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Pelvic exams while under anesthesia sparks debate

Pelvic exams while under anesthesia sparks debate
By Karen Rowan
Published October 05, 2012


As a medical student, Dr. Shawn Barnes had an experience that he says left him feeling ashamed and conflicted. During his rotation through the obstetrics and gynecology ward of a teaching hospital in Hawaii, Barnes performed pelvic exams on women under anesthesia without the women's explicit consent to the procedure. The women were all having gynecological surgery, and had signed a long form indicating they agreed to allow medical students to be involved in their care.

However, to Barnes, the "implicit consent" patients gave when signing the forms didn't ensure they understood exactly what happened while they were unconscious — a relatively inexperienced medical student palpated their ovaries and uteruses to check for, and better understand, potential abnormalities in these organs.

"For three weeks, four to five times a day, I was asked to, and did, perform pelvic examinations on anesthetized women," Barnes wrote in an editorial published in the October issue of the journal Obstetrics and Gynecology. Teaching hospitals should stop this practice, Barnes told MyHealthNewsDaily. Instead, patients should be asked to "explicitly consent" to the procedure, meaning they specifically say they will allow a medical student to conduct a pelvic exam.

Two doctors at a Boston hospital, writing in a counterpoint to Barnes' editorial, say they agree that obtaining only implicit consent is "morally unsound," but also say that this practice has largely faded away. Guidelines from doctors' groups say that women should be fully informed about the procedure, they noted.

"We have many providers who trained in other institutions, and in conversation with them," it's clear that women are usually asked specifically for their consent to a student-performed exam, said Dr. Carey York-Best, an obstetrician and gynecologist at Massachusetts General Hospital and one of the doctors who wrote the counterpoint to Barnes' editorial.

But Barnes says the exams are done without explicit consent more often than these doctors indicate. A 2003 survey of Philadelphia medical students found that 90 percent reported being asked to perform pelvic exams on women who had not explicitly consented to the procedure.

Both Barnes and York-Best said there are no recent data available on exactly how many hospitals nationwide are not abiding by the guidelines recommending that explicit consent be obtained.
In any case, Barnes said that guidelines do not govern real-world practice — for this, laws are needed. During his residency, Barnes said he raised his concerns regarding pelvic exams with his superiors, but was told these exams were a long-standing, standard practice. "In fact, I was told I was the first medical student or resident in institutional memory to express concern over the practice," he wrote in his editorial. York-Best said such laws would potentially overregulate doctors' activities, and that the field is already far more regulated than many others.

Why not just ask for permission?

Performing pelvic exams on anesthetized women just prior to surgery provides medical students with a unique and valuable learning experience, Barnes and York-Best both said. For one, muscles relax under anesthesia, allowing the exam to proceed more easily and giving the surgeon and medical student a clearer picture from which to plan the details of the surgery.

Additionally, women undergoing surgery have conditions that make their anatomy abnormal. Most patients who come in for routine exams performed by medical students don't have gynecological diseases, but medical students need to be able to recognize and diagnose abnormalities.

In his editorial, Barnes presented the arguments he heard — from attending physicians, residents, and other medical students, along with published medical literature — that a woman's signature on a long form was sufficient proof of her consent.

One argument is that such consent forms are simply the standard practice, so the exams are not an issue. But the fact that professional guidelines — from groups such as the American College of Obstetricians and Gynecologists and the American Medical Association — say that explicit consent is needed shows that this should not be the standard practice, Barnes said.

Another argument he heard is that medical students don't ask for specific permission to retract tissue or cut sutures during surgery, and that the pelvic exam portion of the procedure is no different.
But Barnes argues that it is different. In fact, male medical students must be chaperoned when performing pelvic exams on conscious patients, but not when they remove surgical staples — this requirement reflects an understanding on the part of medical practitioners a pelvic exam is a more personal practice.

Do guidelines do enough, or are laws needed?

York-Best and her co-author, Dr. Jeffrey Ecker, suggest that the physician responsible for the patient's care should ask the patient for permission to allow a student to perform the exam, ideally well before the surgery. Patients should also be given the opportunity to meet the medical student prior to the surgery, they write.

Most patients are willing to let the student do an examination when asked by their own physicians, York-Best said, pointing to a 2009 study in which 74 percent of patients consented to a student performing a pelvic exam when they were asked by their doctor. In contrast, another study found that 53 percent consented when they were asked by students. "When it is a stranger, especially a nervous or awkward student, who asks, they do not yet know if they can trust that person, and are likely to err on the side of saying no," York-Best said.

It's important for doctors at teaching hospitals to advocate for the teaching process in order to ensure that their students receive adequate training, she said. Barnes called this "a good idea," but maintained that laws are needed to make sure that women understand what they are consenting to.

Hawaii is now one of four states (California, Illinois and Virginia are the others) where doctors are legally required to obtain specific consent for pelvic exams under anesthesia. The Hawaii law grew out of Barnes' outreach to lawyers about the issue, and he testified before the state legislature regarding the practice while the bill was under consideration.


Read more: http://www.foxnews.com/health/2012/10/05/pelvic-exams-while-under-anesthesia-sparks-debate/#ixzz28bwZ2Baq
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by on Oct. 7, 2012 at 7:19 AM
Replies (31-40):
NatashaOlivia
by on Oct. 7, 2012 at 4:31 PM
I'm sorry, I got bored reading that. Can anyone give me the key points?
Posted on CafeMom Mobile
JoshRachelsMAMA
by JRM on Oct. 7, 2012 at 4:48 PM

It's totally cool that you have no issues icing  offering your cooch up in the name of education/science. Others are not so comfortable with that.

Quoting lga1965:

 The women were all having gynecological surgery, and had signed a long form indicating they agreed to allow medical students to be involved in their care.

However, to Barnes, the "implicit consent" patients gave when signing the forms didn't ensure they understood exactly what happened while they were unconscious — a relatively inexperienced medical student palpated their ovaries and uteruses to check for, and better understand, potential abnormalities in these organs.

**************************************


They are STUDENTS and they are learning, and I would not be bothered by this at all!  If they want to learn by palpating my uterus ,etc. while I am under anaesthesia, they can go right ahead and I would feel that I was contributing to their education.


DO you think they are having sex while you are knocked out?LOL


This is soooooo silly and so picky. I just don't understand the many ways people including CM moms can find something to be all pissed off about.


@@

....I am only responsible for what I say,NOT for what you understand.....
Sunshinebee0502
by Member on Oct. 7, 2012 at 4:54 PM

I think allowing me consent to the possibility of it happening should be a real thing to look into and I find a lot of concern for the students who morally objected but then went along with it anyway... If I disagree with something I don't do it.

Ziva65
by Gold Member on Oct. 7, 2012 at 5:11 PM


Quoting cjsbmom:


Quoting Ziva65:

 

Quoting cjsbmom:

Don't be too sure about that. When I had my son, I had (I kid you not) 5 students come in within an hour's time, all wanting to feel my abdomen to see if it had retracted normally after birth. Five. In less than an hour. That was ridiculous.

Quoting Ziva65:

I do think it should be more explicitly outlined and explained to the women in advance, as part of the consent. However,

It appeared as if they were directly with the surgeon just prior to the procedure, in which case, it's easily understood, it is a teaching hospital after all.  It doesn't sound like there are multiple students doing this on the same patient time after time (which the title sort of implied), it is directly associated with the procedure for which they are there. Really not any different than if the person were awake in the exam office with a student there.

That is what you get at a teaching hospital anyway. In my nursing rotations in ICU guess where the arterial blood gases got done by students, in the ICU.

I 1) never go to a teaching hospital and 2) when I have been somewhere where there are medical or nursing students, I let them watch but will not be practiced on :) I know it's important, and I did it too (as an FNP), but I have always obtained a clear consent when I was a student. And, not at all offended when they said no, as I too say no :)


I think that is horrible. I hope you were able to stop it. I know being in a hospital bed, feeling not in control, etc. It is hard... it was hard for me to (though it was only 1 at a time) and I ended up being a total bitch about it...

I had to totally pull the bitch routine to get it to stop. I was getting no rest due to the steady influx of interns wanting to poke or peek at me. It got old after a few hours.

It is terrible. There was one point, just before I had to go in for a c section, that I had horrible contractions. I was 29 weeks. I had a cerclage (where they stich up the cervix). I called for help, and got a resident and a nurse. They said no one else was available, so the resident looked in there to see what was up... Well, he looked and appeared confused. He said to the nurse in front of me "I don't know what I'm looking at" THAT was lovely. She looked in there and said "It's a hand around the stiches.... we need to get her to the OR...."

It was awful, proved my point that I was a guinea pig and they know nothing :)

lga1965
by on Oct. 7, 2012 at 5:17 PM

 well that was classy. @@

Quoting JoshRachelsMAMA:

It's totally cool that you have no issues icing your cooch up in the name of education/science. Others are not so comfortable with that.

Quoting lga1965:

 The women were all having gynecological surgery, and had signed a long form indicating they agreed to allow medical students to be involved in their care.

However, to Barnes, the "implicit consent" patients gave when signing the forms didn't ensure they understood exactly what happened while they were unconscious — a relatively inexperienced medical student palpated their ovaries and uteruses to check for, and better understand, potential abnormalities in these organs.

**************************************


They are STUDENTS and they are learning, and I would not be bothered by this at all!  If they want to learn by palpating my uterus ,etc. while I am under anaesthesia, they can go right ahead and I would feel that I was contributing to their education.


DO you think they are having sex while you are knocked out?LOL


This is soooooo silly and so picky. I just don't understand the many ways people including CM moms can find something to be all pissed off about.


@@

 

ShadowLark
by Bronze Member on Oct. 7, 2012 at 5:28 PM
Is the baby ok?


Quoting Ziva65:



Quoting cjsbmom:




Quoting Ziva65:


 


Quoting cjsbmom:


Don't be too sure about that. When I had my son, I had (I kid you not) 5 students come in within an hour's time, all wanting to feel my abdomen to see if it had retracted normally after birth. Five. In less than an hour. That was ridiculous.


Quoting Ziva65:


I do think it should be more explicitly outlined and explained to the women in advance, as part of the consent. However,


It appeared as if they were directly with the surgeon just prior to the procedure, in which case, it's easily understood, it is a teaching hospital after all.  It doesn't sound like there are multiple students doing this on the same patient time after time (which the title sort of implied), it is directly associated with the procedure for which they are there. Really not any different than if the person were awake in the exam office with a student there.


That is what you get at a teaching hospital anyway. In my nursing rotations in ICU guess where the arterial blood gases got done by students, in the ICU.


I 1) never go to a teaching hospital and 2) when I have been somewhere where there are medical or nursing students, I let them watch but will not be practiced on :) I know it's important, and I did it too (as an FNP), but I have always obtained a clear consent when I was a student. And, not at all offended when they said no, as I too say no :)




I think that is horrible. I hope you were able to stop it. I know being in a hospital bed, feeling not in control, etc. It is hard... it was hard for me to (though it was only 1 at a time) and I ended up being a total bitch about it...


I had to totally pull the bitch routine to get it to stop. I was getting no rest due to the steady influx of interns wanting to poke or peek at me. It got old after a few hours.


It is terrible. There was one point, just before I had to go in for a c section, that I had horrible contractions. I was 29 weeks. I had a cerclage (where they stich up the cervix). I called for help, and got a resident and a nurse. They said no one else was available, so the resident looked in there to see what was up... Well, he looked and appeared confused. He said to the nurse in front of me "I don't know what I'm looking at" THAT was lovely. She looked in there and said "It's a hand around the stiches.... we need to get her to the OR...."


It was awful, proved my point that I was a guinea pig and they know nothing :)


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Sisteract
by Whoopie on Oct. 7, 2012 at 5:32 PM
Wonder if the women asked more ?s re possible student involved, and if so, if they were given the full truth?
Posted on CafeMom Mobile
lga1965
by on Oct. 7, 2012 at 5:37 PM

 You know what.....I bet the women who are all pissed off about a med student doing a pelvic while they are under and consider it an invasion are the same women who were all in favor of strippers and stripping (---this was in another post today about strippers). I would NEVER strip and allow a bunch of horny, low life men see my naked body.   But I have no fear of being examined by a medical doctor or medical  student.Its the way they learn in teaching hospitals and its like they are checking the motor in a car for all they care.

I swear values and opinions are all backwards and inside out.

cjsbmom
by Lois Lane on Oct. 7, 2012 at 5:53 PM

Nope. I do not fit that category.

It's not just about someone you don't know or didn't consent to seeing your woman parts. It's about having an inexperienced resident or student performing medical procedures on your body without your express consent.

I didn't mention this earlier, because it just pisses me off when I think about it. But when I was in labor, I was under the impression the woman at my uterus was the doctor. Nope. Find out *after* she panics and the nurse has to call in the real OB on staff that she was just a student. A freaking STUDENT was trying to suction my kid out of my vagina during a difficult birth. My son has autism. There are days I look back at that fiasco and wonder if that inexperienced student -- whom I did not consent to perform that procedure -- is the reason.

Quoting lga1965:

 You know what.....I bet the women who are all pissed off about a med student doing a pelvic while they are under and consider it an invasion are the same women who were all in favor of strippers and stripping (---this was in another post today about strippers). I would NEVER strip and allow a bunch of horny, low life men see my naked body.   But I have no fear of being examined by a medical doctor or medical  student.Its the way they learn in teaching hospitals and its like they are checking the motor in a car for all they care.

I swear values and opinions are all backwards and inside out.



TCgirlatheart
by TC on Oct. 7, 2012 at 6:52 PM
Totally missed that. Thanks Seeker! I thought the winky face would be enough to see I was joking. Guess not! lol

Quoting SEEKEROFSHELLS:

 TC has been around a while. I like a lot of her comments. I am sure somewhere in the past I have debated with her or she with me. When I see her name "fucking idiot" doesn't come to mind. 


Quoting :


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