DermViser]

I think some of this is a very narrow view. I don't mean to marginalize the concerns about the pelvic exam in specific - and have said as such above.

But this kind of oh the student is just on a 6 to 8 week rotation" - they don't need to actually learn how to do this, attitude is emblematic of some of the issues in medical education.

The idea that all actual specialty learning should/does occur in residency is why intern year is increasingly being marginalized and we find that we have to teach our interns the very basics of patient care rather than actually allowing them to practice the more specialized aspects of a field.

Every student should learn how to do a competent bimanual exam and be at least comfortable enough to recognize gross pathologic findings on said exam. For one thing, every student who goes into a primary care field should be comfortable doing them as a part of their practice. It's sad that there are a ton of medicine docs out there who refer otherwise healthy women to an OB for a routine pelvic exam - it would be easier, more cost effective, and more convenient for the patient if that doc felt comfortable doing the exam right there in clinic themselves.

EXACTLY. This is how you can easily separate the excellent med student (Honors level) vs. the mediocre med student (Satisfactory Pass). The ones that want to excel on clerkships never have the attitude of, "Well I'm not going into that specialty" or "I'm only here for 8 weeks", and so feel it's no big deal if they don't actually do anything. They are then the first ones to be shocked that they weren't handed "Honors" and feel entitled to it just bc they showed up and aced the NBME shelf exam. Then when they enter residency training, and the buck stops with them, they're playing a game of complete catch up.

 

[Winged Scapula]

The sexualization of the pelvic exam by medical students here astonishes me. I feel like I'm in Pre Allo.

 

[Anastomoses]

The patient has the right to refuse a trainees involvement.
I have the right as an attending to require medical students and other trainees to be involved in the care of any patient I deem appropriate. If the patient does not agree, I either refuse to treat the patient or remove the trainees from the case. Let's no confuse this with some personal opinion I have.

In regards to consent forms, they all mention that the procedure will be performed by Dr X and their associates/assistants and may include anything I deem medically necessary. I will agree that they are vague however the standard that they are held to is that of a reasonable person and the standard practices of a physician in that specialty. Therefore a pelvic exam by the attending and their trainees is reasonable if one is doing a hysterectomy, or rectocele repair etc. This includes placing Foleys, starting IVs etc - I do not need to clarify who is doing it. It would not be reasonable in most peoples estimation to do a vaginal exam someone is under anesthesia for a thyroidectomy for example. You do not get free reign to do anything just because the consent form doesn't list every possible procedure or everyone in the room.

Right. "in the care of the patient" might be where a lot of this is getting muddled. Not at the whimsy of the attending or for the learning of the student. And if the patient is not adding any extra work to the hospital (and in the case of objecting to a student learning pelvic pathologies by touching said patient), I would suspect a spiteful motivation by anyone refusing that patient.

I think some of this is a very narrow view. I don't mean to marginalize the concerns about the pelvic exam in specific - and have said as such above.

But this kind of oh the student is just on a 6 to 8 week rotation" - they don't need to actually learn how to do this, attitude is emblematic of some of the issues in medical education.

The idea that all actual specialty learning should/does occur in residency is why intern year is increasingly being marginalized and we find that we have to teach our interns the very basics of patient care rather than actually allowing them to practice the more specialized aspects of a field.

So I understand those who feel entitled to use patients as dummies once they've come in for medical care at a teaching hospital, but the reality is...medical education needs to find a way to enhance student learning without assuming the patient's body to be manipulated for learning. Any probing of any kind which is not required for the betterment of the patient is absolutely not "for their care or health". I'm unclear as to whether teaching hospitals are hospitals first or teaching facilities first? There are solutions to enhancing medical education without trampling the right of a patient to not be treated like a specimen.

It seems what a lot of you are suggesting is that the patient should incur the cost of a positive externality...aka a med student's enhancement. Is this like one of those "Pay it forward" type things? You want something fair? Incentivize. Anything else is coercive.

Every student should learn how to do a competent bimanual exam and be at least comfortable enough to recognize gross pathologic findings on said exam. For one thing, every student who goes into a primary care field should be comfortable doing them as a part of their practice. It's sad that there are a ton of medicine docs out there who refer otherwise healthy women to an OB for a routine pelvic exam - it would be easier, more cost effective, and more convenient for the patient if that doc felt comfortable doing the exam right there in clinic themselves.

1. I support ignoring any patient issue which does not involve actual invasive touching. Melanoma of the ear? No problem.
2. I think you may also have a solid case with patients getting free medical care needing to offer consent in exchange - maybe.
3. I wholeheartedly wish for us all to be "renaissance doctors" as much as possible and admire those who know way more than their specialty - with consenting patients.

 

[Anastomoses]

EXACTLY. This is how you can easily separate the excellent med student vs. the mediocre med student. The ones that want to do well never have the attitude of, "Well I'm not going into that specialty" or "I'm only here for 8 weeks", and so feel it's no big deal if they don't get to do anything. They are then the first ones to be shocked that they weren't handed "Honors" and feel entitled to it just bc they showed up and aced the shelf exam. Then when they enter residency, and the buck stops with them, they're playing a game of complete catch up.

You make the most nonsense extrapolations at every turn. I don't think you can even be fixed. It's like some intrinsic flaw, right?

The sexualization of the pelvic exam by medical students here astonishes me.

I'm not sure this is about sexualization but about invasiveness for reasons that don't pertain to a patient's health. Any procedure is already cumbersome on the patient. To add being probed and prodded by more hands for purposes other than his or her health... It kind of boggles my mind that some of you are so removed from understanding this, ethically.

Geesh, and I think I'm unfortunately stellar at objectification.

 

[DermViser]

You make the most nonsense extrapolations at every turn. I don't think you can even be fixed. It's like some intrinsic flaw, right?

When you say, "When the phrase "medical trainee" is being used in this thread, are we discussing residents or medical students? I think we all know there's a difference between a resident practicing their intended specialty and a student on a 6 to 8 week rotation. Just want to make sure we're discussing the same thing." --- The point which you missed is that this is IRRELEVANT. Every trainee, resident or med student should know how to do a proper bimanual pelvic exam.

Read here: http://www.ama-assn.org/ama/pub/edu...question-of-month/graduates-being-denied.page
"Secondly, and sadly, US medical graduates have been passed through courses in medical school with inadequate training, despite enormous increases in tuition. Too much of their "clinical" education occurs on simulators or computers. You can pass a clinical surgery rotation without learning how to do a sterile scrub, prep a patient, or suture a wound. Most students pass obstetrics without delivering a single baby and they have never seen a pelvic exam done when they pass gynecology. Sure, they watch from the corner, but that falls short of truly educating them. Most are, however, quite adept at delivering a plastic fetus from a plastic pelvis. It is time to correct this deficiency in our medical education. The "clinical" years need to return to clinical medicine. Graduates should be able to suture, scrub, tie knots, maintain sterile technique, give at least a limited differential diagnosis, and write a progress note or operative report. If you can't do these simple things, you should not be labeled as a physician. Graduates should be able to talk to patients, not input data to manikins. I know that patient safety concerns have driven education away from direct patient care, but all this has accomplished is to defer the patient safety issues until the newly minted physicians finally do encounter real patients in residency. At some point, medicine must be learned by practicing (under supervision) on real patients."

 

[SouthernSurgeon]

So I understand those who feel entitled to use patients as dummies once they've come in for medical care at a teaching hospital, but the reality is...medical education needs to find a way to enhance student learning without assuming the patient's body to be manipulated for learning. Any probing of any kind which is not required for the betterment of the patient is absolutely not "for their care or health". I'm unclear as to whether teaching hospitals are hospitals first or teaching facilities first? There are solutions to enhancing medical education without trampling the right of a patient to not be treated like a specimen.

It seems what a lot of you are suggesting is that the patient should incur the cost of a positive externality...aka a med student's enhancement. Is this like one of those "Pay it forward" type things? You want something fair? Incentivize. Anything else is coercive.

I think you exaggerate the degree to which involving a student traumatizes the patient. I also think you have yet to see the limits to which you can effectively teach/learn clinical medicine without a real live patient involved. Not manipulated. Involved. It is actually quite easy to get patients to buy into the importance of a student's education in most cases.

One of my goals when I am on our emergency general surgery service is to get every student the chance to examine an acute abdomen at least once. Because I want them to actually feel what involuntary guarding is, or what real rebound tenderness feels like, or a real Rovsing's sign. Not some SP going "ooowww" in a sim lab and clenching their abs.

This is, understandably, painful for the patient. It is an extra exam, and they have peritonitis. And yet, 9 out of 10 times, when I discuss with the patient what I would like to do and why, and when I talk through the exam with the student, they agree without concern. I get the patient to buy in to the importance of education. Most of them, despite their discomfort, are actually quite interested. It also helps foster a relationship between the student and the patient - and I then have the student scrub in on the operation, and follow the patient for the duration of their stay in the hospital.

 

[Psai]

You know how the people who know how to do pelvic exams learned how to do it? They did it on patients when they were medical students. It's not for a medical student's benefit, it's for the patients' well-being. I'm not learning all of this information just to stroll around with an M.D. after my name and have flowers lain at my feet. Everything I learn is to benefit the people I will be responsible for treating. People come to see the doctor because there is something wrong with their body. This "probing" as you so indelicately put it is a necessary step in the process of healing. I listen to hearts to know what the heart sounds like so I can figure out what's wrong when the time comes. You know what the incentive is? Better health.

 

[Elisabeth Kate]

The sexualization of the pelvic exam by medical students here astonishes me. I feel like I'm in Pre Allo.

I don't see anyone sexualizing the pelvic exam. What some of us are saying is that some PATIENTS view the pelvic exam, without explicit consent, as a violation. And frankly, that's not an opinion. It's fact.

 

[Anastomoses]

When you say, "When the phrase "medical trainee" is being used in this thread, are we discussing residents or medical students? I think we all know there's a difference between a resident practicing their intended specialty and a student on a 6 to 8 week rotation. Just want to make sure we're discussing the same thing." --- The point which you missed is that this is IRRELEVANT. Every trainee, resident or med student should know how to do a proper bimanual pelvic exam.

Read here: http://www.ama-assn.org/ama/pub/edu...question-of-month/graduates-being-denied.page
"Secondly, and sadly, US medical graduates have been passed through courses in medical school with inadequate training, despite enormous increases in tuition. Too much of their "clinical" education occurs on simulators or computers. You can pass a clinical surgery rotation without learning how to do a sterile scrub, prep a patient, or suture a wound. Most students pass obstetrics without delivering a single baby and they have never seen a pelvic exam done when they pass gynecology. Sure, they watch from the corner, but that falls short of truly educating them. Most are, however, quite adept at delivering a plastic fetus from a plastic pelvis. It is time to correct this deficiency in our medical education. The "clinical" years need to return to clinical medicine. Graduates should be able to suture, scrub, tie knots, maintain sterile technique, give at least a limited differential diagnosis, and write a progress note or operative report. If you can't do these simple things, you should not be labeled as a physician. Graduates should be able to talk to patients, not input data to manikins. I know that patient safety concerns have driven education away from direct patient care, but all this has accomplished is to defer the patient safety issues until the newly minted physicians finally do encounter real patients in residency. At some point, medicine must be learned by practicing (under supervision) on real patients."

Which part of "incentivize" don't you understand? You want to create a community consciousness campaign? Go ahead...no problem with that. Otherwise, I guess we're just gonna have to...uh, coerce patients into letting us learn on them? No. Scary you fail to understand this.

And it is relevant that a proper ob/gyn resident (who may be lacking in the clinical skills you worry so much for) is being discussed vs a rotating student 90% of whom have zero interest in anything involving a vagina or uterus. If you don't see how a patient would see a difference, you're hopeless and I can't do anything for you.

And fyi, my previous comment is in reference to your silly implication that...letting someone do pelvic exams is going to somehow "change" the type of student that does the minimum required on rotations they don't care about. A great student is going to try to learn on every rotation, duh. What kind of backward argument was that anyway?

 

[alpinism]

Right. "in the care of the patient" might be where a lot of this is getting muddled. Not at the whimsy of the attending or for the learning of the student. And if the patient is not adding any extra work to the hospital (and in the case of objecting to a student learning pelvic pathologies by touching said patient), I would suspect a spiteful motivation by anyone refusing that patient.


So I understand those who feel entitled to use patients as dummies once they've come in for medical care at a teaching hospital, but the reality is...medical education needs to find a way to enhance student learning without assuming the patient's body to be manipulated for learning. Any probing of any kind which is not required for the betterment of the patient is absolutely not "for their care or health". I'm unclear as to whether teaching hospitals are hospitals first or teaching facilities first? There are solutions to enhancing medical education without trampling the right of a patient to not be treated like a specimen.

It seems what a lot of you are suggesting is that the patient should incur the cost of a positive externality...aka a med student's enhancement. Is this like one of those "Pay it forward" type things? You want something fair? Incentivize. Anything else is coercive.

The incentive is that at university hospitals, patients typically receive better care from supervising attendings who are leaders in their field using the latest technology.

The main purpose of university hospitals is to train the next generation of physicians. Since neither med students nor residents are board certified in OB/GYN, both would be considered trainees.

 

[alpinism]

The sexualization of the pelvic exam by medical students here astonishes me. I feel like I'm in Pre Allo.

This is what I don't understand. While the patient may unfortunately feel this way due to being uneducated or having a personal bias, for medical students there's nothing sexual about performing a pelvic exam.

I feel like this is appropriate:

 

[Anastomoses]

I think you exaggerate the degree to which involving a student traumatizes the patient. I also think you have yet to see the limits to which you can effectively teach/learn clinical medicine without a real live patient involved. Not manipulated. Involved. It is actually quite easy to get patients to buy into the importance of a student's education in most cases.

One of my goals when I am on our emergency general surgery service is to get every student the chance to examine an acute abdomen at least once. Because I want them to actually feel what involuntary guarding is, or what real rebound tenderness feels like, or a real Rovsing's sign. Not some SP going "ooowww" in a sim lab and clenching their abs.

This is, understandably, painful for the patient. It is an extra exam, and they have peritonitis. And yet, 9 out of 10 times, when I discuss with the patient what I would like to do and why, and when I talk through the exam with the student, they agree without concern. I get the patient to buy in to the importance of education. Most of them, despite their discomfort, are actually quite interested. It also helps foster a relationship between the student and the patient - and I then have the student scrub in on the operation, and follow the patient for the duration of their stay in the hospital.

1. I don't think involving a student would or should traumatize 90% of patients. I've asked a few friends since this thread was made and a few just flat out said they wouldn't entertain a teaching hospital if they knew it was one, unless death was imminent.
2. Let's not take the inability of patients to refuse medical care for granted. I agree with you that many people could be persuaded to allow medical student involvement and I wholeheartedly support this - no...I not only support it, I'm hugely grateful for it.
3. Your strategy is brilliant and as a student I'd be grateful to have someone persuasive and interested in my learning to that degree. First time I saw a goiter I almost leapt onto the patient, bouncing on the balls of my feet wanting to touch her (only slight exaggeration). The IM attending could see the fascination and he told me to relax and hold on. This wasn't even any kind of internal touching but I could easily see how the patient might have felt infringed upon despite consent - I obviously wasn't touching her for her own benefit.

 

[DermViser]

Which part of "incentivize" don't you understand? You want to create a community consciousness campaign? Go ahead...no problem with that. Otherwise, I guess we're just gonna have to...uh, coerce patients into letting us learn on them? No. Scary you fail to understand this.

And it is relevant that a proper ob/gyn resident (who may be lacking in the clinical skills you worry so much for) is being discussed vs a rotating student 90% of whom have zero interest in anything involving a vagina or uterus. If you don't see how a patient would see a difference, you're hopeless and I can't do anything for you.

And fyi, my previous comment is in reference to your silly implication that...letting someone do pelvic exams is going to somehow "change" the type of student that does the minimum required on rotations they don't care about. A great student is going to try to learn on every rotation, duh. What kind of backward argument was that anyway?

No need to "coerce" a patient to learn on them. They sign a consent form at the very beginning in which they acknowledge that they are ok with trainees (residents and medical students being involved in their care). Patient doesn't like it? Fine. Go to a non-teaching hospital that accepts your insurance in which you will only see an attending.

"And it is relevant that a proper ob/gyn resident (who may be lacking in the clinical skills you worry so much for) is being discussed vs a rotating student 90% of whom have zero interest in anything involving a vagina or uterus." ---- Yes, keep being the entitled medical student. Feel free to tell your OB-Gyn resident that since you are not going into OB-Gyn, specifically, you don't need to know how to do it. It's not as if you don't have resident rotators through OB-Gyn. It's not like EM docs, FM docs, Peds (on adolescent women), etc. do pelvics. Yup, the ONLY specialty that needs to know how to do pelvic exams are OB-Gyns.

 

[Anastomoses]

No need to "coerce" a patient to learn on them. They sign a consent form at the very beginning in which they acknowledge that they are ok with trainees (residents and medical students being involved in their care). Patient doesn't like it? Fine. Go to a non-teaching hospital that accepts your insurance in which you will only see an attending.

"And it is relevant that a proper ob/gyn resident (who may be lacking in the clinical skills you worry so much for) is being discussed vs a rotating student 90% of whom have zero interest in anything involving a vagina or uterus." ---- Yes, keep being the entitled medical student. Feel free to tell your OB-Gyn resident that since you are not going into OB-Gyn, specifically, you don't need to know how to do it. It's not as if you don't have resident rotators through OB-Gyn. It's not like EM docs, FM docs, Peds (on adolescent women), etc. do pelvics. Yup, the ONLY specialty that needs to know how to do pelvic exams are OB-Gyns.

I had to debate for 2 minutes whether to just ignore this post or to remind you of how poor you are with logic.

Someone, for the love of all that is good - get this man a book on critical thinking skills + logical fallacies. You are a non-ending well of false dilemma, red herrings, non-sequiturs, and strawmen, post hoc ergo propter hoc every fourth time you post.

 

[DermViser]

I had to debate for 2 minutes whether to just ignore this post or to remind you of how poor you are with logic.

Someone, for the love of all that is good - get this man a book on critical thinking skills + logical fallacies. You are a non-ending well of false dilemma, red herrings, non-sequiturs, and strawmen, post hoc ergo propter hoc every fourth time you post.

You just aren't getting it. Never mind.

 

[Anastomoses]

You know how the people who know how to do pelvic exams learned how to do it? They did it on patients when they were medical students. It's not for a medical student's benefit, it's for the patients' well-being. I'm not learning all of this information just to stroll around with an M.D. after my name and have flowers lain at my feet. Everything I learn is to benefit the people I will be responsible for treating. People come to see the doctor because there is something wrong with their body. This "probing" as you so indelicately put it is a necessary step in the process of healing. I listen to hearts to know what the heart sounds like so I can figure out what's wrong when the time comes. You know what the incentive is? Better health.

No, communist...that's not how it works.

In legal mumbo jumbo, you are asking the patient to shoulder the burden of a positive externality - which seems to be a popular emotional argument in this thread. How will your learning from this case benefit this particular patient? How did you arrive at them as being the ones to involuntarily pay this price?

If they volunteer, we should be grateful. If they want to better us and their community by offering consent, I applaud this. The overentitlement is kind of scary. I'm beginning to wonder whether we should really be included with the intelligentsia. Maybe doctors have no business making policy.

 

[Psai]

You don't understand communism.
Also, this is how the doctor patient relationship works. It's not entitlement to have an understanding that patients are there to get better and doctors are there to learn and treat. Patients get better because doctors trained. Doctors train by learning from patients. This is how it works. I'm not sure why you're having trouble with this, especially as a medical student.

 

[boogaloo]

And it is relevant that a proper ob/gyn resident (who may be lacking in the clinical skills you worry so much for) is being discussed vs a rotating student 90% of whom have zero interest in anything involving a vagina or uterus. If you don't see how a patient would see a difference, you're hopeless and I can't do anything for you.

Guess I'm part of the 10%. I have a lot of interest in things that involve those body parts.

 

[Wordead]

The only time I placed foleys (a handful of times), I got permission beforehand. Name me one med student who walks in and stitches a face or neck without permission. I suppose on a surgery rotation, that question might be relevant, but I didn't deal with face or neck injuries on my surgery rotation. The only time I encountered a patient who needed stitches on the face was in my ER rotation and you better believe I asked permission before I touched them.

I placed foleys and cut/closed face lacs a bunch of times....I highly doubt the attending even brought it up with the patient. Even awake foleys it wasn't "can my med student do it", it was "he's going to place a foley now".

I don't see anyone sexualizing the pelvic exam. What some of us are saying is that some PATIENTS view the pelvic exam, without explicit consent, as a violation. And frankly, that's not an opinion. It's fact.

Are you wanting an explicit line in the consent form or for every attending to bring it up orally? I'd be in full agreement with a line in the consent form discussing the pelvic, but having every attending bring it up would contribute nothing to patient care and add a ****-ton of time.

Which part of "incentivize" don't you understand? You want to create a community consciousness campaign? Go ahead...no problem with that. Otherwise, I guess we're just gonna have to...uh, coerce patients into letting us learn on them? No. Scary you fail to understand this.

And it is relevant that a proper ob/gyn resident (who may be lacking in the clinical skills you worry so much for) is being discussed vs a rotating student 90% of whom have zero interest in anything involving a vagina or uterus. If you don't see how a patient would see a difference, you're hopeless and I can't do anything for you.

And fyi, my previous comment is in reference to your silly implication that...letting someone do pelvic exams is going to somehow "change" the type of student that does the minimum required on rotations they don't care about. A great student is going to try to learn on every rotation, duh. What kind of backward argument was that anyway?

You realize that providing incentives is extremely unethical because then we would only practice on poor people, right? That's like bioethics 101.

 

[DermViser]

I'm not sure this is about sexualization but about invasiveness for reasons that don't pertain to a patient's health. Any procedure is already cumbersome on the patient. To add being probed and prodded by more hands for purposes other than his or her health... It kind of boggles my mind that some of you are so removed from understanding this, ethically.

It's like you're purposefully being obtuse. Congrats. Nearly everything a medical student does does not pertain to the patient's health. That's not the objective. If this was the case, medical students wouldn't even be rotating. I don't think you actually understand what MS-3 clerkship rotations for med students are for. Hint: It's not just to shadow and play doctor. If this is how clerkships are run (which happens at a lot of D.O. school rotations) then your medical school is doing you a disservice.

 

[DermViser]

You know how the people who know how to do pelvic exams learned how to do it? They did it on patients when they were medical students. It's not for a medical student's benefit, it's for the patients' well-being. I'm not learning all of this information just to stroll around with an M.D. after my name and have flowers lain at my feet. Everything I learn is to benefit the people I will be responsible for treating. People come to see the doctor because there is something wrong with their body. This "probing" as you so indelicately put it is a necessary step in the process of healing. I listen to hearts to know what the heart sounds like so I can figure out what's wrong when the time comes. You know what the incentive is? Better health.

And this is what attendings are talking about, when they refer to the quality of med students going down. They know very well that medical students are not allowed to actually do things, and med students are content with not doing it bc it's "icky" and believe that it's ok bc they read it out of Bates.

 

[Elisabeth Kate]

It's like you're purposefully being obtuse. Congrats. Nearly everything a medical student does does not pertain to the patient's health. That's not the objective. If this was the case, medical students wouldn't even be rotating. I don't think you actually understand what MS-3 clerkship rotations for med students are for. Hint: It's not just to shadow and play doctor. If this is how clerkships are run (which happens at a lot of D.O. school rotations) then your medical school is doing you a disservice.

Whoa, where did you learn that clerkships at "a lot of DO schools" involve just shadowing? Let's stay on-topic here and not throw in erroneous unrelated beliefs and try to pass them off as facts.

 

[DermViser]

Whoa, where did you learn that clerkships at "a lot of DO schools" involve just shadowing? Let's stay on-topic here and not throw in erroneous unrelated beliefs and try to pass them off as facts.

It is well known that D.O. schools (esp. new ones) have their MS-3 rotations at community (non-university) private hospitals, which since they are suburban community private hospitals, don't allow their students to do much. It's more shadowing than anything else in which students don't write notes, etc. D.O. schools don't have their OWN hospitals so standardizing proper grading is near impossible without offending that hospital and no longer being a teaching facility.

That's why ACGME allopathic residencies are reluctant to take DO graduates as their first choice.

 

[Elisabeth Kate]

It is well known that D.O. schools (esp. new ones) have their MS-3 rotations at community (non-university) private hospitals, which since they are suburban community private hospitals, don't allow their students to do much

Just because their students rotate at community hospitals does NOT mean they don't do much. Quit making crap up and passing it off as fact. You have no idea what you're talking about.

t's more shadowing than anything else in which students don't write notes, etc.

100% false.

D.O. schools don't have their OWN hospitals so standardizing proper grading is near impossible without offending that hospital and no longer being a teaching facility

Wait a minute, is third year grading standardized at U.S. allopathic schools???? Because if so, I'm guessing the vast majority of third years missed that memo.

That's why ACGME allopathic residencies are reluctant to take DO graduates as their first choice.

And yet, 78% of DOs who want allo residencies get one.

 

[NickNaylor]

I will give a personal example as to how this is relevant.

I have absolutely zero interest in doing OB/GYN. Nothing would make me happier than never examining a vagina again in my life. As a future psychiatrist, I clearly fall in the "90% of students who have no interest in OB/GYN.

And yet, I will be doing a minimum of 3 months of general medicine during my intern year. I imagine I will be doing at least one pelvic exam on a real live patient during that time, if not more. How am I serving the patient well if I have never had the opportunity to practice these skills? What happens when it's ultimately me that's responsible (to an arguable degree) for making sure the patient is receiving adequate care? I'll be sure to tell the OB/GYN resident I consult, "sorry guys, this patient is complaining of abdominal pain and has a history of ovarian pathology but unfortunately my medical school failed to give me the skills necessary to do a proper pelvic exam. Can you please come examine this patient for me?"

I don't think anyone fails to recognize patient rights on this issue. But at the same time, I'm going to be a goddamn doctor and I need to competent in these exams if only to perform my duties as an intern. My school has an obligation to give me a basic level of training to adequately perform in that role. It's not because I'm a medical student and I deserve it. It's because there will soon be a time when the buck stops with me and I will be expected to do these things.

With the exception of Elizabeth, I think it's interesting that those arguing the opposite point in an exceptionally vocal way are still preclinical students if I remember correctly. I probably would've thought the same way. But at some point a few months ago, I had an epiphany and realized, "holy ****, someone is going to entrust me fully with their medical care, and doing a substandard job could negatively affect them... forever." Perhaps once you have this realization your opinion will change, or maybe not, I dunno. But it's something worth considering that, as Derm said, I don't think some of you are really "getting." Or in reading your posts it doesn't come across that way.


Sent from my iPhone using Tapatalk

 

[DermViser]

I will give a personal example as to how this is relevant.

I have absolutely zero interest in doing OB/GYN. Nothing would make me happier than never examining a vagina again in my life. As a future psychiatrist, I clearly fall in the "90% of students who have no interest in OB/GYN.

And yet, I will be doing a minimum of 3 months of general medicine during my intern year. I imagine I will be doing at least one pelvic exam on a real live patient during that time, if not more. How am I serving the patient well if I have never had the opportunity to practice these skills? What happens when it's ultimately me that's responsible (to an arguable degree) for making sure the patient is receiving adequate care? I'll be sure to tell the OB/GYN resident I consult, "sorry guys, this patient is complaining of abdominal pain and has a history of ovarian pathology but unfortunately my medical school failed to give me the skills necessary to do a proper pelvic exam. Can you please come examine this patient for me?"

I don't think anyone fails to recognize patient rights on this issue. But at the same time, I'm going to be a goddamn doctor and I need to competent in these exams if only to perform my duties as an intern. My school has an obligation to give me a basic level of training to adequately perform in that role. It's not because I'm a medical student and I deserve it. It's because there will soon be a time when the buck stops with me and I will be expected to do these things.

With the exception of Elizabeth, I think it's interesting that those arguing the opposite point in an exceptionally vocal way are still preclinical students if I remember correctly. I probably would've thought the same way. But at some point a few months ago, I had an epiphany and realized, "holy ****, someone is going to entrust me fully with their medical care, and doing a substandard job could negatively affect them... forever." Perhaps once you have this realization your opinion will change, or maybe not, I dunno. But it's something worth considering that, as Derm said, I don't think some of you are really "getting." Or in reading your posts it doesn't come across that way.

Sent from my iPhone using Tapatalk

You forget - preclinical med students already know based on their vast experience what is necessary and what is not, what is tested on the boards (a.k.a. anything in First Aid or a board review book) and what is not, and what clinical experiences are necessary and what is not, based on their preordained specialty that they've already selected for themselves.

 

[DermViser]

Just because their students rotate at community hospitals does NOT mean they don't do much. Quit making crap up and passing it off as fact. You have no idea what you're talking about.



100% false.



Wait a minute, is third year grading standardized at U.S. allopathic schools???? Because if so, I'm guessing the vast majority of third years missed that memo.



And yet, 78% of DOs who want allo residencies get one.

The percentage of DO students who pursue ACGME residencies in the first place is small - the very slim subsection who take the USMLE and COMLEX. 78% of an already small group is an even smaller number.

I didn't say it's standardized across all medical schools. I said it's standardized at one medical school bc the faculty at that hospital are direct faculty at the medical school many of whom get involved in curriculum development.

This may not be the case at your ostepathic medical school which is much more established and has built a track record.

 

[Elisabeth Kate]

The percentage of DO students who pursue ACGME residencies in the first place is small - the very slim subsection who take the USMLE and COMLEX. 78% of an already small group is an even smaller number.

Actually, it's more like half of DO students pursue an ACGME residency and not all of them take the USMLE.

I didn't say it's standardized across all medical schools. I said it's standardized at one medical school bc the faculty at that hospital are direct faculty at the medical school many of whom get involved in curriculum development

You forget that some allopathic schools don't send all their students the same hospital either. In fact, some send their students to "community hospitals" as well and sometimes, those allo students work side-by-side with DO students in 3rd and 4th year.

This may not be the case at your ostepathic medical school which is much more established and has built a track record.

It's not the case at the majority (if not all) of osteopathic medical schools. In the interest of not derailing this thread any further, PM me or start a new thread if you want to discuss this further. I just couldn't let your erroneous statements stand without a rebuttal.

 

[Winged Scapula]

I don't see anyone sexualizing the pelvic exam. What some of us are saying is that some PATIENTS view the pelvic exam, without explicit consent, as a violation. And frankly, that's not an opinion. It's fact.

I agree that patients can view it that way which is why I said I felt like I was in Pre- Allo (ie, amongst the uneducated). Believe me, I'm sensitive to that and have even spearheaded a change in hospital policy here which had required all patients to remove their underwear, even if having short outpatient non Foley requiring, non pelvic surgery.

My sense is that there is a lot of inflammatory language used in this thread by medical students describing the exam as "poking and prodding", etc, calling the genitalia "private parts", all which imply some childish sexualization IMHO.

 

[DermViser]

I agree that patients can view it that way which is why I said I felt like I was in Pre- Allo (ie, amongst the uneducated). Believe me, I'm sensitive to that and have even spearheaded a change in hospital policy here which had required all patients to remove their underwear, even if having short outpatient non Foley requiring, non pelvic surgery.

My sense is that there is a lot of inflammatory language used in this thread by medical students describing the exam as "poking and prodding", etc, calling the genitalia "private parts", all which imply some childish sexualization IMHO.

They didn't use the proper Scrubs term, "bajingo".

 

[Psai]

You forget - preclinical med students already know based on their vast experience what is necessary and what is not, what is tested on the boards (a.k.a. anything in First Aid or a board review book) and what is not, and what clinical experiences are necessary and what is not, based on their preordained specialty that they've already selected for themselves.

 

[DermViser]

Not you. Certain posters here.