pelvic exam on anesthetized women

[BrooklynDO]

Let me preafce my further statements by this:
1. I hate lawyers. I hate the way they make their living, for the most part.
2. My best friend is a DA (lawyer if you dont know).
3. the above are mutually non-exclusive
therefore anything i may say about lawyers is to be taken in that light. Yes , I am biased.

The basic topic seems to be, essentially :" What procedures should the medical student be allowed to perform?"

There is a huge issue currently with medical students doing procedures for edification purposes. How else will they learn? If students are not allowed to learn on current patients, then, in oh a decade or two, the ATTENDINGS will never have had the chance to perform basic procedures. Before someone answers with the rebuttal that there are usually enough willing patients, etc, let me just say that as a medical student it is very easy to wind up in a hospital where you dont learn anything hands on because most of the community has certain religious or ethical etc beliefs. Now I dont have anything against respecting religious beliefs, I am just making a point that it is very obvious that a student may become a doctor and never having done a pelvic exam. This shouldnt be the case since our licenses are general ones.
As to the point that all of these things can be learned during residency : when you keep bumping up procedures to the "next level" you have surgical chief residents who have never done a whipple, etc. also, I have seen plenty of interns (DOCs!!) screw up simple things like pelvics, bloods, foleys (Ripping the urethra!) because they didnt do enough of those simple things as students, but are now expected to do them on their own.

Please note, i did not address the issue of consent. I believe all procedures should have adequate consent, unless they are immergent, etc. It is also not ok in my book to do have more than one or two students do "practice runs" on one patient. However, if there is a pathology that can be palpated... the student who is going to become and FP, etc ad naseum, should have a chance to palpate a rectal, vaginal, etc mass, etc, even if he will never step into the OR again... this one experience may save a future patient's life.

Delchrys : the basic reason a lot of docs or medtards hate lawtards and liers (the degreed form of lawtard) is that here we have one profession which seeks to and does impose practice restrictions, whether through case law or through a strong influence in the legislature, on another entirely different profession. Also, assuming you have taken some med law courses, you do know this : legally , doctors have no rights... they only have responsibility... this is a very tricky situation to live in. For example : if an insurance company fails to agree to pay for a patient's medication for some reason, it is required that the doctor provide his service as well as the required medication for free. Basically , the doctor pays to do his job.
In this situation, the company that refused to pay for treatment for this patient can not be sued in any way/shape . the doctor , however can!
he is now left with the option of providing free treatment at his own expense, or be sued for malpractice or patient abandonment. What other profession REQUIRES service to be provided at a cost to the one providing the service. I know that lawyers often do some cases pro bono, this is not equivalent however, because they can choose which ones to do pro bono. A doc has no similar choice.

Also, on a totally different topic, i feel that most lawyers were once pre med and couldnt get in (esp those who work in med law). I also think that most lawyers are scumbags, its a pre-req .

---

Members don't see this ad.

 

[delchrys]

1) brooklynDO, your post was very entertaining (seriously)--i enjoy someone who can use humor and sarcasm rather than vomit bile and venom in the more mundane (and boring!) style of some other posters.

2) we share the same opinion of lawyers. i possibly hate them more, since i deal with them more.

3) i never applied for med school, but i will probably go to med school (DO school being my preference) once my loans are all paid off (120k...8 years?).

4) my point is not that the multiple-student-exams are bad, it is that multiple-student-exams without consent are shady. there is no orifice more sacred to most women. generally, women are willing to give consent to pelvic exams by students; all it takes is asking them. refusing to ask for consent implies one of two things about the physician in question: (1) the physician views her consent as irrelevant--she's getting the exam whether she wants it or not; or (2) the physician doesn't want to ask because they know that the patient would refuse. either way, circumventing the patient's wishes is inappropriate and unethical.

5) lawyers as a whole blah blah blah, i'm not the group, i'm an individual, and my views and goals are generally VERY different from the community of "lawyers" that you might imagine to exist with some massmind governing their behavior. in any event, it is arrogant to presume that ANY profession can be wholly self-governing while consistently acting in the best interests of the product of their work (such as doctors with their patients). notice that not once have i advocated for any particular change to the laws in terms of pelvics. note, too, that several others, some of whom are physicians, have supported the idea that it is highly unethical to have a boatload of students do pelvics on anesthetized women without their consent. all of your doom and gloom projections about a future without students doing pelvic exams are irrelevant, since i don't think a single person on this thread has suggested that they be prohibited; people have only suggested that CONSENT is a necessary element of the process. so, if you object to something, please indicate whether you object to the idea that consent should be required prior to a line of students doing a pelvic on an unconscious woman, or you object to the idea that pelvics should be done by as many students as who want to do the exams on women regardless of consent, because those are the only two positions that have been stated here. oh, and the ever-warm-and-fuzzy "i hate lawyers" stance, which is cute, but 100% irrelevant to the topic at hand.

 

[BrooklynDO]

I am ALL about the cuteness

I wasnt commenting on the specific issue of pelvics, nor do i believe in doing anything without concent.
I was talking about what I feel is a trend lately in medicine : learning to do things later in practice or not at all because of constraints put on the medical profession via the work of the legal profession. I think it is detrimental to our medical education and in the end, to the patient... especially the patient's right to be diagnosed and treated by a competent and hopefully somewhat experienced doctor.

also this statement caught my attention :
in any event, it is arrogant to presume that ANY profession can be wholly self-governing while consistently acting in the best interests of the product of their work (such as doctors with their patients).

Correct me if im wrong, I may be... even tho im a doctor almost... who governs the legal profession? i thought it was lawyers... at least thats what the lawyer teaching my med law class stated.
I understand that the above statement of yours is in response to an implication by me that doctors should be wholly self governing. I did not maen to imply that. In fact, what I did say is that currently doctors are from a legal/practical stand point not the ones who police doctors. sad but true.
also, do you have an opinion on this situation that i mentioned :
: legally , doctors have no rights... they only have responsibility... this is a very tricky situation to live in. For example : if an insurance company fails to agree to pay for a patient's medication for some reason, it is required that the doctor provide his service as well as the required medication for free. Basically , the doctor pays to do his job.
In this situation, the company that refused to pay for treatment for this patient can not be sued in any way/shape . the doctor , however can!
he is now left with the option of providing free treatment at his own expense, or be sued for malpractice or patient abandonment. What other profession REQUIRES service to be provided at a cost to the one providing the service. I know that lawyers often do some cases pro bono, this is not equivalent however, because they can choose which ones to do pro bono. A doc has no similar choice.:::

i am actually interested in what you have to say...you may be defending me some day when i couldnt afford to pay for my patient's operation.

 

[Winged Scapula]

Ok guys and gals...

The tone of this thread is taking a turn which I and the SDN administration does not care for. I believe the thread to be an interesting and valuable topic worth discussing but if the users cannot control the insults and demeaning tones of their threads, this thread will be closed.

The offending parties have been warned by PM and a few temporarily banned from posting.

Thanks for understanding.

 

[OzDDS]

Remember, the discussion is about "a parade of male students doing bimanuls/pelvics on anesthetizes women".

So, it's ok for a parade of female students to do bimanuals/pelvics on anesthetized women? Does, that also go for men having a removal of testicular cancer in a "teaching hospital".. The male students doing rotations through urology can examine and learn, but the female students can't.

Grow up!

 

[EMDrMoe]

So, it's ok for a parade of female students to do bimanuals/pelvics on anesthetized women? Does, that also go for men having a removal of testicular cancer in a "teaching hospital".. The male students doing rotations through urology can examine and learn, but the female students can't.

Grow up!

Oz - I was thinking about this earlier. Should there be a sign in sheet that asks (1) your sex and (2) your sexual orientation, just in case? So many things are regulated and it's sad. If people respected patients as people, regardless of sex or procedure or whatever, I don't think many of these "guidelines" would ever need to be brought up.

 

[Idiopathic]

So, it's ok for a parade of female students to do bimanuals/pelvics on anesthetized women? Does, that also go for men having a removal of testicular cancer in a "teaching hospital".. The male students doing rotations through urology can examine and learn, but the female students can't.

Grow up!

I dont think this is an issue of "growth" as you like to put it, but rather this: There are few more potentially threatening things, in my mind, than being an anesthetized female examined by numerous male students (admittedly, an overstatement). It is one of the few day-to-day medical activities that would qualify as assault outside of a hospital. Yes, even if we changed the sex of either/both parties, the situation would be the same. The OP did factor sex into the equation, but I think this applies to both sexes, personally. I think that it is less of a 'violation' to have someone examine my penis, but I cant speak for females (and their penises).

 

[Doc Ivy]

I dont think this is an issue of "growth" as you like to put it, but rather this: There are few more potentially threatening things, in my mind, than being an anesthetized female examined by numerous male students (admittedly, an overstatement). It is one of the few day-to-day medical activities that would qualify as assault outside of a hospital. Yes, even if we changed the sex of either/both parties, the situation would be the same. The OP did factor sex into the equation, but I think this applies to both sexes, personally. I think that it is less of a 'violation' to have someone examine my penis, but I cant speak for females (and their penises).

I beg to differ with you, a lot of what goes on in the room between you and the patient, even just the questions you ask etc, would probably be grounds for sexual harrassment outside of that room... the physician-patient relationship is unique and by definition very personal and private. That is no more true when you ask someone about their drinking habits than it is when you do a rectal exam, that assumption made, to even think that a medical professional would do an internal exam purely for lascivious purposes is to forget that we respect EVERY encounter with a patient, no matter how "innocent" it may be.

 

[Ypo.]

my point is not that the multiple-student-exams are bad, it is that multiple-student-exams without consent are shady. there is no orifice more sacred to most women. .

I never considered my "orifice" to be sacred, just private.

And I for one would not want a parade of residents doing pelvic exams on me while I was under anesthesia. I don't mind one or two-but I actually would prefer to be notified before it happened.

 

[TX OMFS]

Delchrys : the basic reason a lot of docs or medtards hate lawtards and liers (the degreed form of lawtard) is that here we have one profession which seeks to and does impose practice restrictions, whether through case law or through a strong influence in the legislature, on another entirely different profession.

it is arrogant to presume that ANY profession can be wholly self-governing while consistently acting in the best interests of the product of their work (such as doctors with their patients).

Correct me if im wrong, I may be... even tho im a doctor almost... who governs the legal profession? i thought it was lawyers... at least thats what the lawyer teaching my med law class stated.

I'll attempt to tone done my mud slinging at the moderators request. I honestly do enjoy getting into childish arguements on the internet, though, because here you can say stuff you couldn't say in the real world. It appears that our lawyer friend takes things much more seriously than he claimed in a previous post.

Now, as for the above quotes, these points can't be overemphasized. Who governs the legal profession? What an awesome question.

Has anyone else had a similar experience on their ob/gyn clerkship?

Back to the OP. I still maintain that there is nothing wrong with students doing pelvics on anesthetized pts. I don't think the entire class should do a pelvic on the same woman, but there's no problem with the one or two students in the room doing it.

For me personally, as I previously stated, I avoid doing anything during this rotation b/c I'll never use the skills again so why make these women my lab rat? I'm trying to see at least one of each procedure for my education, but otherwise I try not to even go into the room unless it's just to do a history or a annual exam that won't be repeated.

Maybe my situation is different since I'm already a resident and don't have to impress anyone. Either way I don't care if a student wants to do a bimanual on every woman in the clinic. That's why you pay tuition.

 

[Ypo.]

Back to the OP. I still maintain that there is nothing wrong with students doing pelvics on anesthetized pts. I don't think the entire class should do a pelvic on the same woman, but there's no problem with the one or two students in the room doing it.

.

Of course its necessary for residents/students/interns to learn how to perform procedures-otherwise we wouldn't have any future doctors.

But what about informed consent? At a teaching hospital you expect that less experienced doctors will be working on you- but certain things (such as pelvic examination under anesthesia) should be made aware to the patient.

 

[TX OMFS]

Of course its necessary for residents/students/interns to learn how to perform procedures-otherwise we wouldn't have any future doctors.

But what about informed consent? At a teaching hospital you expect that less experienced doctors will be working on you- but certain things (such as pelvic examination under anesthesia) should be made aware to the patient.

Sure it's nice to tell the woman, but what are you going to do when you're in the room and the attendings orders you to do the exam? Run over and check the consent, then refuse if the situation isn't noted on the consent? Besides, how to you as a student know the woman wasn't warned? At our school we're rarely involved in the consent process. I think there's something to be said for implied consent.

 

[Ypo.]

What would I do in that situation? I would follow the laws of that state. I think someone else posted that currently only California requires informed consent for pelvics under anesthesia.

However, that is not to say that other states shouldn't follow suit.

 

[Idiopathic]

I beg to differ with you, a lot of what goes on in the room between you and the patient, even just the questions you ask etc, would probably be grounds for sexual harrassment outside of that room... the physician-patient relationship is unique and by definition very personal and private. That is no more true when you ask someone about their drinking habits than it is when you do a rectal exam, that assumption made, to even think that a medical professional would do an internal exam purely for lascivious purposes is to forget that we respect EVERY encounter with a patient, no matter how "innocent" it may be.

What is this about? I think that I have at least as much grasp of the physician-patient relationship as you, but I dont think you have as much grasp of what I was saying as you think you do. Nobody is suggesting that any lascivity is going on here, but does there have to be intent for there to be harm? If you found out later on that you were examined by no fewer than 6 people, how would you feel. What if the exam was a lap-chole, but "since you were out", a pelvic was done anyway. What does that do to the physician-patient relationship?

 

[OzDDS]

Now, as for the above quotes, these points can't be overemphasized. Who governs the legal profession? What an awesome question. .

That's exaclty what we need.. Lots of Lawyers controlling the direction of medicine in the US. Haven't they done enough damage as it is?

Please oh please.. can't we have 10 more John Edwards.. or how about 50. That would help out medicine so much. Thanks!


http://www.washingtontimes.com/national/20040816-011234-1949r.htm

 

[rxfudd]

I am somewhat surprised that people who study medicine on a daily basis cannot get over the fact that a vagina is a part of the human body as much as a liver or a kidney. If you were on a surgical rotation, you would not think twice about palpating these structures pre-operatively if they were the central focus of the surgery to be performed. Why is it so unusual for the same to be said of the cervix, vagina, ovaries, etc? I expect the layperson to have hangups about genitalia, but not medical students.

 

[Ypo.]

Well, I don't think anyone has a hard time realizing the vagina is part of the female body.

The issue at hand is whether or not its OK to have a whole bunch of doctors do a pelvic exam on a patient who is under anesthesia-without her informed consent.

It'd be nice to know, but hey-surgery is invasive, period.

 

[rxfudd]

But that's my point - this is only an issue if you think of female genitalia and reproductive organs as being obviously different and "off limits" as compared to the rest of the body. This is fine from the point of view of the patient, and if she says she doesn't want students involved in her care, that is one thing. But if she has been seen by students the whole time up until the point of her surgery, I see no problem allowing those students to continue in her care just as a resident or attending would. And seriously, maybe this is just at my hospital, but I have never seen more than two students involved in an OR case at a time. I'm sure it happens here and there, but usually you have so many residents and attendings in on a case that more than one or two students isn't even feasible.

I would hope you would find it unusual if only 1 out of 3 or 4 people in a gen surg case palpated a mass in the colon or liver before resection. It is beyond me why the cervix or vagina should be any different.

 

[Idiopathic]

This is fine from the point of view of the patient, and if she says she doesn't want students involved in her care, that is one thing.

So do you give her a choice? Or do you wait for her to bring it up? I think that is what is at issue here. The woman doesnt know, and if she did, I would wager that most would not be terribly pleased about it.

 

[rxfudd]

This really is a lot more simple (or should be) than you would imagine from reading this thread. There are three basic ways students pick up patients: you see them for the first time in the clinic, on in-patient service, or in pre-op. No matter which of these scenarios I'm in, my opening line to every patient I see is "Hi, I'm rxfudd, I'm a medical student with the team taking care of you and I'll be involved in your care." If at that point she says anything that sounds like "I don't want a student working on me", then it's a done deal - I tell my resident, and I go find another patient (of which there are many at most busy hospitals). If she says "Ok" or "Nice to meet you" or even nothing at all, I consider her to have agreed to allow me to take part in her care the same as anyone else on the team, and I feel fully justified performing the same exams and procedures as anyone else on the team. I don't think that you need signed consent to take part in patient care as long as it is within the realm of modern medical education and practice (or if it's required by law, obviously).

Look, we aren't doing these exams for kicks. If you're going into OB, that's one thing - you'll have the rest of your life to fine-tune what I believe is the most difficult exam there is to perform in routine healthcare. However, if you're like me and going into something like EM, this is your only shot to get it right before it is expected that you know it cold. If someone agrees to let you perform an exam on in-patient service or in a clinic, that's great, but it is frankly not the optimal scenario to learn the exam for the many reasons outlined above. If I have an opportunity in the OR to both 1) appreciate the anatomy/pathology that has put this patient in the OR in the first place, and at the same time 2) further develop my clinical skills - and if the patient has never objected to a student taking part in her care - I have absolutely no qualms about furthering my education for the sake of future patients during residency and beyond. Once I designate myself as being part of the team, I consider myself to have the same extent of care as others on the team (up to what they allow me, of course). All she has to do is tell me at any point that a student is not welcome, but I'm not going to obsess about it the entire time I'm working with her.

 

[Ypo.]

But that's my point - this is only an issue if you think of female genitalia and reproductive organs as being obviously different and "off limits" as compared to the rest of the body..

They are obviously different! You've got to look at patients as more than just a set of organs!-because they certainly look at themselves that way! All I'm saying is that informed consent might be a good thing. I don't mind students putting their hands in private places whil I"m under anesthesia-but I would want to know!!!

Really!

This is fine from the point of view of the patient, and if she says she doesn't want students involved in her care, that is one thing. But if she has been seen by students the whole time up until the point of her surgery, I see no problem allowing those students to continue in her care just as a resident or attending would.

I agree with this point-as long as the patient knows what they are getting into, its fine. But they SHOULD at least know!

 

[rxfudd]

I don't necessarily think that looking at patients as both patients and examples are mutually exclusive. I imagine most of my residents and attendings would say that when I'm with a patient at the bedside, I am as respectful and compassionate as you would want someone who is involved in your care to be. At the same time, I'm the first to admit that if my patient has pathology to appreciate (adnexal masses, fibroid uterus, etc), I want to learn from it hands-on rather than from across the room. Of course patients aren't just a set of organs, but that doesn't change the fact the Mrs. X the person also happens to have clinically interesting or unique pathology/anatomy.

I still don't see how palpating a liver or colon cancer is so different from palpating a cervical cancer. I feel that if you don't come away from OB with the understanding that genitalia and reproductive organs are no different from (and deserve no less attention to or experience with) the rest of the human body, you have not gotten out of OB what you need to. I understand that patients don't necessarily see things this way, and if they really object that's fine. But otherwise, I really don't see the ethical dilemma. Nothing is going to change the fact that the cervix, uterus, and adnexa are only accessible in the clinic or ER via the vagina. If we're going to actually learn how to catch any of these diseases, we need to learn how to identify them somewhere, and for most of us it is on our OB rotation.

 

[Harrie]

I always thought this was a very interesting issue. When I was on my OB/Gyn rotation, before the student was allowed to do an exam under anesthesia the nurses would run around the room trying to find out if the patient had signed the consent (a little box on the consent allowing or disallowing a student to do an exam). However, nobody asked the patient if it was okay for a student to make the incision, or suture, or anything else. I don't know about you, but I'd much rather have an inexperienced student stick two fingers into an orifice while I'm asleep than take a sharp knife to my skin...just my opinion.

 

[MustafaMond]

duke does a lineup of students, 4-6 in a row, for pelvics on anesthetized women.

Medschool gang-bang... :

 

[14022]

I don't know about you, but I'd much rather have an inexperienced student stick two fingers into an orifice while I'm asleep than take a sharp knife to my skin...just my opinion.

What about a sharp knife into an orifice?

 

[Ypo.]

I still don't see how palpating a liver or colon cancer is so different from palpating a cervical cancer. I feel that if you don't come away from OB with the understanding that genitalia and reproductive organs are no different from (and deserve no less attention to or experience with) the rest of the human body, you have not gotten out of OB what you need to. .

Just because you respect the fact that human beings place a different emphasis on their sexual organs than on other organs in their bodies, does NOT mean that as a doctor you will (or should) be spending less attention on or gaining less experience with these organs. But if you treat a papsmear the same as looking down a persons throat-you are going to get some offended patients.

 

[rxfudd]

But if you treat a papsmear the same as looking down a persons throat-you are going to get some offended patients.

I'm not quite sure why you keep taking this idea to such an extreme, I think my points have actually been directly opposite to this statement.

 

[rxfudd]

Just because you respect the fact that human beings place a different emphasis on their sexual organs than on other organs in their bodies, does NOT mean that as a doctor you will (or should) be spending less attention on or gaining less experience with these organs.

And now that I look at this statement, I don't think this is always true either. As someone pointed out above, you could feasibly go through an entire rotation without getting adequate experience performing a routine pelvic exam if you do not take every opportunity to do so. In my opinion, this is both spending less attention and gaining less experience.

Again, I think medicine (and particularly OB-GYN) is a field where it is essential to be able to differentiate between the patient being a person and the patient being a case or example and be able to go back and forth between the two. Too far to one side or the other, and either you're going to be disliked or incompetent. Declining to perform EUA, especially when you have been taking part in the patient's care, is too far to the latter IMHO.

 

[Ypo.]

And now that I look at this statement, I don't think this is always true either. As someone pointed out above, you could feasibly go through an entire rotation without getting adequate experience performing a routine pelvic exam if you do not take every opportunity to do so. In my opinion, this is both spending less attention and gaining less experience.

Wow, I guess I don't see your point. Is it that much more difficult to notify the patient that they will be recieving a pelvic from their doctor and a resident? I certainly think its worth taking the time...or maybe we don't take the time because we're afraid the patient will say no?

 

[Ypo.]

I'm not quite sure why you keep taking this idea to such an extreme, I think my points have actually been directly opposite to this statement.

I think we both agree that residents need to spend adequate time on both sexual and nonsexual organs...to ensure good patient care this is necessary.

I just think that patients have a right to know what procedures are going to be performed on them (sexual/nonsexual organs) while they are under anesthesia, and by whom.-no matter how much of a nuisance this is to doctors.

Because of the special views that people have towards their sexual parts, I think informed consent is important.

I'm really tired of this thread so I'm just going to let this die now-its a difference of opinion-and seeing how I am not even in medical school, my views may change once I get there.

But I hope not.

 

[TX OMFS]

I always thought this was a very interesting issue. When I was on my OB/Gyn rotation, before the student was allowed to do an exam under anesthesia the nurses would run around the room trying to find out if the patient had signed the consent (a little box on the consent allowing or disallowing a student to do an exam). However, nobody asked the patient if it was okay for a student to make the incision, or suture, or anything else. I don't know about you, but I'd much rather have an inexperienced student stick two fingers into an orifice while I'm asleep than take a sharp knife to my skin...just my opinion.

Harrie, EXCELLENT POINT. Also, ever notice how good nurses are at running around the room? Finally, consent is always good and I can't argue that having consent is better than not, but if there isn't consent it not that big a deal. If an attending and his assistant (resident) can do the exam, you're in a teaching hospital, it's blatently obvious students are around, it's hard to make a point that we need expressed written consent for the student to do the exam. Unless you think pt's are stupid, which is another debate entirely.

 

[jhadow]

They are obviously different! You've got to look at patients as more than just a set of organs!-because they certainly look at themselves that way! All I'm saying is that informed consent might be a good thing. I don't mind students putting their hands in private places whil I"m under anesthesia-but I would want to know!!!

Informed consents are a tool thought up by lawyers, written by lawyers, and argued by lawyers in court.

They're not about ethics; they're about trying to save your butt in a tort action.

Instead of arguing about the IC -- argue about concern for the patient.

Have a BAD bimanual exam, speculum insertion, uretheral swab, hernia check, IV insertion, blood draw, etc... and then wonder why your caregiver wasn't "better" trained.

This situation is a win-win. The pt isn't hurt; the student becomes a better trained future doctor.

J.

 

[Ypo.]

Informed consents are a tool thought up by lawyers, written by lawyers, and argued by lawyers in court.

They're not about ethics; they're about trying to save your butt in a tort action.

Instead of arguing about the IC -- argue about concern for the patient.

Have a BAD bimanual exam, speculum insertion, uretheral swab, hernia check, IV insertion, blood draw, etc... and then wonder why your caregiver wasn't "better" trained.

This situation is a win-win. The pt isn't hurt; the student becomes a better trained future doctor.

J.

I don't think it necessarily has to be a signed informed consent.

I think it is 100% appropriate to let the patient know what procedures are going to be performed and by whom. I think I would-for example-its OK to say "so and so resident will be doing the incision-and I will be standing right there to make sure nothing goes wrong"

 

[Harrie]

I don't think it necessarily has to be a signed informed consent.

I think it is 100% appropriate to let the patient know what procedures are going to be performed and by whom. I think I would-for example-its OK to say "so and so resident will be doing the incision-and I will be standing right there to make sure nothing goes wrong"

YOU HAVE GOT TO BE KIDDING ME!!!
I am assuming by that response that you haven't yet done your clinical rotations. There is no way that anybody would have the time/patience to go through the entire procedure step-by-step and who will be doing each part. And then if the resident gets paged, do you suggest that they stop the procedure until they can return, since the other resident does not have permission to operate??? Give me a break!
Besides, not such a good idea to tell patients "to make sure nothing goes wrong." This does not instill a lot of confidence.

 

[Ypo.]

YOU HAVE GOT TO BE KIDDING ME!!!
I am assuming by that response that you haven't yet done your clinical rotations. There is no way that anybody would have the time/patience to go through the entire procedure step-by-step and who will be doing each part. And then if the resident gets paged, do you suggest that they stop the procedure until they can return, since the other resident does not have permission to operate??? Give me a break!
Besides, not such a good idea to tell patients "to make sure nothing goes wrong." This does not instill a lot of confidence.

*sighs in exasperation*

Whatever -I already said I'm not in medical school yet, let alone clinical rotations.

In light of this, I suppose I should just have kept my uneducated opinions to myself-but its never too early to start thinking about these issues.

However, I still think it is good to explain in lay person's terms whats going to happen to the patient (doesn't "doctos"- mean teacher?)-and to say some reassuring words - such as "I will be there during the operation"-but you are right that those words shouldn't include "nothing will go wrong"-as thats just setting you up for trouble.


But, I still believe my heart is still in the right place on this issue-as far as treating patients with respect-informing them, educating them (one of the roles of a doctor), not forgetting they are more than a set of organs, and that they ascribe special meaning to certain organs...

 

[starayamoskva]

Respect, inform and educate your patients. By all means tell them they will have an exam, if the law requires get a written consent signed. But please, please, please get over this idea that the vagina is some sacred wondrous holy realm. Sex is a normal function of the body, the vagina is an organ just like all the others. I would bet it is much worse (embarrassing/violating) for a man to have a prostate exam!!

Relax, if you behave professionally treat the exam matter of factly and don't get embarrassed yourself and make a big deal about these exams you will find the majority of your patients will be much more relaxed and much less embarrassed about them as well.

Before you slam me, I do understand that there women out there have cultural backgrounds that make this exam far worse than it should be.

 

[vanelo]

*sighs in exasperation*

Whatever -I already said I'm not in medical school yet, let alone clinical rotations.

In light of this, I suppose I should just have kept my uneducated opinions to myself-but its never too early to start thinking about these issues.

However, I still think it is good to explain in lay person's terms whats going to happen to the patient (doesn't "doctos"- mean teacher?)-and to say some reassuring words - such as "I will be there during the operation"-but you are right that those words shouldn't include "nothing will go wrong"-as thats just setting you up for trouble.


But, I still believe my heart is still in the right place on this issue-as far as treating patients with respect-informing them, educating them (one of the roles of a doctor), not forgetting they are more than a set of organs, and that they ascribe special meaning to certain organs...

Stick to undergrads forums where you dont make a fool of yourself

 

[MechE]

Before you slam me, I do understand that there women out there have cultural backgrounds that make this exam far worse than it should be.

At the free clinic I volunteer at we help poor pregnant women. Hispanic women don't want a man anywhere near them when they're having their physicals. White and black women don't seem to care who sees them naked.

 

[Ypo.]

Stick to undergrads forums where you dont make a fool of yourself

Did you read what I said? I fully plan on educating my patients and being sensitive to their cultural beliefs. If that makes me a fool in your eyes, then so be it.

 

[GeoJungle]

Many posters misconstrue the nature of informed consent and also the rules governing medical education.

Informed consent: The patient agrees to the general outline of the procedure(s) only and the common and worst case risks involved. Also she agrees to Dr So and So being the lead surgeon. She does not get to agree or disagree as to each step of the procedure. She does not get to agree as to who the assistant surgeons are or to how much of the surgery they perform. She would agree to anesthesia, but it is up to the professional opinion of the anesthesilogist as to what drugs, when, what needles where, and so on.

She agrees to a possible TAH, possible BSO, possible omentectomy, possible cystectomy, possible colostomy. The physician will do none, some or all of these once he is inside and can make a judgement as to the best course of treatment. Why "none"? Sometimes the neoplasm to too extensive (not uncommon with ovarian ca) and the best choice is to take some biopsies and close immediately. It's up to the treating physician.

Pelvic exams are part of the Standard of Practice in GYO surgery and the doctors scrubbed in the case would be negligent if they FAILED to perform this exam. The implicit permission to do so includes residents and students directly involved in her care because they need to know what is going on to properly TREAT her. Education issues are another subject.

Several delusional posters thought they would sue if not informed as to this subset of standard care was being performed. No chance. The consent form covers this under the general consent, just as it covers, but does not explicitly say the the doctor will be sticking GIGANTIC METAL TOOLS into her vagina and doing rude things to delicate parts with those tools.

This is a matter of settled law and policy, and hospitals don't remotely care about students' opinions on this.

 

[bigfrank]

Die Thread, Die!!!

 

[GenSurg]

A thorough preoperative exam should always be done. In general surgery, we always palpate the abdomen, breast, or whatever we operate on. It is the best time to get a good physical exam. I understand that a pelvic exam is a more private part of the anatomy, but theoretically you could diagnose a tumor in the adnexa when only a vag hyst is scheduled.

http://www.freeiPods.com/?r=20049323

 

[dynx]

But, I still believe my heart is still in the right place on this issue-as far as treating patients with respect-informing them, educating them (one of the roles of a doctor), not forgetting they are more than a set of organs, and that they ascribe special meaning to certain organs...

Save it for the interviews honey.
The road to hell is paved with good intentions and all this touchy feely "wouldn't it be nice if everybody knew everystep of the operation and who would do it" is not how the real world works.
I can't believe that people would question the right of a student (or students) to perform a standard pre-op exam while caring for a patient.

 

[ermonty]

Heres the thing about all of this, and theres really no getting around it. What we as medical professionals (and others in the medical field) think is right, ethically just, and even legally sound matters very little. Unless every possible thing we may do to the patient is disclosed and documented, then we are at the discretion of lawyers to rip us apart should the opportunity arise. So, to do or not to do pelvic exams on anesthetized women can be debated, but lest you get your ass in a sling, it better be discussed, documented, and ok'd by the patient via a general I.C. or otherwise.

 

[nutmegs]

I'm really not about to read through the other 2 pages of this, but I would like to add if it hasn't already been mentioned that at the instituion I was just as, the patient signs a paper stating, among other things,
"I understand this is a teaching institution and that those in the training programs will be participating in my care."

The exam by attendings/residents/some students is not for practice and it is misleading to characterize it as such.

As for the student's exam, if it is for "practice" alone it is unethical, if the student is part of the patient's care team and will be participating in the procedure the exam is done as a provider and acceptable. Whether one person or 2 people do it when it's medically indicated, without causing the patient undue comfort and when they have consented on admission, makes no difference.

Consider this- if one attending did the exam, was unsure, and called another older attending in to check would that be unethical? The first attending in this situation is a student to the more experienced attending. The initals MD do not stop the process of "practicing" anything.

 

[lotanna]

Let me pose a question. I am on gynecological surgery and several different residents and attendings have told me that prior to surgery it is a great idea to perform a pelvic exam on the anesthetized woman in order to get practice. Many have said it is not traumatic to the patient and you get a more technically adequate exam since the patient is not guarding. Sure enough, before every procedure the attending and resident (and I have worked with 6 attendings and 4 residents, both males and females, at two different hospitals, both community and academic hospital) perform a quick pelvic exam.

Is this wrong? The attending does it for one last chance to feel for any previously undiagnosed masses or other abnormalities, but the resident and student do it primarily for educational purposes. The patient has consented to the surgery, but not for the pelvic exam. Does consent to surgery of the uterus, vagina, vulva, ovaries, etc. also imply consent to manual palpation of these structures during the surgery?

Has anyone else had a similar experience on their ob/gyn clerkship?

wow I'ma 2nd yr and we just had this in our small group Ethics discussion last week. WIsh I had seen this tread before hand

 

[LADoc00]

Let me pose a question. I am on gynecological surgery and several different residents and attendings have told me that prior to surgery it is a great idea to perform a pelvic exam on the anesthetized woman in order to get practice. Many have said it is not traumatic to the patient and you get a more technically adequate exam since the patient is not guarding. Sure enough, before every procedure the attending and resident (and I have worked with 6 attendings and 4 residents, both males and females, at two different hospitals, both community and academic hospital) perform a quick pelvic exam.

Is this wrong? The attending does it for one last chance to feel for any previously undiagnosed masses or other abnormalities, but the resident and student do it primarily for educational purposes. The patient has consented to the surgery, but not for the pelvic exam. Does consent to surgery of the uterus, vagina, vulva, ovaries, etc. also imply consent to manual palpation of these structures during the surgery?

Has anyone else had a similar experience on their ob/gyn clerkship?

Hmmmmm, why not practice on your girlfriend if you need it that bad...

 

[njbmd]

The reason I ask is because in another thread people have said that a rectal exam should not be done on a patient by a student unless it is absolutely indicated. And I suggested that when its utility is questionable and the patient consents to the exam then it should be performed, because in an academic hospital students are expected to do these things in order to learn. I guess I do not understand how this is any different. One student performing a rectal exam of questionable utility on one consenting person versus three people performing a pelvic of established utility on an anesthetized women.

Hi there,
If you are doing a history and physical exam on a patient, you should perform a rectal and pelvic exam on the patient. You are not performing these exams for the fun of it but because your patient needs to be thoroughly examined. You do not hesitate to look into a patients mouth or ears so why the hesitation to examine the pelvic organs or rectum?

I have heard of patients with huge rectal tumors that were discovered at the time of surgery because no one bothered to do a simple rectal exam. I have heard of female patients undergoing appendectomies with the findings of a normal appendix but cervical motion tenderness and a vaginal discharge i.e. pelvic inflammatory disease. How would you differentiate between a ruptured ectopic pregnancy on the right, a ruptured ovarian cyst and an inflamed cecum in a woman of childbearing years?

It is not a violation of a patient's rights to examine the pelvic organs or rectum if the patient is anesthetized. Sometimes in cases of anal fissures, it is far too painful to perform these exams without the aid of anesthesia.

You are a professional and should always have the patient's health in the forefront of your mind as you do your history and physical. You explain what you are doing and why you are performing the exams and get them done. One of our favorite saying in General Surgery is that the only reason not to perform a digital rectal exam is that the patient does not have an anus and you do not have a finger.

njbmd

 

[bigfrank]

Die Thread, DIE!!!

 

[MechE]

Die Thread, DIE!!!

I thought this thread did die several times already. I'm always suprised when I see a: "Reply to post 'pelvic exam on anesthetized women'" in my inbox.