Exams Without Consent

[Hudson_Hawk]

Date: 1/28/2010 8:48:00 PM
Author: purrfectpear
''Probing'' is the least of my worries. Here in American hospitals your primary surgeon routinely walks out of the operating room as soon as the surgery is done and asks his/her intern to ''close''. Personally I''m paying the surgeon and I expect them to be there operating as primary from first incision to last stitch.


I think consent should be requested for exams, etc. but then I''m also not one who would give a darn who does the probing and practicing. No one is going to die from a pelvic, unlike an intern that might screw up the close.

True, however it''s a violation of your rights and a violation of the Hippocratic oath (do no harm). The mental anguish and stress that would most likely come from this experience is harmful to the patient, not to mention problems that could occur from a student being too rough or doing something wrong.

You can''t honestly tell me that if you woke up to discover that exams, tests and other procedures had occurred without your knowledge or consent, you''d be ok with it. I don''t believe that for a second PP.

 

[ksinger]

Yeah, my gyno is a teaching doc, and routinely brings in students. I said yes a couple of times but then started refusing. That standing room only feel started to get on my nerves. He stated it clearly in the office, now I can only wonder if he was/is so ethical in the actual operating room when you''re knocked out.

A friend of mine who is an ER doc, said he did poorly in his training in gynecology. Not because he did poorly, but because he got mouthy and challenged the docs he was training under, for their abominable, disrespectful treatment of the women who came in for treatment. His opinion of gynos was that in general they either hated women, or had "issues" with mom. Undoubtedly something of a generalization, but this guy is not unperceptive at all and I trust his observations. I know I personally have encountered docs - gynos and others - who are subtlely disdainful of women...

 

[Shoopy]

I would not be happy about this at all.

 

[basil]

Doing a pelvic exam under anesthesia is a routine part of a lot of gynecological surgery.

In my med school, medical students were expected to introduce themselves to the patients and ask permission to attend their surgery. Of course, the consent forms in all teaching hospitals also have a clause about trainees and students participating in procedures, but the philosophy there is that there should not be anyone in the room whom the patient has not met prior to surgery.

I did not specifically ask women if I could do a pelvic exam while they were under anesthesia. But since the attending physician was going to do one, he/she would often have me perform the exam before or after as a teaching point. I never did, never would have done, and was never asked to do a pelvic exam on someone when it would not otherwise have been performed.

FWIW, I hated doing pelvic exams and I''m so glad I don''t have to do them anymore!!!

 

[drk]

I can't honestly remember what I did a few years back in med school. I know we did learn the pelvic exam on volunteers in small groups. If I did do an exam while the patient was under anesthesia, the only time it would happen was if they were having a hysterectomy that they knew a student was participating in, where palpating the uterine size was a part of planning the surgery.
When learning how to check the dilation of a cervix, med students were only allowed to do it if the patient had an epidural in place, and they were specifically asked each time if they would mind if the student did a check before the resident confirmed it.
Honestly, what pissed me off more was the time at a teaching hospital where the patient I was about to give an anesthetic to asked if the staff surgeon was going to be doing the procedure or at least present. The fellow said he would, and then the staff surgeon never showed his face at all. I specifically reminded them that the patient wanted the staff to be there too, but they ignored me. Grr.

 

[tlh]

This is disturbing and a huge violation of the patients rights. We are granting you consent to do a certain proceedure, not to do anything other than what the patient agreed to. Any Dr that would perform an exam on an unconscious patient who did not give consent is on the same level as a dude having sex with an unconscious female he slipped the date rape drug to. I see no distinction. The lady may have said yes to intercourse, or the exam, but you removed that right from her to REFUSE - until after you violated her - and hoping she might not find out... *after the fact *** DISGUSTING, and I think any DR that did so should lose their license.

 

[Mrs Mitchell]

I''m surprised that most people think this is an issue of ethics and lisencing. For me, this would be a criminal act and the police would deal with it.

 

[ChinaCat]

It''s not that difficult to ask consent. And I probably would give consent in many cases.

Would find it a huge violation of my rights and also an illegal invasion of my privacy. Agree with MrsMitchell on this one.

What I find weird is this part:

?It got me thinking,” Sara Wainberg said. “I had done this numerous times in my training and it had never occurred to me that it might be unethical.”

Seriously? It never occurred to her that doing an invasive exam on an unconscious patient without their consent could be unethical? And then she had to do a poll to find out? Strange for a woman, IMO.

That being said- IF the pelvic exam was a routine part of the surgery, then I''m not sure that I would care who actually performed it during surgery.

 

[Octavia]

Date: 1/29/2010 1:20:25 PM
Author: ChinaCat
It''s not that difficult to ask consent. And I probably would give consent in many cases.


Would find it a huge violation of my rights and also an illegal invasion of my privacy. Agree with MrsMitchell on this one.


What I find weird is this part:


?It got me thinking,” Sara Wainberg said. “I had done this numerous times in my training and it had never occurred to me that it might be unethical.”


Seriously? It never occurred to her that doing an invasive exam on an unconscious patient without their consent could be unethical? And then she had to do a poll to find out? Strange for a woman, IMO.


That being said- IF the pelvic exam was a routine part of the surgery, then I''m not sure that I would care who actually performed it during surgery.

+1.

If my surgery was gynecological in nature, I''d assume a pelvic exam was part and parcel for the procedure and that my surgical consent form covered it (of course, being an almost-lawyer, I''d also read the form if I was in a condition to do so...but I know a lot of people don''t or can''t). As long as only one PE was performed, I really wouldn''t care who did it. If five or six students trooped in and all prodded my parts, I''d be livid if I found out about it, though.

I see it as both an ethics and licensing issue and a criminal act. The two aren''t mutually exclusive.

 

[cara]

Date: 1/28/2010 8:53:34 PM
Author:EBree
Imagine that you are undergoing a fairly routine surgery – say, removal of uterine fibroids or hysterectomy. During or right after the procedure, while you are still under anesthesia, a group of medical students parades into the operating room and they perform gynecological exams (unrelated to the surgery) without your knowledge.

Well this bit is a little odd. Is it the timing of events that makes the exam unrelated to the treatment? It'd be one thing if someone ended up with a gyne exam when they went in for knee surgery, but a hysterectomy? I guess your point is that maybe all the gyne exams happened after the surgery and weren't relevant to the treatment? That's not cool.

I think one thing that is missing here is that a lot of times these extra exams could be conducted under the standard consent form in a teaching hospital. It would make it harder to sue for assault if one signed off on everything, though it would still be unethical if the form wasn't explained properly or they were intentionally misleading women about the extra exams and then having them sign the form.

I would possibly expect more than one pelvic exam if I went in for gyne surgery in a teaching hospital, assuming I'm not in pain or uncomfortable during them, and I was properly consented and informed of whom would be participating in my treatment. Its a bit unreasonable (*) to expect only one exam if more than one medical person is participating in your procedure and its a teaching hospital.

Just for reference, I've had knee issues and often will have 2-3 physical exams by different people all in one visit. Usually just two, one by a physician assistant/resident/fellow, and one by the attending doctor, but I did have a whole troop of students come in once. Obviously less touchy area than gyne, but when done properly the exams would cause me some discomfort. While I would hope that gyne issues would be handled with *more* tact and compassion, some of these horror stories are pretty appalling.

(*)unless that's what you want and ask for. Then its perfectly reasonable!

 

[megumic]

Date: 1/29/2010 1:11:31 PM
Author: Mrs Mitchell
I''m surprised that most people think this is an issue of ethics and lisencing. For me, this would be a criminal act and the police would deal with it.

I''m in this boat too. Assault and battery alarms went off when I read the OP. This is about consent, and if there is no consent, then intentional unconsented touching is present. Ick.

 

[Mrs Mitchell]

Octavia, I think if an act is criminal, it''s gone beyond being a question of ethics.

 

[Amber St. Clare]

If this happened to me I would consider it a form of rape.


And I would consult the authorities about pressing criminal charges.

 

[Octavia]

Date: 1/29/2010 3:12:11 PM
Author: Mrs Mitchell
Octavia, I think if an act is criminal, it''s gone beyond being a question of ethics.

Sorry, I didn''t state my thoughts very well. I meant that the contemplation of something like this is an ethical question and could/should be taught as such -- sort of a "what are your thoughts on this, what are the ramifications for the patient, the doctor, the hospital, etc" discussion. Actually DOING it is where criminality would come in. And while it would seem logical that a criminal conviction should equate to a revocation of license to practice, but I''m not sure this is the case 100% of the time in the US -- maybe one of our docs could say?

 

[icekid]

Add me to the list of former medical students who has never seen or heard of this happening.

At my school, as previously mentioned by basil, the medical students always introduced themselves and mentioned that they would be involved in the care. So if this practice is common in Canada, we can be pretty certain that is NOT the case in the US.

 

[cara]

Since we have not had multiple headline cases where doctors were convicted of assaulting unconscious patients for practicing their pelvic exam skills on them, I think we can assume that this issue does not often make a good case for successful criminal prosecution. It would take witnesses - how would the unconscious patient know? - and those witnesses are probably perpetrators or colleagues of perpetrators. People in medicine are often conservative (small c) and their career success depends on getting along with others. To accuse your colleagues of practicing or abiding by routine sexual assault for an accepted training practice is quite ... outside of the usual decorum for medicine, even for extreme things like this that certainly raise lay people''s hackles and make them want to sue/prosecute/never go to the doctor again.

Also you need the right legal environment to get a conviction. In the US the consent form for most teaching hospitals includes something about the medical trainees. I''m not a lawyer or an expert, but if you sign the piece of paper consenting to treatment in a facility with an education program in place, it might be hard to sue or prosecute someone for assaulting you with an unnecessary procedure if it was done in the course of your treatment and reasonably appropriate, but you got one exam from the attending and one exam from the staff-in-training. Obviously it starts looking worse if you got 10 unnecessary exams instead of one, but legally? If you signed a piece of paper saying it was okay, and the paper was written quite broadly, then it might be hard to prosecute. In Canada, the article mentions that consent to exams by trainees is considered ''implicit'' - this wording sounds a bit like the antiquated wording on marital rape, in that a wife has implicitly consented to sex with her husband by the act of marrying him so it is legally impossible for him to rape her. So perhaps this is another case of outdated language that would make prosecution difficult.

This is why the better approach is educate the public on this unethical practice and change the legal and medical training standards. Which has obviously been done in some places but not uniformly across the world. Write newspaper articles like the one''s Ebree posted so people get up in arms. Get hospitals and medical training programs to post their standards for consenting women to pelvic exams, and doing unnecessary exams on unconscious people. Find out who the medical trainees practice exams on in medical schools and teaching hospitals. Publish articles in the medical literature on how the old practice was/is unethical. Those things do get read and incorporated into policy decisions. On the legal front, you need to pass a law to get rid of the ''implicit'' part of the consent in Canada, and possibly add additional consent requirements, ie. California''s law, that add extra hurdles for pelvic exam consenting of patients. Doctors are quite risk-averse and *will* change their practices if given the proper types of motivation and education. I mean, your average med student is not interested in sexually assaulting women or conducting unethical exams. They are trying to survive their training, and most want to do so in a legal and ethical manner.

 

[ang3199]

Date: 1/28/2010 9:24:20 PM
Author: EBree

Date: 1/28/2010 8:26:07 PM

Author: upgrade

I think that anything (not medically necessary) done without consent while a patient is under anesthesia is a violation. This is shocking to me, especially as a Canadian who''s been to a teaching hospital. The upsetting part to me is that if only the patient was asked, many would likely give their permission.

Apparently, this happens in the US too. This article was posted in another of my online communities, and a med student who lives in the US admitted to doing it in the comment section. She said something to the effect of ''ask any med student...we''ve all done it.''

This just makes me ill.

 

[TooPatient]

I''ve never liked or trusted medical people. So many little things I''ve heard that may or may not be true. And now this...

This is just wrong.
What else do the "practice" on? Colonoscopies? Prostate exams?

 

[Mrs Mitchell]

Date: 1/29/2010 6:59:01 PM
Author: cara
Since we have not had multiple headline cases where doctors were convicted of assaulting unconscious patients for practicing their pelvic exam skills on them, I think we can assume that this issue does not often make a good case for successful criminal prosecution. It would take witnesses - how would the unconscious patient know? - and those witnesses are probably perpetrators or colleagues of perpetrators. People in medicine are often conservative (small c) and their career success depends on getting along with others. To accuse your colleagues of practicing or abiding by routine sexual assault for an accepted training practice is quite ... outside of the usual decorum for medicine, even for extreme things like this that certainly raise lay people's hackles and make them want to sue/prosecute/never go to the doctor again.

Also you need the right legal environment to get a conviction. In the US the consent form for most teaching hospitals includes something about the medical trainees. I'm not a lawyer or an expert, but if you sign the piece of paper consenting to treatment in a facility with an education program in place, it might be hard to sue or prosecute someone for assaulting you with an unnecessary procedure if it was done in the course of your treatment and reasonably appropriate, but you got one exam from the attending and one exam from the staff-in-training. Obviously it starts looking worse if you got 10 unnecessary exams instead of one, but legally? If you signed a piece of paper saying it was okay, and the paper was written quite broadly, then it might be hard to prosecute. In Canada, the article mentions that consent to exams by trainees is considered 'implicit' - this wording sounds a bit like the antiquated wording on marital rape, in that a wife has implicitly consented to sex with her husband by the act of marrying him so it is legally impossible for him to rape her. So perhaps this is another case of outdated language that would make prosecution difficult.

This is why the better approach is educate the public on this unethical practice and change the legal and medical training standards. Which has obviously been done in some places but not uniformly across the world. Write newspaper articles like the one's Ebree posted so people get up in arms. Get hospitals and medical training programs to post their standards for consenting women to pelvic exams, and doing unnecessary exams on unconscious people. Find out who the medical trainees practice exams on in medical schools and teaching hospitals. Publish articles in the medical literature on how the old practice was/is unethical. Those things do get read and incorporated into policy decisions. On the legal front, you need to pass a law to get rid of the 'implicit' part of the consent in Canada, and possibly add additional consent requirements, ie. California's law, that add extra hurdles for pelvic exam consenting of patients. Doctors are quite risk-averse and *will* change their practices if given the proper types of motivation and education. I mean, your average med student is not interested in sexually assaulting women or conducting unethical exams. They are trying to survive their training, and most want to do so in a legal and ethical manner.

Cara, I do agree with you, especially since you've clarified what consent forms in the US look like. In my experience (NHS and private care in Scotland) consent for medical students to attend or participate in any procedure in any capacity is seperate from the consent to the procedure itself, which is slightly different to what you've described. Also (and I'm laughing and laughing at my own stupidity here) I would need to KNOW that it happened before I could take any action, which is possibly less likely if I'm having a general anaesthetic at the time, right? Um yeah. I have a finely honed, sharp legal mind...

That said, if I found out, or had a good reason to suspect that I had been used as a teaching aid without my consent, I would make a police report straight away. It would need corroborated evidence, which may have to be taken under oath before a judge (Scots law process for getting information out of reluctant witnesses) and it may not succeed to conviction, but I would take that route and with as much publicity as I (and my media savvy journalist friends) could attract.

 

[Hudson_Hawk]

Date: 2/1/2010 1:15:57 PM
Author: TooPatient
I''ve never liked or trusted medical people. So many little things I''ve heard that may or may not be true. And now this...


This is just wrong.

What else do the ''practice'' on? Colonoscopies? Prostate exams?

TP I understand your concern, but I think we can all agree on the likelihood of something like this or equally unethical happening is very small. If you have concerns with your treatment or your doctors, you need to do due diligence and research not only diagnoses and treatments, but your practitioners as well. Google any doctor and you''ll find numerous ways in which they''ve been graded. It''s wrong and it''s an abuse, but don''t generalize that all medical people shouldn''t be trusted.

 

[Lauren8211]

Date: 2/1/2010 1:49:06 PM
Author: Hudson_Hawk

Date: 2/1/2010 1:15:57 PM
Author: TooPatient
I''ve never liked or trusted medical people. So many little things I''ve heard that may or may not be true. And now this...


This is just wrong.

What else do the ''practice'' on? Colonoscopies? Prostate exams?

TP I understand your concern, but I think we can all agree on the likelihood of something like this or equally unethical happening is very small. If you have concerns with your treatment or your doctors, you need to do due diligence and research not only diagnoses and treatments, but your practitioners as well. Google any doctor and you''ll find numerous ways in which they''ve been graded. It''s wrong and it''s an abuse, but don''t generalize that all medical people shouldn''t be trusted.

Ditto. People are equally shady in all professions, I''d assume.. and by that I mean there are likely very few anywhere. It''s just that medicine is such a sensitive topic that every anecdotal story makes it seem that doctors are violating patients left and right.

They do wonderful things, and while you should be skeptical about diagnoses, you shouldn''t just write all doctors off. They''re good people who worked hard to have a profession that saves the lives of others!

 

[icekid]

Date: 2/1/2010 1:15:57 PM
Author: TooPatient
I've never liked or trusted medical people. So many little things I've heard that may or may not be true. And now this...


This is just wrong.

What else do the 'practice' on? Colonoscopies? Prostate exams?

Seriously???

How offensive. No, we only "practice" on the annoying patients. (Note: This is said 100% tongue-in-cheek. We take good care of everyone, annoying folks included.)

 

[Porridge]

Date: 2/1/2010 1:15:57 PM
Author: TooPatient
I've never liked or trusted medical people. So many little things I've heard that may or may not be true. And now this...


This is just wrong.

What else do the 'practice' on? Colonoscopies? Prostate exams?

Are you serious? Or is that a poor attempt at bad taste humour?

 

[Brown.Eyed.Girl]

Date: 2/1/2010 1:15:57 PM
Author: TooPatient
I''ve never liked or trusted medical people. So many little things I''ve heard that may or may not be true. And now this...


This is just wrong.

What else do the ''practice'' on? Colonoscopies? Prostate exams?

So what do you do if you have a medical emergency?

 

[LtlFirecracker]

Date: 2/1/2010 2:36:47 PM
Author: icekid

Date: 2/1/2010 1:15:57 PM

Author: TooPatient

I''ve never liked or trusted medical people. So many little things I''ve heard that may or may not be true. And now this...



This is just wrong.


What else do the ''practice'' on? Colonoscopies? Prostate exams?

Seriously???

How offensive. No, we only ''practice'' on the annoying patients. (Note: This is said 100% tongue-in-cheek. We take good care of everyone, annoying folks included.)

So I guess that includes all the medical people posting on this forum???? Thanks.