Pelvic exams without Consent

[Hockeynut]

http://www.theglobeandmail.com/life/health-and-fitness/time-to-end-pelvic-exams-done-without-consent/article4325965/

 

To those of you at or past this stage have you done a pelvic exam without consent?

[JohnDakota]

I had a similar experience at CHEO when I was ~13.

 

I was experiencing severe pain in my scrotum and being an adolescent I was freaking out about it. I was examined by the doctor, who determined it was nothing to worry about - regardless of how painful it was. Then after the examination they paraded in a group of medical students to check me out too - without asking permission.

 

I recognize I wasn't at the age of consent, but my parents weren't there either - so the least they should have done was asked if it was ok with me.

 

I'm sure practices have changed though in the intervening 20 years. It seems like people are more conscious of these issues.

[mrewmrew]

I had a similar experience at CHEO when I was ~13.

 

I was experiencing severe pain in my scrotum and being an adolescent I was freaking out about it. I was examined by the doctor, who determined it was nothing to worry about - regardless of how painful it was. Then after the examination they paraded in a group of medical students to check me out too - without asking permission.

 

I recognize I wasn't at the age of consent, but my parents weren't there either - so the least they should have done was asked if it was ok with me.

 

I'm sure practices have changed though in the intervening 20 years. It seems like people are more conscious of these issues.

 

Man that sounds so rough LOL. Even at 13 I would be highly embarrassed if that happened.

[thebouque]

I had a similar experience at CHEO when I was ~13.

 

And what's the age of consent?

[Jochi1543]

I've done pelvic exams in the OR. I wouldn't call a pelvic exam on someone getting a hysterectomy or a bladder repair "unrelated." If they were getting heart surgery and got a pelvic exam, then yes, by all means, that would be unrelated. Edited to clarify: this was on gyne OR only

 

At least where I trained, patients receive a sheet informing them that a trainee may examine them, so they consent to it.

 

It's actually a valuable experience. You can examine much better when the person is under, since you are not worried that they will feel uncomfortable, so you can really palpate an adnexal mass or a assess a prolapse.

[JohnDakota]

And what's the age of consent?

 

Turns out it doesn't particularly matter in medical contexts. It's more about the psychological capacity.

 

Age of consent

The legal age of majority has become progressively irrelevant in determining when a young person may consent to his or her medical treatment. As a result of consideration and recommendations by law reform groups as well as the evolution of the law on consent, the concept of maturity has replaced chronological age. The determinant of capacity in a minor has become the extent to which the young person's physical, mental, and emotional development will allow for a full appreciation of the nature and consequences of the proposed treatment, including the refusal of such treatments.

-The Canadian Medical Protective Association

 

http://www.cmpa-acpm.ca/cmpapd04/docs/resource_files/ml_guides/consent_guide/com_cg_requirements-e.cfm

 

 

Moral of the story: They should have asked me, or if they still thought chronological age mattered, contacted my parents for consent. Just because a child present himself at the hospital, without parents, isn't a carte blanche to do whatever the hell you want as an MD/MD trainees.

[JohnDakota]

Man that sounds so rough LOL. Even at 13 I would be highly embarrassed if that happened.

 

Ya man... I specifically remember them parading in... had to be 6-10 students and the damn doctor kept probing to produce pain for whatever purpose he saw fit (jackass).

 

All I could think of at the time was 'damn.... a few of these girls are hot!! this sucks.'

[Satsuma]

http://www.theglobeandmail.com/life/health-and-fitness/time-to-end-pelvic-exams-done-without-consent/article4325965/

 

To those of you at or past this stage have you done a pelvic exam without consent?

 

I think this article may exaggerate the truth a bit.

 

I've never seen a bunch of medical students being "paraded" into an OR for the express purpose of assaulting a patient.

 

Consents to procedures done in teaching hospitals include a statement to the effect that learners will be involved in their care.

 

A medical student learning to do a pelvic exam on a patient getting a hysterectomy is not, in my opinion, something that needs explicit consent if they are involved in the case. They are helping with the case, and should be doing an appropriate exam. The OBGYN needs to do a pelvic before they start and so should the medical student. I mean think about it, the medical student is going to be pulling on retractors with all their might etc while helping a person's uterus get removed via their vagina. And someone is really going to have concerns that that medical student did a pelvic exam prior to the procedure?

[mrewmrew]

Ya man... I specifically remember them parading in... had to be 6-10 students and the damn doctor kept probing to produce pain for whatever purpose he saw fit (jackass).

 

All I could think of at the time was 'damn.... a few of these girls are hot!! this sucks.'

 

Plot twist: They were actually undergrads shadowing and not med students hahaha

[Hockeynut]

In Dakota's case it seems totally unethical to me. In my mind ethics as a whole seems to be "upheld" to very high standards in an academic setting and gets put to the wayside in the clinic. (I have some personal experiences as a patient and volunteer that were pretty bad, ethically speaking.

[A-Stark]

I think this article may exaggerate the truth a bit.

 

I've never seen a bunch of medical students being "paraded" into an OR for the express purpose of assaulting a patient.

 

Consents to procedures done in teaching hospitals include a statement to the effect that learners will be involved in their care.

 

A medical student learning to do a pelvic exam on a patient getting a hysterectomy is not, in my opinion, something that needs explicit consent if they are involved in the case. They are helping with the case, and should be doing an appropriate exam. The OBGYN needs to do a pelvic before they start and so should the medical student. I mean think about it, the medical student is going to be pulling on retractors with all their might etc while helping a person's uterus get removed via their vagina. And someone is really going to have concerns that that medical student did a pelvic exam prior to the procedure?

 

This. I'm not sure why this issue is being dredged up again, but the notion that a brief bimanual (even by a learner!) represents the most invasive and upsetting part of, say, a transvaginal hysterectomy is more reflective of lay or rather media ignorance than anything relevant.

 

I used to enjoy Picard's columns but for a while now I haven't found anything he's written altogether relevant. Worse, because he's been a "health reporter" for several years now he fancies himself some kind of expert who can prescribe disinterested analysis.

[ellorie]

I have to say that I feel a little uncomfortable with the "well, they chose to come to a teaching hospital" rhetoric as implied consent to have learners involved in care.

 

For one thing, not everyone has the time or resources to travel to another hospital that is not a teaching hospital. And for another, if you have a very rare/complex condition or there are long waiting lists, you may also not have much of an option.

 

It's a hard balance, I think. I try to be very explicit and ask all my patients if it is okay with them for me to take care of them. Still, I feel that some of them don't fully understand what different levels of training mean/signify.

 

Medical education has to roll on, but I think we always have to be aware of issues of informed consent regarding learners. Yes, there is a LOT of sensationalism in the media - none of us are voyeurs and we are genuinely involved in patient care - but there is also a very uneasy balance between learning and service and I have once or twice felt very uncomfortable with the level of consent that was requested.

 

I recall one situation where I went to a tertiary care centre as a patient because I needed a specialist consult that was not available outside that centre. I was initially evaluated by a resident, which I had no problem with. But when he took me to meet with his staff, the staff thought I was "interesting" and brought more learners without asking my permission. It was a delicate issue and they were all male. At that time, I said to him "I am very uncomfortable and there are a lot of men in the room right now", and he just sort of said "I can see why that would be uncomfortable" and continued on. I found that very inappropriate, because I was pretty clearly indicating questionable consent.

[ploughboy]

http://www.theglobeandmail.com/life/health-and-fitness/time-to-end-pelvic-exams-done-without-consent/article4325965/

 

To those of you at or past this stage have you done a pelvic exam without consent?

 

I assume this is the same article by Andre Picard in the Globe got a lot of chatter when it was first posted in 2010, both here and in other venues. May have even made the CMAJ, if memory serves (but that could just be my Korsakoff's acting up again).

 

Didn't bother to read it again but as I recall it was a little bit inflammatory and over-the-top, which was one of the main criticisms of it.

 

http://premed101.com/forums/showthread.php?t=39347

[rmorelan]

Never ran into anything like this in medical school - the idea of doing a useless exam without permission seems so incredibly wrong to me.

[westcoastlove]

http://www.theglobeandmail.com/life/health-and-fitness/time-to-end-pelvic-exams-done-without-consent/article4325965/

 

To those of you at or past this stage have you done a pelvic exam without consent?

 

Yes, it happens. As a former UWO medical student, it certainly occurred during my clerkship.

[NLengr]

While this article does generate some discussion, I think the unrelated pelvic exam is a thing of the past.

 

The article itself is inflammatory and has a poor idea of what type of operation needs a pelvic exam. If you are scrubbing into a case involving female pelvic surgery, you should be doing an exam. Full stop. It would be inappropriate not to assess the patient prior to the operation. The caveat is the patients should be informed as part of the surgical consent that a pelvic exam may be performed by the surgeon and the assist. But even that is difficult. How much detail do you need to go into? Do you need to inform the patient that the assist may be using a sponge stick placed into the vagina to manipulate the cervix/uterus? How about the assistant placing the operative speculum? Palpating for the end of snap from inside the vagina? How about if the surgeon is doing these things but not the assistant?

 

Like most things, the answer isn't the black and white situation that the author seems to think exists.

 

Doing exams on non female pelvic surgery patients is inappropriate however. But honestly, I have never seen that happen.

 

I'm also pretty sure the globe and mail dragging this back up is mostly related to getting readers and website hits.

[Head Squeeze]

And what's the age of consent?

 

There is no age of consent. You are supposed to get informed consent from the person/proxy everytime before touching someone regardless or age or competence. Exception: Doctrine of Emergency.

[BK47]

There is no age of consent. You are supposed to get informed consent from the person/proxy everytime before touching someone regardless or age or competence. Exception: Doctrine of Emergency.

 

Well, there is such a thing as implied consent... like if you're a 50yo female who presents to a breast clinic for assessment of a breast lump you discovered, you're essentially consenting to a physical exam to assess that mass.

 

And (with the exception of Quebec) it was my understanding in Canada that whether a child/minor can consent to a procedure has nothing to do with chronological age and everything to do with their capacity to understand the proposed procedure/intervention and hence agree to it.

[thebouque]

 

And (with the exception of Quebec) it was my understanding in Canada that whether a child/minor can consent to a procedure has nothing to do with chronological age and everything to do with their capacity to understand the proposed procedure/intervention and hence agree to it.

 

Well done!

 

Finally someone who truly understands consent (with JDakota of course who's done his research). In Quebec (and only in Quebec) it's 14. Everywhere else in Canada it depends on the child's maturity.

[thebouque]

There is no age of consent. You are supposed to get informed consent from the person/proxy everytime before touching someone regardless or age or competence. Exception: Doctrine of Emergency.

 

Not quite. If you're a medical student reread your lecture about informed consent (very important topic for exams and for your life). If you're not in med school yet, don't worry about it now, you have plenty of time to learn about it and many other wonderful things

[Head Squeeze]

Not quite. If you're a medical student reread your lecture about informed consent (very important topic for exams and for your life). If you're not in med school yet, don't worry about it now, you have plenty of time to learn about it and many other wonderful things

 

Well that is the general rule. There are issues like implied consent for ongoing care and stuff, incompetency etc. but consent and assent are important for incompetent patients (which needs to be established and not assumed regardless of age or disability) which can be withdrawn anytime during a procedure unless doing so would cause immediate harm to the patient.